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Wednesday Oct 08, 2014

Asking Right Questions Critical to Making Right Match

It may seem like the academic year just started, but for fourth-year medical students, the decision about where to spend the next three or more years is just around the corner. And the fall and winter, also known as "interview season," is when it gets really interesting.

Fall is the time for fourth-years to prepare for the National Resident Matching Program -- better known as the Match -- by visiting and interviewing with potential residency programs. The AAFP offers a tremendous free resource -- Strolling Through the Match  -- that can be helpful to students regardless of year or specialty interest. The 80-page PDF covers a wide range of topics:

  • residency application timeline and checklist;
  • introduction to the Electronic Residency Application Service and the specialties that participate;
  • a residency program evaluation guide;
  • residency selection steps and interviewing tips;
  • examples of how the Match works for applicants;
  • new tips on post-interview etiquette; and  
  • tips on writing a curriculum vitae and a personal statement.

We used Strolling Through the Match widely at the University of Alabama when I was a student, and the information is practical and thorough. Still, some of the most valuable advice I received when preparing for interview season came from those who had been through the process and got their desired Match results, So, I thought it might be helpful to share the tips and takeaways from my experience just last year.

The most important thing to evaluate at each interview is how well you fit in with the faculty and, most importantly, the residents, because you will be working closely with them for the next three years (or more). If you can't get along with them, your life will be miserable.

After that, you have to prioritize the features you desire in a program, such as teaching exposure and the amount and extent of care you will provide to pediatric, obstetric and adult patients, as well as the amount of time you will spend working in inpatient versus outpatient settings. Your residency experiences form the bulk of your medical training, and if you aren't trained on something during residency, it's far more arduous to make that happen after residency.

If you have a spouse or significant other, involve that person in the decision-making process, especially if you are moving somewhere new. You will be extremely busy during residency, and he or she will have to spend a lot of time without you. Your loved one needs to be happy where you are going.

Realize that you aren't likely to find a perfect program, but you will have a gut feeling about where you belong, and that is more important than anything else.

You may already have interviews scheduled, but do you know what questions to ask? Here are some things to consider asking at each of your visits:

  • What are the program's board passage rates? This will give you an idea of how good the clinical experience is.
  • Where do the program's graduates get jobs? This will tell you whether the graduates are respected and perceived to be well-trained by the local community.
  • What are the strengths and weaknesses of the program? 
  • What kind of interaction do residents and faculty have outside of work?

While you are evaluating the programs you visit, keep in mind that you also are being evaluated at every moment, not just during the formal interviews. Residents will scrutinize you for your "fit" at any moment they interact with you, including meals and tours, so treat every moment seriously and always be on your toes.

Residency representatives will want to know why you are interested in their program and what specific aspects drew you there, so show you have done your research and be prepared to name something about that program other than just its name or reputation.

While fourth-year medical students are planning for the long term, it's not too early for first- through third-year students to start building CVs, learning as much as they can about each specialty, and seeking experiences that can help prepare them to choose their future. Here are some possible scenarios to consider:

  • First-year students, you can use your only summer off during medical school to experience family medicine. Find international service opportunities for students, or find a family physician to shadow. Your faculty or state chapter can help you with this.
  • Second-year students, build your CV by pursuing leadership opportunities on your campus -- for example, with your school's family medicine interest group.
  • Third-year students, get out of the academic health center during your elective rotations and experience primary care where it occurs most often -- in the community. Use the AAFP's clerkship directory to find an elective rotation.

Tate Hinkle, M.D., is the student member of the AAFP Board of Directors.

Friday Oct 03, 2014

The Countdown Begins: One Year to ICD-10

One year. That's how long we have to get ready for the official implementation of ICD-10. Oct. 1, 2015, is the day we have been nervously awaiting since July, when CMS confirmed that as the revised compliance date for the new coding system.

Later this month, the Academy will offer CME courses related to ICD-10 to help us prepare during the AAFP Assembly in Washington. Will your practice be ready?

Every time I read an article about ICD-10, I wonder how small practices like mine will survive this new hurdle. A study conducted by Nachimson Advisors and published by the AMA estimated that small practices could suffer costs between $56,000 and more than $226,000. A large practice's financial impact is estimated to range from $2 million to $8 million. These figures are three times what was estimated by the same research group just five years ago.

ICD-10 has more than 68,000 diagnostic codes compared with ICD-9, which has a little more than 14,000 diagnostic codes. This is a significant shift for family medicine. The differentiation of right, left and bilateral accounts for about 40 percent of the increase in codes for ICD-10. Initial versus subsequent diagnosis codes might create an obstacle for the busy physician but will ultimately be helpful for tracking purposes.

According to the American Health Information Management Association, the new coding system will result in higher-quality data that can improve measures of quality and performance, provide "increased sensitivity" to reimbursement methodologies, and help strengthen public health surveillance.

But how do we get there? Updates to my practice's electronic health record (EHR) system have allowed us to "bridge" to ICD-10 for the past eight months. Testing and payment disruptions are variables that are impossible for me to anticipate, and every consultant we talk to offers a different opinion as we try to assess how to proceed.

In my search for assistance on the web, I found "The Road to 10: The Small Physician Practice's Route to ICD-10," an online resource an online resource to help small physician practices transition to ICD-10. This tool was developed by CMS in collaboration with industry partners. It allows a small clinical practice to create a customized action plan for ICD-10 readiness and preparation. It provides a five-step action plan that covers planning, training staff, updating systems and processes, engaging partners, and testing.

Although that resource is geared to small practices, the AAFP and its journal Family Practice Management have resources that can help practices regardless of size.

In addition, CMS recently announced the dates that it will do readiness testing using ICD-10 codes.  What are you doing to prepare?

Rebecca Jaffe, M.D., M.P.H., is a member of the AAFP Board of Directors.

Wednesday Oct 01, 2014

We’re Doing Our Part to Keep SGR Issue on Congress' Radar

I will only be AAFP president for three more weeks, but there's a lot to do in this final month of my term. Throughout the year, I have had opportunities to represent the Academy at meetings with a number of organizations as we discuss important concepts such as team-based care and the patient centered medical home. One such opportunity came just this week when I participated on a panel for a Capitol Hill briefing that addressed payment reform, including the need to repeal the Medicare sustainable growth rate (SGR) formula.

This event was organized by the Society for General Internal Medicine (SGIM), which reissued a 2013 report developed by the National Commission on Physician Payment Reform. Many of the principles and recommendations in the report are in line with what the AAFP has been advocating for several years. Given the urgent need to push for passage of the bipartisan, bicameral legislation on SGR repeal already in play, this was an ideal time for the commission's report to be reissued.

I joined a panel that was moderated by SGIM president William Moran, M.D., and included SGIM health policy chair Mark Schwartz, M.D., and American College of Physicians EVP Steven Weinberger, M.D., also a member of the commission. We used this opportunity to review the principles and recommendations in detail with a room packed with legislative aides from both the House and Senate. Our most important ask was to encourage legislators to pass the SGR repeal proposal before the Congress adjourns in December.  

The commission's report, like the Academy's longstanding advocacy position, stressed the need to repeal the SGR, which again poses a looming threat to cut physician Medicare payments by more than 20 percent if Congress doesn't act by March 31.

As part of this briefing process, we reviewed many of the report's recommendations, which are in line with what the Academy has been saying in our own discussions with CMS, legislators and congressional staff for years.

Some of these important recommendations include the need to transition away from the fee-for-service model. We outlined the perverse incentives that this model has given rise to in our health care system. Although fee-for-service will continue to be important for some aspects of payment, we have to fix the disparities in current fee-for-service payment rates because they will be a foundation for future payment models. There have to be opportunities to rebalance fee-for-service payments, to boost undervalued evaluation and management codes, and to recalibrate overvalued codes -- many of which have not been revisited in more than 20 years despite huge gains in efficiency.

Our patients' health is becoming increasingly complex to manage, especially in a Medicare population in which 60 percent of patients have three or more chronic conditions. This additional complexity further accentuates the dramatic disparity between how our fee-for-service model pays for procedural services compared to primary care services. New technology has reduced the time it takes to perform certain procedures, yet payment for these services has not been reduced.  This contributes to the erosion of primary care incomes which exacerbates our primary care workforce shortage.

We emphasized the real need to recognize that compared with procedural services, primary care services require face-to-face time that cannot be shortened to increase volume without decreasing patient-centeredness and quality.

Another recommendation specifically addresses the significant potential for cost savings and improved care for patients with chronic conditions. The commission report noted that 5 percent of patients in this country account for 50 percent of our health care spending.  This will continue to drive an increasingly disproportionate share of spending as more and more patients develop multiple chronic conditions. This is an area that has significant potential for cost savings as we continue to transform our practices.

As family physicians, we know what to do. Much of the answer lies  in the patient-centered medical home, and implementing better and more efficient team-based care. Our country needs a stronger primary care foundation -- the essential message of the Commission’s report. The more incentives we can find for primary care and improving access for all of our patients, the more we will save in terms of downstream costs. 

We must move away from “wrong care, wrong place, wrong time” to ensuring patients get the right care, in the right place, at the right time and from the right person.  

Overall, attendees of the briefing were interested in the recommendations. We stressed that this push is a unique opportunity that brings together all of organized medicine in support of proposed legislation. In addition, once the 2014 midterm elections are over, the unique political landscape of a lame-duck session could grease the skids for passage of the bill.

Once the 114th Congress convenes in January, the SGR repeal legislation will lapse.  In addition, because of retirements and potential election-driven shifts in power, significant changes will occur within the committee leadership in Congress, posing potential roadblocks to restarting the bipartisan process.  Therefore, this lame-duck session is a unique and rare opportunity for some congressional lawmakers to put a feather in their hat by moving forward on an important and long-sought-after repeal of this fatally flawed formula.

You can help by contacting your legislators to let them know this must be a priority!

Reid Blackwelder, M.D., is president of the AAFP.

Friday Sep 26, 2014

The Doctor is Out: Retention Poses Major Challenge for CHCs

HHS announced Sept. 12 that it is making nearly $300 million available to nearly 1,200 community health centers (CHCs) across the country. The funding is intended to help CHCs hire more than 4,700 new health care professionals and offer longer hours and expanded services, including oral health, behavioral health, pharmacy and vision.

The funding is expected to help CHCs reach about 1.5 million new patients.

Although the funding for additional staff is needed -- and welcome -- the change doesn't address one of the biggest problems CHCs face -- retention. Not only do these clinics need more physicians, they need the physicians already working in these settings to feel motivated to stay in communities where they are desperately needed.

© 2014 Casey Health Institute
My first job after residency was at a community health center, but I now work at an integrative primary care practice. Research has shown that family physicians at community health centers have lower rates of job satisfaction.

Federally qualified health centers (FQHCs) are a source of primary care for millions of uninsured and underinsured patients. They're also the place where many family physicians -- like me -- get their first "real" job outside of residency.

I spent my first four years out of residency at a CHC, and I loved it despite the challenges. I served a culturally and socioeconomically diverse population that was in need of good health care. I truly felt like I was living up to being the doctor I wrote about in my medical school personal statement.

In addition to the reward of serving a community desperate for medical care, many physicians are drawn to CHCs by offers of loan repayment -- either as part of a National Health Service Corps commitment or through state and local programs. Although many physicians enter these doors excited and eager to help the people they went to medical school to serve, too often, physicians are just as eager to leave after their loans are repaid.

Research tell us that family physicians at CHCs are less satisfied with their work situation than other physicians. The reasons are multifactorial, including low compensation and excessive workload. Isolation from cultural activities and limited career opportunities for physicians' spouses in rural areas also contribute to dissatisfaction.

I saw several colleagues come through, do their time, repay their loans, and move on. This is a common theme, because family physicians often feel burned out after just a few years at a CHC. Many went to an FQHC not just to get their loans paid off, but rather to make a difference and fulfill a personal mission to serve the underserved. One friend and colleague told me she planned to come back to an FQHC at some point in her career. But after five years of having worked in that setting, she felt that if she hadn't left when she did, she would never have wanted to go back.

More than half the states and the District of Columbia are expanding their Medicaid programs under provisions of the Patient Protection and Affordable Care Act. Many of these new Medicaid enrollees will be seen at CHCs because many private practices don't accept Medicaid. This could lead to an increase in patient visits -- and potential headaches -- at the centers, which often struggle to fill vacant positions for physicians and other clinicians. To make matters worse, the low retention often creates a burden for those who do stay.

My interest in CHCs started in high school because I had a mentor who worked in that setting. Later, I volunteered at CHCs during medical school, and I had no doubt where I wanted to go after residency.

When I left my first job at a CHC, it wasn't because I was burned out. I had an amazing opportunity to work as a White House Fellow and spent a year advising the U.S. Department of Agriculture on a range of issues related to nutrition. When my time there was up, I didn't go back to an FQHC. Although I don't miss the headaches, I do miss serving that population.

Today, I'm the medical director of an integrative primary care practice where we incorporate some of the features of an FQHC to ensure access to care, including a sliding payment scale for uninsured patients and a sliding scale for insured patients who seek services that may not be covered, such as chiropractic, acupuncture and massage therapies. At the same time we're trying to ensure access in the way FQHCs do, we're trying to avoid some of the pitfalls these centers face. We try to give our clinicians the time, space and support they need in order to be there for patients and to make them feel valued and respected.

So how do we get more CHCs to operate the same way and improve their recruitment and retention rates?

  • The Bureau of Primary Health Care (BPHC), a segment of HHS that funds health centers, should track physician retention at FQHCs and publish these data along with other quality measures. Ultimately, the goal would be to create a recommended standard for clinician retention that centers can be compared against.
  • Once a physician commits to a community for the long term, that community has a powerful advocate. The BPHC should encourage FQHCs to create strategies for physician recruitment and retention. The National Association of Community Health Centers has already done a lot of work in this area.
  • The AAFP recently established member interest groups to provide a forum for AAFP members with shared professional interests. A CHC member interest group would provide physicians who work in these settings to communicate with each other and develop relevant AAFP policy. If you are interested in starting a member interest group for family physicians in CHCs, you can find more details -- including information regarding the criteria and application process -- online.

Kisha Davis, M.D., M.P.H., is the new physician member of the AAFP Board of Directors.

Wednesday Sep 24, 2014

Lively Debate, Election of New Leaders Await at Congress of Delegates

The deadline for AAFP chapters to submit resolutions to the Congress of Delegates passed this weekend, and more than four dozen items will be up for debate when the Congress meets Oct. 20-22 in Washington.

© 2014 Marketing Images/AAFP
The AAFP's Congress of Delegates will meet Oct. 20-22 in Washington. Here I am addressing the 2013 Congress in San Diego.

The resolutions reflect the breadth of family medicine and the passion of our members, covering a variety of issues -- from clinical topics (contraception, end-of-life care, sterilization, tobacco and vaccinations, to name a few) to physician payment, scope of practice and more.

With more than 115,900 members, the AAFP represents a diverse group of physicians from many different backgrounds, practice types and political affiliations. Our members are passionate about numerous issues, and sometimes those passions collide.

For example, the Minnesota AFP has submitted a resolution urging the Academy to "participate in national deliberations and discussions pertaining to single-payer financing systems for health care reform."

The prospect of supporting a single-payer system likely would thrill some delegates and leave others itching for a fight. But spirited debate is what makes the Congress interesting, and we will no doubt hear from members with widely divergent views

Each chapter can send two delegates and two alternate delegates to the Congress. Delegates typically are individuals who have played leadership roles in their chapters. It's worth noting, however, that although only delegates may vote during the Congress business sessions, any Academy member present may speak and give testimony during the reference committee hearings.

A resolution from the Texas chapter seeks to examine the Congress' senatorial makeup and consider making the Academy's ultimate policymaking body one "based on limited proportional representation." Such a move would allow more opportunities for member participation in big states such as Texas, where physicians now often have to wait years for leadership opportunities. However, one might expect that delegates from smaller states will offer some impassioned testimony on this resolution.

Delegates also will choose a president-elect, other officers and a new class of Board directors. Unlike most years, when three new directors are chosen to serve three-year terms, delegates to the 2014 Congress will select four directors from a field of six candidates. The candidate receiving the fourth-most votes will serve a one-year term to fill the spot vacated by Clif Knight M.D., who resigned his position on the board earlier this year to become the AAFP's vice president for education.

For those who can't join us in Washington, you can follow the business sessions of the Congress via streaming video on aafp.org. More details about that will be published in AAFP News before the Congress convenes.

John Meigs, M.D., is speaker of the Congress of Delegates, the policymaking body of the AAFP.

Friday Sep 19, 2014

'What? Me Worry?' Family Medicine Residency Trained Me Well

From the first day of medical school we start a countdown to graduation and cannot wait until we are finished. Then we do the same thing in residency with even more vigor. The most frequently asked question we hear is, "When will you be finished?" We all answer -- with longing in our eyes -- that we are eager to be free, out on our own and liberated from residency requirements. No more checking out to attendings, holding interns' hands, or eating five consecutive meals in the hospital cafeteria.

It wasn't that long ago that I was worried about seeing patients outside the comfort zone of my residency program. Now I am  mentoring David Paxton, left, a fourth-year medical student at West Virginia University.

But there is a point -- near the end of June -- when the end is in sight, and it is terrifying. The elation I thought I would experience (in my head, it always involved singing and skipping through the office past the exam rooms) was replaced by a GERD-inducing, mind-numbing fear that bordered on panic. I kept thinking, "Next week, I will see a patient and have NO ONE to ask to look at that rash or listen to this murmur. I will be alone."

Then, after a couple of weeks of being consumed by the fear of leaving my residency faculty, it was suddenly time to go to work. I had never even met my nurse. I was going to see patients -- MY patients -- who I will follow for the rest of their lives. And although I had my own panel of continuity patients during residency, there seemed to be so much more at stake with these new patients. What if they don't like me? What if I can't figure out what to do with the very first one? It felt like a major case of stage fright.

Much like during my medical school rotations, when the day arrived, I got up, made coffee, and left early ... but not too early because I've sat many a time in a parking lot of an office that wasn’t even unlocked yet. My drive to work is 25 miles on a two-lane state road along a river where there is zero cell phone service and little traffic. About halfway to the office I saw something huge and black leap out of the river and attempt to sprint across the road. I slammed on the brakes and then watched a black bear climb up the side of the mountain that borders the road. All the while I was thinking that no one would believe this. But when I got to work and told my new co-workers about my bear sighting, they were unimpressed. They have all hit bears with their cars or seen them in their yards.

A couple of hours later, it was time to see a patient. My first patient. The front desk gave me an easy case, a walk-in who already had been diagnosed. I finished that patient, struggled through using a new electronic health records system and even submitted billing. I survived (so did the patient) and the world had not ended.  I knew what to do and how to do it.

I looked a few days ahead in my schedule and found some seriously complicated stuff: refractory cases, uncommon or rare diseases, undiagnosed problems and genetic disorders -- lots of all of them. After about a week of seeing patients, I emailed my residency program director at Marshall University to say thanks. I had the training and background to take care of every patient who had walked through the door.

I love my job, and now I feel silly that I was ever nervous. Family medicine residencies are rigorous, and for good reason. We are the primary care workforce, and we have to be well trained and confident to manage complex patients and serve our communities well.

I had multiple patients who reported their reason for visiting was that they had been "waiting for the new doctor to come." These patients had high hopes, and I had to meet those expectations. Although I am not doing obstetrics (there isn't one hospital in the entire county) I have had multiple pregnant patients, so I have to know how to safely treat -- and just as importantly, counsel -- them, so my obstetrics training is well utilized. There are days when I see more pediatric patients than adults, and there are other days that the average age is 70. 

Throughout medical school and residency, I heard every argument that exists against choosing family medicine. The one I can 100 percent discount after just two short months of practice is the concept of getting bored doing primary care. Really? Bored? I could be a lot of things in my office (annoying, loud, messy) but bored is not one of them. Every day is full of amazing variations that I think highlight family medicine as a specialty.  I learn new things, read new articles and teach every day. 

My patients are my favorite part of my job, but my second-favorite part is that I have medical students. I'll never forget my first patient as a student, my first continuity patient as a resident, or my first patient in my new office. And I'll definitely always remember the first medical student who trusted me to teach him family medicine. Of all the awards and achievements I have hanging on the walls, nothing beats having a medical school place a student in my office. 

I remember asking my rural preceptor when I was a third-year medical student why she took students into her office. Did she get paid or have access to university resources? Now I know why she just smiled at me and explained that she thought they gave her an email address.

Obviously, no one asks me when I'm going to be finished with school/residency anymore. But now I have new daily questions that follow a similar theme: Where are you from (and they want a town name because they can already tell that, like them, I'm from West Virginia)? Are you going to stay here? How long do you think you'll stay?

It feels good to be wanted, and it feels good to be a family physician. And yes, it feels amazing to be done with residency!

Kimberly Becher, M.D., is the resident member of the AAFP Board of Directors.

Wednesday Sep 17, 2014

GME Reform: An AAFP Call to Action

Primary care is the foundation of high-performing health care systems throughout the world, but in the United States, we primary care physicians make up less than one-third of the physician workforce, and our numbers are dropping.

 I talked about the need to reform the graduate medical education system during a presentation Sept. 15 in Washington. Other speakers, from left, were pediatrician Fitzhugh Mullan, M.D.; Kisha Davis, M.D., M.P.H., the new physician member of the AAFP Board of Directors; AAFP President Reid Blackwelder, M.D.; and AAFP EVP and CEO Douglas Henley, M.D.

A growing number of organizations -- including the Association of American Medical Colleges, the Council on Graduate Medical Education (COGME), the Pew Health Professions Commission and the Robert Wood Johnson Foundation -- have stated that at least 40 percent of U.S. medical graduates need to enter primary care fields if we are to meet the needs of our nation's health care system. But our current GME system is failing to hit that mark because nearly 80 percent of new physicians are choosing subspecialty careers. We are rapidly falling behind.

A primary care physician shortage already exists, and it will only be exacerbated by our changing health care needs: a growing population, the increase in chronic disease seen in our aging population and expansion of health insurance coverage.

The calls for change are mounting. Last year, COGME -- which was created by Congress to provide assessments of physician workforce issues -- released a report that called for drastic changes in the GME system, including increased funding to support 3,000 more graduates per year and prioritized funding for high-priority specialties, including family medicine.

Just this July, the Institute of Medicine released its analysis of GME in the United States and found that the current system lacks transparency and accountability and is producing a physician workforce that doesn't meet the country's needs -- despite an annual $15 billion investment from U.S. taxpayers.

On analysis, it's not surprising that our current GME system produces the outcomes that it does, because funneling funds through hospitals leads to residency workforce decisions based on the financial needs of those local institutions and not on the overall needs of our health care system.

This week, I was pleased to join other AAFP leaders on Capitol Hill as we took things a step further, unveiling a new budget-neutral proposal that would address those issues of transparency and accountability while aligning funding resources with actual workforce needs. The Academy's proposal recommends that policymakers and legislators take the following steps:

  • Establish primary care thresholds and maintenance-of-effort requirements for all sponsoring institutions and teaching hospitals that currently receive Medicare and Medicaid GME financing.
  • Require all sponsoring institutions and teaching hospitals seeking new Medicare- and Medicaid-financed GME positions to allocate one-half of their new positions to primary care.
  • Limit direct GME and indirect medical education (IME) payments to training for "first-certificate" residency programs. Repurposing funding currently spent on fellowship training would be used to create more than 7,500 new first-certificate residency training positions.
  • Align financial resources with population health care needs through a 0.25 percent reduction in IME payments and reallocation of those resources to support community-based primary care training.
  • Fund the National Health Care Workforce Commission. The Patient Protection and Affordable Care Act created this panel to review health care workforce supply and demand, but Congress has failed to allocate funding for it.

Yet it is important to note that the current and future physician workforce cannot be corrected through GME reform alone.

Earlier this year, a task force created by the Council of Academic Family Medicine -- which comprises the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors, the Society of Teachers of Family Medicine and the North American Primary Care Research Group -- with support from the AAFP, the AAFP Foundation and the American Board of Family Medicine, created the "Four Pillars for Primary Care Workforce Reform" concept, a comprehensive approach that includes:

  • the medical school pipeline,
  • the process of medical education, 
  • improving the practice environment for a more rewarding professional setting and 
  • primary care payment reform.  

Even as we work on all of these comprehensive reforms, changing the GME system is one of the most important policy levers we can pull now because of the vast government investment in the program and the multiple recent national reports calling for reform. Our GME system is stale. It was created in 1965 -- a different time -- and for a different purpose. Now, it is one of the few areas of the health care system that has not experienced major disruption in composition, function or financing.

Please join me in engaging our nation's leaders in a conversation about why our GME system should be reformed. It is time for the investment our nation makes in GME to be transparent and accountable and to produce the physician workforce our country needs and deserves.

Jeff Cain, M.D., is board chair of the AAFP.

Thursday Sep 11, 2014

FSMB Offers Licensing Solution for Docs Looking to Practice in Multiple States

My home state -- Iowa -- shares its borders with six other states. With my state-issued driver's license, I can drive not only in all six of those states but in any other state in the nation. As part of this system, a longstanding interstate compact allows the vast majority of states to share information regarding license suspensions and traffic violations of nonresidents. The states where infractions occur may forward information to a driver's home state, which then applies its own laws to the out-of-state offense.

That system makes sense. Unfortunately, the same can't be said of the way states view medical licenses. I've been in practice for more than 20 years, but the second I drive across one of those state lines, my Iowa medical license is invalid.

On Sept. 5, the Federation of State Medical Boards (FSMB) took a major step toward solving this problem when it finalized model legislation to create an Interstate Medical Licensure Compact that would expedite the process of issuing licenses for physicians who wish to practice in multiple states.

The key word here is "expedite." Under the current system, physicians who wish to practice in more than one state have to navigate a fairly burdensome process that involves paperwork, fees and three to six months of waiting.

Expediting the process would benefit physicians who live near a state line, are licensed to practice on one side of that state line and seek privileges at a hospital or other facility on the other side of that line. The change also could help alleviate physician shortages in rural and underserved areas and pave the way for greater use of telemedicine. (It's worth noting that earlier this year, FSMB adopted new guidelines for telemedicine.)

Under the terms of the model legislation, a physician would apply for a multi-state license through his or her home state. That state would determine whether the physician meets the following eligibility requirements for the compact:

  • Possession of a full and unrestricted license in a compact state;
  • Successful completion of a graduate medical education program approved by the Accreditation Council for Graduate Medical Education or the American Osteopathic Association;
  • Specialty certification or possession of a time-unlimited certification recognized by the American Board of Medical Specialties or the American Osteopathic Association Bureau of Osteopathic Specialists;
  • A clean disciplinary record;
  • No discipline from any agency related to controlled substances;
  • No pending investigations by any agency or law enforcement entity.

The proposed legislation would make it easier for states to share information and improve tracking and investigation of physicians who have been disciplined or are under investigation. Physicians who do not meet these criteria may still be able to receive a license in multiple states but not through the expedited process.

The model legislation has the potential to help put more physicians in the areas where we are needed most, but, ironically creating an expedited process could take time. Now that the model legislation has been finalized, state legislatures and medical boards can begin to consider its adoption. Each state must pass the compact to participate. That means family physicians who want this proposal to succeed should talk to your state chapters, who could help move this issue forward, or your state medical boards. Better yet, share your opinion directly with your state legislators.

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

Friday Sep 05, 2014

Called to Serve: Being Patient-Centered Puts Joy Back Into Practice

One of the exciting things about being president of the AAFP is the many opportunities to interact with medical students from all over the country. I have frequently said that students are not so much our future as they are our present. They have the ability to affect us in a positive way with their curiosity, fresh perspective and drive. And we, in turn, have the ability to make an impact on them and to influence their education and training.

Along those lines, I wanted to share two recent experiences and challenge each one of us to step up and build these critical relationships.

Our recent National Conference of Family Medicine Residents and Medical Students drew more than 1,200 students and nearly 1,100 residents to Kansas City, Mo.

I was honored to be asked to welcome all attendees to the National Conference of Family Medicine Residents and Medical Students a few weeks ago in Kansas City, Mo. This is the largest meeting of medical students and residents in the country, and this year we had record attendance, with 1,211 medical students and 1,092 residents.

For students in particular, National Conference is a critical leadership development opportunity. Obviously, we want to expose them to family medicine, and the experience of attending the conference often solidifies students' decision to pursue family medicine as their specialty of choice. But the conference has another important function: educating and challenging students to advocate and be part of our policymaking process.

One of my main messages at National Conference also was the focus of my closing main stage presentation. During that session, I challenged students to be patient-centered in all they do. I let them know that they have this opportunity, from the ground up, to be patient-centered even before they enter the workforce.  

National Conference is a great experience for attendees, but our engagement needs to extend beyond those three days each year. We can all look for other ways to reach out to medical students where they are. For example, we recently had our second Family Medicine on Air session using Google Hangout. This is an innovative approach to connecting people, and it is a technique the Academy likely will be using in other ways to connect with members.

The structure of the Google Hangout -- which you can view on Google Plus or YouTube -- allowed people to actually see me, moderator Alice Esame (a fourth-year student from Howard University School of Medicine who also is the AAFP's student liaison to the Student National Medical Association), and AAFP student interest staff as we talked about the patient-centered medical home (PCMH). I gave a brief introduction in which I emphasized that the PCMH is truly about a philosophy and an attitude as well as about being patient-centered. Students need to understand the PCMH, yes, but most importantly, they need to be empowered to become patient-centered even if they don't yet understand all the aspects of practice transformation.

The opportunity to be patient-centered truly is a way to put joy back into a practice. It is a way for all of us to remember that we are called to serve, and that we can truly help our patients often just through the compassion we display in recognizing that they are dealing with difficult issues. This is especially important for students to understand as they consider choosing a career in family medicine that will be satisfying to them, as well as to their patients.

I was impressed with the quality of the questions that came from the students. For example, they were concerned about the administrative hurdles that come with practice transformation. This allowed me to emphasize our advocacy efforts to help streamline the process involved with PCMH recognition.

Another question acknowledged the important role of other members of the health care team, such as care managers, nurses and others. Specifically, the student's question addressed how to assemble a team in rural settings where there are fewer resources. This gave me a chance to talk about how at my first practice in Trenton, Ga., the small town's health care professionals (chiropractors, pharmacists, public health officials, etc.) worked together even though we weren't in the same building -- or the same business -- to make sure that we provided the care our community needed. The key was good communication as well as the recognition that we all were working together for our patients' well-being.  

The students were on top of recent evidence, too, quoting an article in JAMA that found PCMH pilots from 2008-11 were not associated with health outcome improvements. I pointed out that this article described older PCMH models, and so was essentially similar to being concerned about a review of the iPhone 2 when we're actually using the iPhone 5. PCMH models now are significantly different. Those pilots did not have many of the patient-centered changes in place such as extended hours, and did not really study decreased ED visits, and hospitalizations which are clear improvements in current PCMH pilots.

Students keep us on our toes. They challenge us, in a good way, with their fresh viewpoints, inquisitive minds, and drive to do things the best way possible. And the questions these students asked amply illustrated that reality.

The challenge for us as educators is to recognize that our students need a different approach for many of these issues. If you are an educator, or involved with a family medicine interest group, consider watching the Hangout and sharing the link. You can also refer to or use supporting materials that are available to help our family medicine interest groups, faculty and others who influence medical students frame these critical issues for them.

For members who work with students -- even if you're not faculty, I challenge you to engage them in discussion about patient-centeredness. Talk about how you have been changing your practice to become more patient-centered. Take advantage of this chance for us to walk our talk and demonstrate to our students how much we love what we do.  

Although I still say students are our present, they are definitely also our future. We have a chance to give them a solid grounding in patient-centered education, and they can help to move us forward in our own processes.

Our next edition of Family Medicine on Air will address what medical students need to know about direct primary care. Stay tuned for more details about that event, which is planned for November.

Reid Blackwelder, M.D., is president of the AAFP.

Tuesday Sep 02, 2014

Family Medicine for America's Health to Launch at Assembly

I am extremely excited that the launch of Family Medicine for America's Health is less than two months away; the official rollout will occur in October in Washington, D.C., at the 2014 AAFP Assembly. As president-elect of the AAFP, I want to personally invite you to be there for this big event. This is truly history in the making, placing family medicine at the center of health care delivery in our nation.

For those of you who are unable to attend the Assembly in person, stay tuned, because we are working on a plan to deliver this event to you through digital channels.

Here is our latest update on this important project.

Family Medicine for America's Health
Organizational Update No. 8
September 2014

The goal of the Family Medicine for America's Health initiative is to meet the needs of the American public by achieving the triple aim of better care, better outcomes and lower costs. This initiative includes two integrated elements: a communications program aimed at consumers, policymakers, payers and the medical community and a strategic plan that will focus on addressing key issues facing the specialty of family medicine. I will unveil the communications program at the first Assembly general session on Oct. 22.

 Family medicine's strategic direction is composed of seven statements. Working together with its health care colleagues and other engaged stakeholders, family medicine aims to achieve the following:

  • Show the value and benefits of primary care.
  • Ensure every person has a personal relationship with a trusted family physician or other primary care health professional in the context of a medical home.
  • Increase the value of primary care.
  • Reduce health care disparities.Lead the continued evolution of the patient-centered medical home.
  • Lead the continued evolution of the patient-centered medical home.
  • Ensure a well-trained primary care workforce.
  • Improve payment for primary care by moving away from fee-for-service and toward comprehensive primary care payment.

The strategic plan is focused on six key implementation areas: practice, payment, workforce education and development, technology, research, and engagement. We are in the process of developing teams that will focus on tactics in each of these six areas. These teams will rely on support and input from a broad network of expertise in family medicine and beyond. Please be on the lookout for ways you can get involved.   

We strongly welcome and encourage your input on this process. We are developing a calendar of events where you can hear directly from, and share your views with, Family Medicine for America's Health leadership about this initiative. We will work to ensure you have a wide variety of in-person and virtual opportunities for engagement. Look for a calendar of events in the next update. We are also in the process of building a website -- FMAHealth.org -- to keep you fully informed on the progress of this effort.

As a reminder, the list below shows the members of the Family Medicine for America’s Health Board of Directors and the organization or other affiliation each represents. We are still working to identify a patient advocate to join the team and expect to have that vacancy filled in time for the launch.

Representative and Organization/Affiliation

  • Glen Stream, M.D., M.B.I., Chair, AAFP
  • Michael Tuggy, M.D., Vice Chair, Association of Family Medicine Residency Directors
  • Paul Martin, D.O., Secretary and Treasurer, American College of Osteopathic Family Physicians
  • Jen Brull, M.D., represents full-scope, full-time practicing family physicians
  • Thomas Campbell, M.D., Association of Departments of Family Medicine
  • Jennifer DeVoe, M.D., D.Phil., North American Primary Care Research Group
  • Lauren Hughes, M.D., M.P.H., represents family physicians early in their careers
  • Vincent Keenan, C.A.E., represents AAFP chapter executives
  • Jerry Kruse, M.D., M.S.P.H., Society of Teachers of Family Medicine
  • Robert Phillips Jr., M.D., M.S.P.H., American Board of Family Medicine
  • Jane Weida, M.D., AAFP Foundation
  • TBD - patient advocate

Additional background and earlier updates on this project are available online

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

Wednesday Aug 27, 2014

More Than Meets the Eye: Value of Small Practices Shouldn't Be Ignored

For years, we've been hearing about the decline -- even death -- of the small primary care practice, but I'm here to say that obituary is premature, if not flat-out wrong. When a recent study published in Health Affairs touted the value of small practices, I didn't need convincing. I'm a small practice owner and have been for nearly 30 years.

The study found that primary care practices with one or two physicians had one-third as many preventable hospital admissions compared with practices with 10 to 19 physicians. The study also reported that smaller practices achieved their impressive results despite caring for a higher percentage of patients with chronic conditions than larger practices.

© 2014 Texas AFP

My rural, two-physician practice recently achieved Level 3 patient-centered medical home recognition from the National Committee for Quality Assurance.

So how did the small practices in the study manage to have better results regarding preventable admissions (and likely lower costs) than their larger counterparts? The authors point out patients in smaller practices may have closer relationships with their physicians, which might offer greater insight into patients' comprehensive health needs while facilitating ready access to care.

Patient-centered care, which includes enhanced access to care along with other elements, has become a focal point of the movement to improve our health care system in the past decade and, increasingly, is being embraced by small and large practices alike. Large practices, in particular, are likely to benefit from economies of scale that enable them to readily invest in health information technology and other organized care processes recognized as components of the patient-centered medical home (PCMH) model. And indeed, in this study, some of the larger practices appeared to use more such processes than the smaller practices, yet didn't fare as well in keeping patients out of the hospital.

Clearly, there's more to the story.

An abundance of evidence tells us that the PCMH can lower costs and improve outcomes. Just think: How much more could we bolster those outcomes if we combined the efficiencies of a Level 3 PCMH with the strengths and accessibility of a small practice?

Welcome to my small rural practice, which recently achieved Level 3 recognition from the National Committee for Quality Assurance (NCQA).

Regardless of a practice's size, there are hurdles to jump through on the way to PCMH recognition. The process can be overwhelming at the outset, and the AAFP has discussed the need to simplify the process with the NCQA and other such groups.

Although the process can be especially difficult for small practices, which lack the time, capital and resources of larger practices, it can be done. My two-physician practice achieved Level 3 recognition, from start to finish, in two years. We did it by working together with other small practices in our area, combining our efforts and resources.

The key, for me, was taking the process one step at a time, which made it seem more attainable. To that end, the AAFP has created a PCMH Planner to help practices of all sizes transform to the new model; that resource offers a step-by-step guide to follow.

I'm sure many small-practice physicians look at the PCMH checklist and think, "I'm already doing this. I'm already patient-centered."

I was one of those docs. And I was wrong. That's a difficult thing to realize, but my practice is better now than it was two years ago. We've improved vaccination rates, lowered the number of missed screenings and made care more accessible.

I realize now that it's important to be open to change and to always be looking for opportunities to improve. For example, I initially thought a patient portal -- a requirement to achieve the recognition level we did -- would be money wasted, but it's actually changed the way I practice. Giving patients access to their individual records improved the overall quality of our data. I've had patients point out mistakes in their records that were quickly corrected, and I even had one patient point out something we hadn't billed for that we should have. One benefit I had not expected is that my patients who are hearing-impaired now communicate with my office more often and with greater ease through the portal.

For our patients, the quality of care we provide has improved; so what's the payoff for the practice? BlueCross and BlueShield has agreed to a 5 percent payment differential for small practices in the group we are working with if they achieve Level 3 recognition. Four of the practices already are there, and six have Level 2 or Level 3 paperwork pending.

Moreover, my accountable care organization, which also is made up largely of small primary care practices, is in negotiations with two other payers to increase payment for those who have achieved PCMH recognition.

For years, payers marginalized small practices, which lacked the bargaining power of our larger counterparts, leading to more and more employed physicians and fewer and fewer small practices. But if those of us in small practices continue to prove our value, our future may be a lot brighter than anyone anticipated.

As the authors of that recent Health Affairs article noted, "Small practices have many obvious disadvantages. It would be a mistake to romanticize them. But it might be an even greater mistake to ignore them, and the lessons that might be learned from them."

Lloyd Van Winkle, M.D., is a member of the AAFP Board of Directors.

Wednesday Aug 20, 2014

When It Comes to Mentoring, Both Giving and Receiving Are Important

Many mentors helped guide and direct me to medicine, in general, and to family medicine, specifically. There are too many to name here, but there was always someone to help me when I reached the next transition point. From high school to college and through medical school and residency, I could list a steady stream of physicians who were there to offer support, guidance and teaching along the way.  

I truly valued these relationships and took to heart the importance of mentoring. Along my path, I have made a point of reaching back to offer the same guidance to others that was given to me. I treasure being a mentor, continue to learn from the students I teach, and I can't wait to see what they will do in their own careers.

Here I am with AAFP President Reid Blackwelder, M.D. It's important to have a more experienced physician we can turn to for guidance even after we've transitioned from resident to new physician.

I was satisfied with my own transition from mentee to mentor -- or at least I thought I was -- until I had a recent conversation with my husband.

My husband, an administrator in education, had been contemplating a position change. During the application process, he mentioned several mentors that he was turning to for strategic advice. After he accepted the position, he was promptly paired with a new mentor to help guide his professional development.

When I contemplated my own position change, I looked around and, for the first time in my career, saw no one there to help me. My first few years out of residency had been spent at a community health center with several seasoned doctors, one of whom was a mentor and had been faculty at my residency program. Those more senior physicians provided a great bridge to the real world.

However, at my current job, I'm the doctor who has been in primary care practice the longest, despite the fact that I'm only in my seventh year out of residency. I'm also the only family physician.  

Although I know the mentors I have called on in the past would still answer my call, it is easy to get caught up in the daily grind and not have time to reach out. Unlike residency, where there is always an attending around the corner, there are fewer people above us to help guide us after we move into our own leadership roles.  

New physicians are pulled in many different directions, and those who have families and/or are relocating may find it especially difficult to take time to reach out to other doctors and potential mentors. Doctors in small and single physician practices, as well as those in rural areas, are also at risk of feeling like they have to go it alone.

My recent state chapter meeting, however, reminded me that we are not alone. While there, I had the opportunity to discuss my career goals and aspirations with AAFP President Reid Blackwelder, M.D., of Kingsport, Tenn., whom I also now call a mentor. In addition, the meeting provided a chance to reconnect with friends and colleagues and swap stories and experiences. State chapters have a wonderful opportunity to bring family physicians of all different career experiences together, and that can facilitate these types of exchanges between new physicians and our more seasoned colleagues.

The chapter meeting's educational program was appreciated, but what really will stick with me is having that opportunity to reconnect with peers and learn from those more experienced than I am. I can't wait to do it on a grander scale at the AAFP Assembly in October. I hope to see you there.

Kisha Davis, M.D., M.P.H., is the new physician member of the AAFP Board of Directors.

Thursday Aug 14, 2014

On Air: AAFP President Engages With Students in Online Forum

I recently returned from the AAFP's National Conference of Family Medicine Residents and Medical Students -- which set attendance records, by the way, with more than 1,200 students and nearly 1,100 residents -- and I am tremendously fired up! The energy of that group, and the challenges they put before us, motivate me and all of our Board members to do an even better job representing these critical members of our Academy.

With that in mind, I want to share some innovative new things we have been working on to connect with students and residents.

My Google Hangout with Family Medicine Interest Group leaders in July allowed students to ask questions on a variety of topics, including direct primary care, leadership development and patient satisfaction.

Almost a year ago, I was invited to be a featured speaker for the American Medical Student Association's National Primary Care Week webinar series, part of the AAFP's collaborative efforts with AMSA on this annual event. I participated in a webinar with a number of student leaders. This exciting experience allowed me to get the message of family medicine out to students nationally. That led me to think about ways we could start a similar process within the AAFP. I have been trying hard to increase our use of technology and to find new ways for the Academy to connect with medical students where they are and how they want to be reached. Many medical students and residents are extremely adept at using Facebook, Twitter, YouTube and Skype and actually prefer to access information digitally.  

I often have ideas and send out frequent emails to Academy staff asking questions and seeking suggestions for growth. On this topic, our Medical Education Division responded quickly with a suggestion that we try Google Hangouts to connect with students. I had never heard of this tool before, but the Academy staff members responsible for increasing student interest in family medicine were exceedingly excited about the opportunity. We explored the resources, did test runs, and mobilized our dynamic Family Medicine Interest Group Network leaders to work through it. This process is similar to platforms like Skype; however, in addition to connecting people by video, it also allows users to share screens, use PowerPoint, correspond with other participants in the session and perform other tasks. The utilities seemed ideal for some of the things that we wanted to do.  

We had our first Hangout on July 8, and you can watch it on the FMIG Network's Google Plus page or on YouTube. We recognized that this resource would allow us to reach out to medical students and residents all over the country. We also realized that we needed to focus the content so that these video installments, which are 15 minutes in length or less, are long enough to be informative but short enough for busy med students to work into their schedules.

The results of the first Hangout were outstanding. We received a great deal of positive feedback, and, most importantly, the FMIG Network leaders were excited about having a new tool to help them coordinate FMIG groups all over the country. Google Hangouts allow us to create an immediate connection between AAFP leadership and our students and residents. This is one of the things that we love most -- being able to talk with these enthusiastic members personally, answering their questions and sharing our passion for family medicine. This platform could help connect students who don't have much exposure to family physicians at their medical school with FP leaders who can provide them with insights on important issues in health care.

In addition to using Google Hangouts, I'd like to find other ways of tapping into this technology to help all of our members. For example, one of the biggest challenges we all face in these busy times is traveling to and from meetings. Although face-to-face meetings are critical for some functions and discussions, a great deal of what occurs at many meetings could easily be handled in a different fashion. Email is not always ideal, because visual cues and clues are still important and connect people in significant ways. Perhaps, however, Google Hangouts could allow us to have some meetings in a more dynamic fashion and respect people's need for work/life balance. Any time we can minimize travel and still get the work of the Academy done -- that is a good thing!

Moreover, especially with students and residents, utilizing this technology may allow a quicker connection between these member groups and our leadership for such things as noon conferences, forums and talking groups. In fact, some of you may have ideas about how to use this and similar technology. I would love to hear your thoughts, and I hope we can continue to move our Academy into a more efficient future. In so many ways, this is actually an aspect of the patient-centered medical home (PCMH) because what we can do for ourselves to become more effective and efficient is something we can then also do for our patients.  

These days of telemedicine and telehealth are challenging us to expand our boundaries. I look forward to continuing that expansion with all of you. Our next Google Hangout will be about the PCMH and is scheduled for 12:30 p.m. EDT on Aug. 26. You can join us on Google Plus or YouTube.

Reid Blackwelder, M.D., is president of the AAFP.

Wednesday Aug 13, 2014

Walk the Talk: Students, Residents Step Up to Support AAFP Advocacy Efforts

If you want students and residents to get involved in an issue, sometimes all you have to do is ask.

At an AAFP Board of Directors meeting earlier this year, we heard a report on FamMedPAC, the Academy's political action committee, which helps elect candidates to the U.S. Congress who support the AAFP's legislative goals and objectives.

During the National Conference of Family Medicine Residents and Medical Students, we challenged our respective member segments to see who could raise the most money for FamMedPAC, the Academy's political action committee. Residents and students donated more than $1,000 during the three-day event.

The report included data on the relatively small category of student and resident support.  As the resident and student members of the Board, we thought that category could -- and should -- be much larger. The perception has been that students and residents don't have a lot of money to contribute and, therefore, typically aren't a focal point for fundraising efforts.

However, we thought our colleagues would step up to the plate if given the opportunity, so we came up with the idea of the FamMedPAC Challenge. During the National Conference of Family Medicine Residents and Medical Students in Kansas City, Mo., last week, we rallied our respective groups of students and residents to support the PAC. We knew that the residents and students would answer the call and donate, but the results exceeded our expectations.  

Advocacy consistently ranks among the top Academy priorities for students and residents, and both groups consistently bring issues to the AAFP's attention because they feel so passionate about the advances that can be made for our specialty and, more importantly, our patients. There were nearly two dozen resolutions in the resident and student congresses at National Conference that related specifically to advocacy.  

During the conference, AAFP President Reid Blackwelder, M.D., of Kingsport, Tenn., gave a presentation on advocacy, and the room was packed. As part of that session, students and residents worked up an advocacy issue, which they then transformed into short "elevator speeches" in small groups. Each group practiced pitching their talking points to the entire room, and we were blown away by how well they articulated their messages.  

Throughout National Conference, we spoke about the FamMedPAC Challenge and the PAC from the stage, but we also got the word out through social media and, of course, lots of old-school, face-to-face chatting. Both of us handed out donation forms with $1 (an actual dollar bill from our personal accounts) and a PAC donor ribbon attached. Many students and residents had already donated during the past year, but some gave again by adding $9 to our $1 for a $10 contribution, the minimum amount to get their respective group a point toward winning the challenge. Most donors, however, were new.

The FamMedPAC Challenge was a huge success. We had 51 donations: 31 residents contributed a total of $629, and 20 students gave a total of $431 for a three-day total of $1,060, which is by far the most money ever donated to the PAC during National Conference.

Now we'd like to challenge the rest of the AAFP membership. If medical students and residents -- with their ever-growing student loan burdens -- can reach into their pockets and make a donation to help advance our specialty, won't you?

Kimberly Becher, M.D., and Tate Hinkle, M.D., are the resident and student members, respectively, of the AAFP Board of Directors.

Thursday Aug 07, 2014

Reality Check: Residents Aren't Prepared to Deal With Patients' Financial, Coverage Limits

In medical school, our patient encounters typically consisted of completing a history -- including talking with patients about any concerns or issues that led them to seek care -- doing a physical exam, and developing a diagnosis and treatment plan with the resident and attending.

In the real world, it turns out, it's not that simple. I recently began the first year of family medicine residency, and I quickly realized that some important steps were left out of the learning process. As students, we were not often exposed to what happened next for patients. We missed the part where the physician talked with the patient about his or her insurance, what it covered and what it did not.

 This week I'm attending the AAFP's National Conference in Kansas City, Mo., which offers students and residents opportunities to learn about clinical skills, leadership and more. One thing students don't learn in medical school is how to manage patients who lack the means to pay for needed treatment.

I recently saw a patient, a woman in her mid-30s, who came in for a checkup. In addition to her chronic conditions, including hypertension and diabetes, she complained of joint pain in her knees and hips. After taking her history and talking with her about her discomfort, I wanted to have her tested for rheumatoid arthritis.

Her first question was, "How much will that cost?" The patient had private insurance, but her plan left a lot to be desired. It covered office visits and some medications, but it did not cover labs.

The patient, a single mom who also was supporting her mother, informed me that she already was paying off a large lab bill from a previous visit. She needed to repeat labs related to the medications for her chronic conditions, but she couldn't pay for those, let alone for a blood test for rheumatoid arthritis.

I could have ordered the labs, but there wasn't any point in doing so because she told me it would have to wait. It's not that she would have been noncompliant, she simply couldn't afford to do what needed to be done. From her perspective, doing the labs would have meant asking the people she supports to sacrifice something else.

I asked her to come back in two months so that we could reassess her situation -- both physically and financially. For now, she plans to continue treating her joint pain with OTC medications.

This situation is hard for me to get used to. I can't do what I want to do -- what I've been trained to do -- to help some of my patients. Instead, I have to consider a patient's medical, social and financial situation and work within those limitations.

Medical students should have more exposure to this part of the process so they are more aware of the reality that awaits them. What do you do -- or what can you do -- when your patients' financial or coverage limitations are barriers to needed care?

Tate Hinkle, M.D., is the student member of the AAFP Board of Directors.

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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.