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Tuesday Oct 27, 2015

Surrounded by Ghosts: Wisdom Gained From Patients Past

My exam rooms are full of ghosts, and sometimes it is standing room only.

My patients can't see them, of course, but the ghosts often are here giving advice and warning. Sometimes, when there is a particularly large crowd, the conversations are deafening.

I have worked in the same small town in Alaska for 21 years, caring for a community through all stages of life. During my time here -- as well as medical school and residency -- I have lost many people, and I freely admit that they come back to haunt me. This is not a bad thing. They are people who I liked or loved, and they still have much to offer. The hard part is translating their wisdom to those still living.

Particularly loud are the lost teenagers I hear when I talk with young patients during sports exams about not getting into a car with anyone who has been drinking. I have at least 10 ghosts in the room, all talking at once, when I have these conversations.

"Dude, listen to the doc."

"He told me the same thing."

The hardest to bear are the ghosts of infants and children when I am talking to parents about vaccinations. They don't say anything, but I still see their eyes, throats and backs because I trained in the era before the Haemophilus influenzae type b vaccine. Too much of my time on pediatric rotations in medical school and residency was spent performing lumbar punctures and taking care of periorbital cellulitis and epiglottitis.

The exam rooms are full of ghosts, I tell you. There are none, however, who died from complications of vaccines.

The ghosts are with me when I have to tell someone that they have cancer. I have been doing this long enough that they segregate depending on the type of cancer. They are also with me when I talk about the importance of quitting smoking or screening for colon, breast or cervical cancer.

The ghosts are especially present when I talk about end-of life-issues and the importance of maintaining quality of life -- even at the expense of life-sustaining measures -- and they advise me as I help patients and their families through this process.

The ghosts of those who died from alcohol and drug abuse are fatalistic and sad when I tell my patients that they must stop or they will die within the year. They nod and whisper among themselves that I told them the same thing. Sometimes I think that perhaps this particular group of patients can actually see the ghosts, but rarely is it enough to make them change their own lives.

The longer you practice as a physician, the more ghosts you have to keep you company. It's OK. They are good people. They fill the exam rooms and stand by your shoulder when you look at labs or X-rays. Sometimes they are so loud it is hard to believe that the patients can't hear them, but their voices and their stories are a gift you can give to your patients.

I admit that being haunted does take getting used to, but I would never dream of forgetting any of them.

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

Friday Oct 23, 2015

'Stop the Bleed' Aims to Turn Bystanders into 'By-doers'

Imagine yourself standing on a corner when suddenly, a car strikes someone in the crosswalk. The pedestrian is severely injured, with a leg fracture and a profusely bleeding artery.

How would you -- or the average citizen -- react? It's an important question. In the event of a major arterial bleed, an injured person has about four minutes before survival becomes impossible.

© Aaron Tang

Bystanders assist victims in the aftermath of the 2013 Boston Marathon bombing. The Obama administration recently launched an initiative that aims to educate the public on how people can help save lives in an emergency situation.

This type of scenario is the focus of an initiative recently launched by the Obama administration and the Department of Homeland Security that is designed to reduce loss of life due to bleeding.

The 2013 Boston Marathon bombing, which killed three people and injured 264 others, was one of the incidents that prompted this effort. In the aftermath of that terrorist attack, every victim who reached a Boston-area trauma center alive survived. Injured people survived many potentially fatal injuries because of the prompt responses of bystanders who applied pressure and tourniquets to bleeding extremities until emergency personnel arrived.

I recently attended the White House launch of the Stop the Bleed initiative, which aims to educate Americans about how they can offer assistance in an emergency. Family physician Kevin O'Connor, D.O., physician to the vice president, said during the event that we must move more people from being "bystanders to 'by-doers.'"

Speakers also addressed the psychology of intervening in an emergency situation. The concept of diffused responsibility in a group means that the more bystanders there are at an event, the less likely any one of them is to intervene. A lone individual is more apt to take action.

The mindset in our culture has been for the general public to wait for emergency personnel, but with life-threatening bleeding -- even with a quick response time by paramedics -- survival is not likely without immediate action.

In military medicine, physicians have long referenced the importance of receiving care during the "golden hour" after an injury to improve survival. Quick action improves a wounded soldier's chances. In fact, the survival rate for soldiers who make it to a field hospital alive is more than 90 percent.

The U.S. military examined causes of death among the wounded who did not make it to field hospitals alive and found many died from extremity arterial bleeding and blood loss. This led to a change, and now every U.S. field soldier is equipped with a tourniquet and trained to use it. The prevalence of "field casualties" -- injured soldiers who die before reaching a hospital -- dropped dramatically.

Fast forward, and the administration now is implementing several efforts to educate the public about applying pressure or a tourniquet to life-threatening bleeding:

  • There will be an ad campaign with a logo that features a hand and a "Stop the Bleeding" message to remind people that odds of survival increase if direct pressure is applied over bleeding.
  • Bleeding control kits will be placed by defibrillators in public locations. 
  • The Red Cross is developing a "just in time" learning tool.
  • The Federal Emergency Management Agency has developed a short video that tells the story of how a neighbor's quick action saved a woman after a motorcycle accident.

We can share related resources with patients and our communities by posting them on our websites or social media. The bottom line? Don't be a bystander, be a by-doer.

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

Monday Oct 19, 2015

Prescription for Pain? Important Questions Patients Should Ask

Earlier this year, I shared with you a story about being willing to take carefully considered risks, boldly sticking your neck out to make your message heard. Specifically, I made an appearance on The Dr. Oz Show in May because it was an opportunity to reach roughly 2 million TV viewers (and even more online) with a message about the importance of primary care and why everyone needs a family physician.

Fast forward a few months, and I was asked to make another appearance on the show, this time for a segment about proper use of pain medications. According to the CDC, nearly 2 million Americans abuse prescription painkillers and roughly 7,000 patients are treated every day in emergency departments for that misuse. Opioid prescribing, pain management and opioid abuse are issues the AAFP has been working on diligently for years -- including efforts related to advocacy, public health and education -- so I was eager to participate.

Here I am with Ada Cooper, D.D.S., spokesperson for the American Dental Association, and Mehmet Oz, M.D. We discussed appropriate use of opioids during a recent taping of The Dr. Oz Show.

The episode aired Oct. 19, but more on that in a minute.

It's been a rough year-and-a-half for host Mehmet Oz, M.D. He was called before Congress last year because of his promotion of weight loss medications, and a group of his peers called for his dismissal from his post at Columbia University.

His critics certainly got his attention. Oz conducted a listening tour with various medical groups this year and has vowed to make his show more evidence-based. He has sought input from many physicians and physician groups along the way, including the AAFP. I recently met with Oz, his staff, AAFP staff and members of the New York State AFP to talk about how family medicine can help make his show more evidence-based while also reflecting the importance of prevention and primary care.

The first step in this potential collaboration was the episode addressing the epidemic of opioid abuse. Use of opioid pain relievers in the United States quadrupled between 1999 and 2010. Among the 22,810 deaths related to pharmaceutical overdoses in 2011, nearly three-fourths involved opioids. In 2012, U.S. health care professionals wrote enough prescriptions -- 259 million -- for every American adult to have a bottle of pills.

So with access to an audience of millions of American patients, Oz and I discussed important questions patients should ask their doctors before starting a prescription pain medication. Here's a look at some of the questions and the information I provided.

What is the goal of taking this prescription?
This is an important question because patients need to make informed decisions. Too often, people take medication without understanding its risks and benefits and without asking if other options are available. Patients need to understand why they are taking a pain reliever, what kind of pain reliever they are taking and how much relief they should expect.

How long should I take these drugs?
Opioids are best used for the shortest time possible and at the lowest dose possible. I told the audience that they should know from the start how long they are supposed to take a medication. And if they think they have been on a medication too long, they should talk to their physician.

Are there any risks to me from these pills?
When I perform a risk assessment, I look for the following factors:

  • any history of addiction to or misuse of opioids;
  • any history of addiction to or misuse of alcohol or drugs other than opioids;
  • depression or other behavioral health disorders; and
  • is the patient taking any medications that might provoke an adverse reaction in combination with the opioid?

What do I do with extra pills?
We discussed the importance of safe disposal, including take-back programs, and the need to store pills in a secure location.

The questions can be downloaded as a resource for patients receiving a prescription for pain killers.

The AAFP will continue to work on this important issue. On Oct. 21, I will be in Charleston, W.Va., when President Obama speaks with law enforcement, educators, lawmakers and health professionals during a forum on opioid addiction. Watch for more details about that event in AAFP News.

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

Friday Oct 09, 2015

Leadership Gives Female Physicians More Control of Career Path

I've worn a lot of hats in my nearly three decades as a family physician. I've been an associate residency program director, founded a health care consulting firm, worked in a federally qualified health center, advised my state's governor as physician general and served as a health correspondent for the region's NBC affiliate -- all while functioning as a family physician and putting our broad training to work.

I never made my gender an issue in any of those jobs, but in my newest role -- president of the AAFP -- I may have underestimated how important it is to some. During our recent Congress of Delegates  -- and in my year as president-elect -- a significant number of our female members told me they were inspired to see a woman in my position. These are women who want to make a difference, feel they can be leaders and are seeking opportunities for growth. Fortunately, leadership isn't closed to them at the AAFP. There are five women on our Board of Directors. Three of the Academy's seven commissions were chaired by women this past year. Women also play important leadership roles in our state chapters and at the National Conference of Constituency Leaders.

I received the President's Medal during my installation at the recent Congress of Delegates in Denver.

I am only the third female president in the long history of the AAFP, but women in leadership is a trend that is growing in family medicine. Forty-two percent of our active members are women, and the numbers are even higher among our younger members, with women accounting for 55 percent of our residents and 56 percent of new physician members.

Forty years ago, there were a little more than 35,000 female physicians in the entire country. Today, the number has swelled to more than 321,000, and women represent nearly one-third of the U.S. physician workforce.

Medscape recently surveyed more than 3,200 female physicians, and what they had to say about leadership, career satisfaction and work-life balance was interesting. (It's worth noting that 15 percent of respondents were family physicians.)

More than half the women said they hold at least one leadership position. Forty-two percent were leaders in their practice, 12 percent were leaders in academic departments, and 12 percent were leaders in a professional organization.

Although we've made progress, there are still notable gaps. For example, none of the respondents were deans or vice deans. And I'm clearly in the minority, because only 4 percent were presidents of professional organizations.

Survey participants were asked why they sought leadership roles, and the No. 1 answer leaders gave was to be a positive influence (70 percent), followed by a desire to make change (68 percent). Those are great answers, but the response that resonated with me was from the 53 percent of female leaders who said it was because they want to shape their own path.

When I get frustrated in my practice with my clunky electronic health records system, meaningful use or any of the other challenges we face, I think about the work we're doing as an Academy, and I know it won't always be this way. Although we may be frustrated by our circumstances, we can use that as motivation to be active agents of change. We can use our stories of adversity -- both our own and those of our patients -- to make good things happen through advocacy.

When we are in control, things are better at home and work. Is it a perfect process? Absolutely not, but doing something about our problems improves situations for ourselves and our patients.

The women surveyed (90 percent of those who identified as leaders and 86 percent of nonleaders) agreed that it is important for women to be involved in leadership. But they diverged on whether or not it was an important personal goal, with 76 percent of leaders saying it was important to them compared with 42 percent of nonleaders.

The most common reason cited for not getting involved was time constraints. Interestingly, when the women were asked if they were happy with their careers and personal lives, leaders were more likely to be professionally satisfied and had similar responses to those of nonleaders about personal life satisfaction despite the added demands on their time.

Of course, timing is everything. I'm the first mom to serve as Academy president, but my daughters are both in their 20s. It's important to consider not only what you can do but when you can do it.

Women who were not in leadership were asked why they chose not to get involved. Some of the reasons they gave are things we should change, including lack of female mentors and lack of support. As women become a larger percentage of the physician workforce, these barriers become totally surmountable. We must help guide our aspiring young leaders (male and female), and we all need to build our own network of support both within and outside of medicine.

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

Wednesday Sep 30, 2015

Medical Students, We're Only Looking for the Best

For too long, medical students have heard from their mentors that they are "too smart" for primary care. Family medicine, they’re often told, is a solid safety choice, at best, if they fail to match into a residency program in the specialty they really want.

This misguided narrative, combined with the income gap between family physicians and our subspecialty colleagues, has fueled a worsening shortage of primary care physicians.

Photo courtesy of Pennsylvania AFP
Here I am with members of the Penn State University College of Medicine's family medicine interest group. I talked to medical students all over the country in the past year.

In my year as AAFP president-elect, I traveled the country to chapter meetings, media opportunities, Academy conferences and more. Wherever I went, I worked meetings with students into my schedule so I could give them my perspective on family medicine.

About one-fourth of the nation’s medical students are members of the AAFP, but that impressive statistic hasn’t translated into specialty choice often enough. I wanted to help students understand that family medicine is an exciting, viable career choice that will allow them to make a difference for patients and their families.

During a trip to North Carolina, I visited four medical schools in two days. I talked with students during chapter meetings in places like Arkansas, Kansas and Ohio. I would call med school faculty or chapter staff in advance and say, “I’m going to be in your area. Put me to work.”

Some meetings, however, happened on the fly. During the Family Medicine Congressional Conference in Washington, a family medicine interest group leader reached out and asked if I would come to his med school. So I made room in my schedule, he picked me up in his car, and off I went to spend my birthday with 40 medical students.

I was eager to share my insights about our specialty, but as our discussion got started it became clear to me that many of those students were disinterested and were there simply for a free lunch.

So I told them what I thought about using family medicine as a safety choice.

I said that if you aren’t passionate about your patients, we don’t want you in family medicine.

If you’re in medicine for the money, I said, we don’t want you.

If you won’t be an advocate for your patients, we don’t want you.

In short, I took the tale they’ve been told about family medicine and turned it on its ear. We want the best and brightest because family medicine is not a backup plan. This is a specialty for people who are willing to and capable of learning more than one body system and providing comprehensive care to entire families and, in some cases, entire communities. We deliver babies, provide end-of-life care and so much more in between, performing procedures, providing preventive care, managing chronic conditions and doing it all for both genders and all age groups.  

We talked about the many opportunities in family medicine, highlighting that our members work not only in traditional family medicine practices but also in sports medicine, geriatrics, urgent care facilities, hospitals, academia and more.

I told them about my former resident Bruce Vanderhoff, M.D., a family physician who is a chief medical officer of OhioHealth, a system with more than a dozen hospitals, nine urgent cares, 30 rehabilitation centers and more than two dozen imaging centers.

I told them about family physicians like Richard Wender, M.D., the chief cancer control officer for the American Cancer Society, and about former Surgeon General Regina Benjamin, M.D.

Their stories resonate, and these students had never heard them before. We had a robust question-and-answer session, and by the end, even the students who had initially showed up only for the free food were engaged and asking questions.

In my trips to medical schools this year, I heard from students who thought family physicians earned less -- far less -- than $100,000 a year. They were pleasantly surprised when I directed them to a physician survey that showed family physicians earn, on average, more than $220,000 year. And family physician income is increasing at a faster rate than that of our subspecialty colleagues. We’re slowly closing the gap.

As the Health is Primary campaign is making clear, family physicians are the solution for what ails American health care. And we need many more of us.

Unfortunately, family physicians have a tendency to not toot our own horns -- even though we do much of the heavy lifting in our health care system. I appreciate humility, but it’s now my job to toot that horn -- or perhaps blare that horn -- not only to students but also to payers, legislators and federal agencies. People, students included, need to know what we do and why it’s important.

Wanda Filer, M.D., M.B.A.,
is president of the AAFP. Her term begins today.

Tuesday Sep 22, 2015

Practice Perspective: Patient Stories Get Attention of Media, Policymakers

One of the most important roles of the AAFP president is spokesperson, and I’ve done a lot of speaking this year.

In the first few weeks of September -- my last month as president -- I talked to reporters about health care apps, ICD-10, meaningful use, vaccination rates, workforce issues and more. On one particularly busy day, I did seven interviews.

As I traveled around the country this year to roughly a dozen constituent chapter meetings, it was clear there is a perception by many of our members that AAFP directors aren’t practicing physicians. But that isn’t the case. Although I traveled about 200 days during my term, I’m still a practicing small-town doc with a solo practice in rural Nebraska. So when members say to me that I don’t know what it’s like dealing with the day-to-day issues of a family practice, I say, “Yes, I do. I do what you do.”

That in-the-trenches perspective has helped me in my role as spokesman and advocate. For example, I know how challenging meaningful use has been and how the many shortcomings of electronic health records are hampering our practices. I’ve talked about it not only with the media but also with Congress.

What I've found is that whether I’m speaking with reporters or legislators, being a practicing physician makes a difference because both groups want to know how health care issues affect patients (their readers and constituents, respectively).

“Do you have an example?” is a question I’m asked on a regular basis. Invariably, my answer is, “Yes, I do.” And I’ve noticed that when I provide journalists with a compelling patient story, it almost always makes it into their articles.

Sharing stories about how patients are affected by things such as access to care or how physicians are being affected by issues such as payment helps inform public debate and, ultimately, shape policy. There’s no better example from this past year than the repeal of the sustainable growth rate (SGR) formula. The AAFP and our members advocated relentlessly for years to have this flawed formula replaced. Thanks to your numerous letters, emails and phone calls, Congress voted overwhelmingly to replace the SGR and move forward with a new model for Medicare payment.

Thank you to everyone who joined us in this battle. Our voice and our stories are being heard and are a powerful force for changes in our health care system. The patient-centered medical home is mentioned in the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act, the legislation that repealed the SGR, largely because of our advocacy efforts.

Of course, our work is not done. We continue to communicate with Congress and federal agencies about many other challenges, including meaningful use.

Some vital programs that support and promote primary care -- including the Agency for Healthcare Research and Quality and the Health Resources and Services Administration -- have been targeted for cuts as Congress looks to reduce federal spending. But rest assured that the Academy is pushing back.  You can follow the AAFP’s advocacy efforts on these issues (and others) and get involved in our grassroots movement on our advocacy Web page.  

Sharing our stories is a powerful thing.

Robert Wergin, M.D., is president of the AAFP. He will transition to the role of Board chair on Sept. 30.

Wednesday Sep 16, 2015

Building Relationships at Core of Family Medicine, Leadership

It's hard to believe that this will be the last blog I write as an AAFP officer. For me, the past six years on the AAFP Board of Directors have flown by. I have had an incredible journey full of once-in-a-lifetime experiences. However, one of the most important lessons I have learned is a basic one that is a core trait of being a family physician: It is all about relationships.

Although we say this routinely, it is such a profound truth that it can be overlooked in our busy lives. But when we embrace it, it is the fundamental approach to how we do what we do as family physicians.

Here I am sharing a laugh with Academy members (clockwise from top) Kim Yu, M.D., Jennifer Bacani McKenney, M.D., and Kevin Wang, M.D., during an AAFP event. Building relationships is critical not only in our practices but also in leadership.

It is also the foundation on which health care reform must be built. One of the biggest dangers associated with the fragmented and siloed care many Americans still receive derives from a failure to respect this core principle. In all the discussions about primary care, providers, teams and the latest acronyms, we can lose sight of this basic truth: We care for individual people, and we must do so with teams of people who value the uniqueness of that person.

I have been able to travel the country and meet hundreds of AAFP members in their home states. This constantly reminded me to put our relationships into the right context. You are most "yourself" in your natural environment. As an AAFP Board member, and as an officer for the past three years, I needed to have the full understanding of who you are and how you are affected by all the changes that are happening in our health care system. Conversations, phone calls, meetings, notes, emails and social media interactions all helped teach me about you. This allowed me to better represent family physicians and to advocate more forcefully for our specialty.

My wife Alex and I have been welcomed into so many of your chapters, as well as into many people’s homes. We have broken bread together, enjoyed good drink, engaged in stimulating conversation, played music and sang songs, roasted marshmallows around bonfires, hiked incredible vistas, and enjoyed the peace of friendships all over the country. We have felt like a part of your families, and we thank you for that kindness and hospitality.

Life on the road can be challenging. AAFP officers travel more than 200 days a year. One of the things that keeps us going is the sense of connection and appreciation we feel at the many meetings and events we attend. This support makes it much easier to do the important work of engaging different groups outside of family medicine and making sure they know who we are, what we do and why it matters.

Of course, it helps to have a wonderful message. There is nothing better than seeing the light go on in the eyes of a congressional staffer, a legislator or a health care colleague when they finally "get it."

Although we each have our own perspectives, and our individual chapters may have slightly different challenges and priorities, we really are all singing the same song when it comes to the importance and value of family physicians. We are stronger together.

Accordingly, one of the challenges I'll leave each of you with is to make sure that you don't turn your back on the sacred nature of the relationships you create and nurture. It can be easy when you're frustrated by changes to allow that frustration to overtake the incredible joy that comes with answering the call to service. For those of you who are leaders within our national or state academies and in your communities, I challenge you to also seek out and nurture the relationships you create in those roles. It is critical that we truly represent those who depend on us to take their voices forward.

For those who would like to be more involved in leadership, the Academy offers many opportunities. For example, the deadline is fast approaching for state chapters to nominate members for AAFP commissions. I cannot emphasize enough how invigorating it is to move to the next level of involvement. Please jump in -- the water's fine!

My time on the AAFP Board will come to an end later this month when the Congress of Delegates  convenes in Denver. Thank you for the tremendous honor of representing you. Although I will not be contributing in this particular forum any longer, you will continue to hear from me. I'm excited about my role on the Family Medicine for America's Health Board of Directors. I also will continue to serve as the Academy's liaison to the CMS Health Care Payment Learning and Action Network guiding committee.

My time on the AAFP Board has prepared me to take on these roles as we continue to navigate challenging waters ahead. I am confident we are moving in the right direction, and that others are seeing family medicine more clearly, listening to us more openly and believing in our message.

Thanks for being on this journey with me. Thanks for your support. And thanks for making me feel like a part of your family.

Reid Blackwelder, M.D., is the Board chair of the AAFP. His term ends Sept. 30.

Friday Sep 04, 2015

Royal Pain: Team's Chickenpox Incident Offers Lesson for Patients

The Kansas City Royals have become a shining example of how to succeed in a small market in an era when baseball teams with the highest payrolls are often the biggest winners when it comes to the playoffs. After decades of futility, the reigning American League champions reversed their fortunes by pouring money into their scouting department and creating an elite team based on speed, defense and pitching.

Unfortunately, my hometown team recently became an example of what not to do, and it's a lesson family physicians can use when talking with patients and parents who have reservations about immunizations. After the Royals built a seemingly insurmountable lead in the American League's Central Division, a vaccine-preventable disease has done what few opponents have been able to do -- make this first-place team look vulnerable.

© Keith Allison
Kelvin Herrera of the Kansas City Royals delivers a pitch. Herrera and teammate Alex Rios were recently diagnosed with chicken pox.

According to The Kansas City Star, the team's medical staff collects information from players about vaccinations and childhood illnesses every year during spring training. Apparently, that information wasn't reliable this time around, because in the thick of a pennant race, otherwise healthy young men have been sidelined by chickenpox, typically considered a childhood illness.

Kelvin Herrera is a 25-year-old All-Star pitcher who can throw a baseball 100 mph and is a key figure in the Royals' vaunted bullpen. Outfielder Alex Rios is a former All-Star and 12-year veteran. Both men are millionaires who have ready access to the team's medical staff and the means to afford excellent health care.

What they didn't have was immunity to the varicella-zoster virus. Now, Herrera and Rios are expected to miss about two weeks of playing time.

The incubation period for chickenpox can last up to three weeks, so it remains to be seen whether any more players will be affected. Sports teams can be a breeding ground for disease because athletes often spend time in tight quarters during games, in locker rooms and while traveling. It was less than a year ago that a mumps outbreak swept through the National Hockey League, affecting nearly two dozen players (including two-time MVP Sidney Crosby) from five teams, as well as two referees.

The take-home message for the general public is that if these strong, world-class athletes with access to quality health care, team doctors and excellent nutrition are susceptible to vaccine-preventable diseases, obviously, so is anyone else who has not been immunized, particularly children, the elderly and people with chronic conditions.

Patient registries and electronic health records can help us identify our patients who may be at risk. Those systems should be far more reliable than the Royals' method, which appears to have included asking athletes if they remember having chickenpox when they were toddlers.

In a study recently published in the Journal of the Pediatric Infectious Diseases Society, CDC researchers compared national health care claims data from 1994 (the year before the varicella vaccine was introduced) to 2012 data and found that outpatient visits for chickenpox fell 84 percent and hospitalizations fell 93 percent. The recommendation for a second dose of the vaccine was introduced in 2007, leading to accelerated declines in the need for both inpatient and outpatient treatment.

Before the vaccine was introduced, about 4 million Americans got chickenpox each year, leading to roughly 11,000 hospitalizations and 100 to 150 deaths, according to the CDC. Despite the efficacy of vaccines, outbreaks of vaccine-preventable diseases continue because of inadequate coverage.

The United States had 23 measles outbreaks last year, affecting more than 600 patients. This year, 188 cases in 24 states had been reported through Aug. 21, with the majority of illnesses stemming from the Disneyland outbreak that started in December.

In each of the past two years, more than 28,000 cases of pertussis have been reported in the United States. There were 48,277 reported illnesses and 20 pertussis-related deaths in 2012.

These sobering numbers should be shared with parents and patients who are resistant to immunizations. Sharing stories about famous athletes forced to sit at home because of the mumps or chickenpox couldn't hurt either.

Michael Munger, M.D., is a member of the AAFP Board of Directors who practices in Overland Park, Kan.

Wednesday Sep 02, 2015

In an Emergency, Family Physicians Have it Covered

We were six hours into a transatlantic flight when the call came over the plane's intercom that a passenger needed medical assistance. I responded, as did another family physician and an emergency room doctor.

Fortunately, the plane was well stocked with oxygen, a pulse oximeter, a blood pressure cuff and more. We worked as a team to determine what was wrong with a woman who had collapsed on the floor. A few minutes in, another woman appeared, identified herself as an OB/Gyn and asked if she could help.

I replied, "Well, we're two family physicians and an emergency room doctor."

She said, "Oh, you've got it covered then."

So I suggested that this fourth physician try to calm down our patient's hysterical teenage daughter.

About 15 minutes later, yet another physician appeared, identified himself as an orthopedic surgeon and asked if we needed help. I repeated that we were two family physicians and an ER physician.

He said, "Oh, thank God, we have real doctors. My wife made me come up here."

I appreciated that he understood our level of expertise.

The flight crew was prepared to divert the plane for an emergency landing, but we were able to stabilize the patient and determine that her condition did not require urgent measures. She had a history of heart problems, had been sitting for hours, stood up too quickly and passed out.

The breadth of our training makes family physicians well-equipped to react to these types of situations, which is good because they seem to be happening to me with increasing frequency.

I was in the Denver airport last year en route to Boise for the Idaho AFP meeting. But I wasn't in the airport long because I had landed at Gate 6 and had about 10 minutes to run -- literally -- to Gate 70 to make my connection.

I made it on the plane, along with several other passengers who had made the 64-gate sprint. We were about 30 minutes into the flight when I heard someone say, "There's a pair of legs sticking out of the bathroom."

A woman had lost consciousness in the bathroom and had forced the bathroom door open when she fell. I volunteered to help the woman, who was ashen and diaphoretic. She had hypoglycemia and was in and out of consciousness, but I was able to deduce what had happened.

She was one of the passengers who had hurried through the airport to make the connection. She was diabetic, had taken insulin but had not had time to eat. Her condition was exacerbated by the plane's air conditioning, which was not working properly.

I asked the flight attendant to bring her orange juice with extra sugar in it, and we packed ice on the woman's neck and under her arms. Within 20 minutes, she was doing better. A little later, she was fully awake and able to eat.

A couple who had been watching this scene unfold asked if I was a paramedic. I said no, I'm a family physician. They then said they were looking for a new doctor and asked if they could come to my practice. They were disappointed to hear that my practice is in Pennsylvania, not Idaho.

Sometimes, we can get called into action before we even get on the plane. On another trip, I was on my way to the Vermont AFP meeting when I saw an elderly woman in the bathroom struggling to get out of a wheelchair. And more importantly, she was struggling to breathe.

I told her I was a family physician and asked if she needed help. She was a tough older lady, and although she acknowledged having heart disease and lung disease, she said she was fine. In reality, she was in respiratory distress. We talked for a bit, and it turned out that we not only were going to the same place, we also were on the same flight.

So I walked her to the gate, identified myself to the gate agent as a family physician and asked her to move my seat next to this woman's so I could keep an eye on her. The woman had some rough moments on the plane, but we made it to Burlington.

When we got off the plane, she wasn't interested in a ride or calling a family member. Instead she insisted on driving herself home. But first I made her promise that she would call her family physician the next day, and she gave me that physician's name.

At the Vermont chapter meeting, I got the contact information for the woman's FP, called the practice and suggested they follow up with their patient. That doctor did call her, and she was admitted to the hospital.

A month later, I received an email from the woman thanking me after she was at home recovering.

A New England Journal of Medicine study looked at nearly 12,000 in-flight medical emergencies and found that physician passengers were able to assist nearly half the time. I'd love to hear your stories of helping fellow travelers in the comments field below.

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

Wednesday Aug 26, 2015

Former 'Orphan' School Embraces Family Medicine to Drive Progress

When I was a student at Emory University School of Medicine, it was a so-called orphan school, meaning it did not have a family medicine department. In fact, I was one of the few students in my class who chose family medicine after graduation, but that is a story unto itself.

It was special, more than 30 years later, to be invited back to my alma mater recently to see what is happening in family medicine there and to be a part of the Atlanta school's new direction.

© 2015 Wilford Harewood/Emory University
An Emory University medical student asks a question during a panel discussion about primary care. Emory launched its chapter of Primary Care Progress this month.

Emory recently launched a chapter of Primary Care Progress, an organization that seeks to not only promote primary care but also develop a new generation of leaders. My invitation to participate in a launch event came about, in part, because of the Academy's efforts to build student interest in family medicine. For example, during the recent AAFP National Conference of Family Medicine Residents and Medical Students, AAFP President-elect Wanda Filer, M.D., M.B.A., led a session about leadership in primary care with Andrew Morris-Singer, M.D., the president and founder of Primary Care Progress.

Reaching out to our students and residents and fostering relationships is vital to building our workforce pipeline. During National Conference, I happened to walk up to a group of students who turned out to be the contingency from Emory. These extremely passionate and engaging students were thrilled to be at the event and told me they were strongly considering family medicine residency.

It's also worth noting that Ambar Kulshreshtha, M.D., Ph.D. -- the resident representative to the AAFP's Commission on Quality and Practice -- was a chief resident at Emory last year and is now a member of the school's faculty. Our specialty is truly about family and relationships.

During my visit to Emory, I met many incredible folks dedicated to moving family medicine forward at this storied institution. I was introduced to an invigorated Department of Family and Preventive Medicine, and I spent a great deal of time with many in leadership who are involved with medical student and resident education. I gave a presentation about the patient-centered medical home that drew residents, faculty and staff, as well as some medical students. I was impressed by their energy and even more so by the demonstration of team-based care that was going on there. We had a chance to talk about steps for the future and finding practical approaches to tap into that energy.

I also participated in a panel discussion with primary care leaders from Emory. That event attracted more than 80 students. Immediately after the panel, I was able to give my "Practical Approach to Patient-Centered Medicine" talk. This was a fun and interactive opportunity to engage students about some things that they had not necessarily considered when they began their medical school path. The energy I felt afterward was inspiring.

Many students signed up immediately to receive more information about Primary Care Progress, and they already were talking to faculty about their interest in family medicine and what we do.

Overall, this was an awesome opportunity to talk about the opportunities that exist at Emory. I was able to emphasize team-based education within a large system that has many resources and ways of better integrating family medicine and primary care into the Emory health system. The school has everything in place to be an outstanding leader.

Perhaps one of the most important messages I tried to deliver is the power of cheerful persistence. Even though it was almost an aberrancy to find oneself in family medicine when I started at Emory, it has become an option that students are asking about proactively as they begin their training. I was excited and proud to see what was happening there.

In fact, my medical school classmate Chris Larsen, M.D., D.Phil., is now the school's dean. He attended the Primary Care Progress launch along with another classmate, Rick Agel, M.D. We reminisced about that special time we had together more than three decades ago when we each started on our journeys, and we reflected on where we find ourselves today, working to transform the health care system in this country.

It’s done one school at a time, one system at a time and one community at a time.

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

Monday Aug 17, 2015

America's Most Wanted: Family Physicians Again Top Search Firm's Wish List

We're No. 1.

Again.

For the ninth straight year, "family physician" was the most highly recruited role in U.S. health care, according to national health care search firm Merritt Hawkins.

© 2015 Tiffany Matson/AAFP
Residency exhibitors talk with medical students during the 2015 National Conference of Family Medicine Residents and Medical Students. The recent event in Kansas City, Mo., attracted record-setting attendance, including more than 1,200 medical students and representatives from hundreds of family medicine residency programs.

Merritt Hawkins publishes a review each year of the more than 3,100 search and consulting assignments it conducts on behalf of its clients. In its 2015 report, the firm noted it sought to fill 734 openings in family medicine from April 1, 2014, to March 31, 2015. Internal medicine was a distant second at 237 openings. It was the ninth consecutive year that general internist ranked second behind family physician, a fact that highlights "the continued nationwide demand for primary care physicians as team-based care and the population health management model continue to proliferate," according to the report.

The report's authors noted that primary care physicians top the list of most-in-demand doctors in part because of the key role we play in patient management and care coordination. Specifically, they likened us to point guards on a basketball team. Patients need to see us first so we can coordinate their care appropriately. We can provide comprehensive care and refer patients to expensive subspecialist care only when needed. Like a point guard, family physicians see the big picture, not merely focusing on a single issue or area.

The report pointed out that primary care physicians are being rewarded for "the savings
they realize, the quality standards they achieve and for their managerial role" in newer models of care.

"That, at least, is the aspiration of these emerging models," said the report.

"In systems where volume/fee-for service still prevails," the report added, "primary care physicians remain the keys to patient referrals and revenue generation." In fact, a 2014 Merritt Hawkins survey found that family physicians generate, on average, more than $2 million a year for their affiliated hospitals.

I don't know about you, but I'd rather be a point guard who is looked to as the leader of a health care team than as a mere referral factory.

"Regardless of which model is in place (or a hybrid of the two) primary care physicians are the drivers of cost, quality and reimbursement and therefore remain in acute demand," the report said.

And that brings us to income.

For the jobs Merritt Hawkins sought to fill, family physicians had an average starting salary of $198,000. Overall, according to the firm, family physician income has increased more than 11 percent since its 2010-11 survey.

Meanwhile, a recent report by the Medical Group Management Association (MGMA) that was based on a survey of nearly 70,000 physicians reported a median salary of $227,883 for family physicians who provide maternity care and $221,419 for family physicians who do not. MGMA reported a median salary of $241,273 for primary care physicians, which was an increase of 3.56 percent compared with the previous year's figure. The same report found that median pay for subspecialists rose 2.39 percent to $411,852.

So although primary care physician income still lags behind that of our subspecialty colleagues, it is increasing at a faster rate. Since 2012, primary care physicians' income increased 9 percent, while subspecialist pay increased 3.9 percent during the same period, according to MGMA.

Part of the reason for the change is the shift to value-based contracts. According to MGMA, 11 percent of primary care payments came from value-based contracts in 2014, up from 3 percent in 2012. Halee Fischer-Wright, M.D., a pediatrician and MGMA’s chief executive officer, said in a recent interview with Forbes that the figure could grow to more than 30 percent within three years.

It's worth noting that Merritt Hawkins reported decreasing incomes for the positions it sought to fill in several subspecialties. Otolaryngology was down 10.2 percent, physiatry dropped 13.8 percent, urology lost 18.3 percent, and noninvasive cardiology declined a whopping 34.2 percent. OB/Gyn (-4.2 percent), general surgery (-4.2 percent), hematology (-7.2 percent) and pulmonology (-7.5 percent) also saw declines.

Our country has a critical need for primary care physicians. To convince more medical students to pick primary care, that payment gap will have to continue to shrink.

Emily Briggs, M.D., M.P.H., is the new physician member of the AAFP Board of Directors.

Wednesday Aug 12, 2015

Shaping Our Future: Volunteer to Help Drive Specialty Forward

During my six years as an AAFP Board member, I have benefitted greatly from meeting hundreds -- if not thousands -- of family physicians at dozens of state chapter meetings, AAFP meetings and other primary care events across the country. The problems, solutions, suggestions and insights you have shared with me have helped shape the AAFP's positions on a myriad of issues. Your voice truly makes a difference. Thank you for eagerly sharing your ideas over the years.

Now more than ever we need your input, and here is an exciting opportunity for members to contribute to the future of our specialty in an even more direct manner.

Family Medicine for America’s Health, a collaboration of the AAFP and seven other national family medicine organizations, launched two years ago to drive improvement of the U.S. health care system and demonstrate the value of primary care. The initiative's Health is Primary communications campaign is a three-year effort to advocate the values of family medicine, demonstrate the benefits of primary care and engage patients in our health care system.

I am honored to be able to continue to serve the AAFP and the specialty on the Family Medicine for America's Health Board of Directors after I complete my term as Academy Board chair. And you have the chance to join me in this work!

Family Medicine for America's Health is seeking volunteers to serve on tactic teams that will focus on six critical areas:

  • engagement of stakeholders,
  • payment,
  • practice transformation,
  • research,
  • technology, and
  • workforce education and development.

Family physicians may participate on the tactic teams in one of three roles: project team members, advisory group members or communicators.

Each team will be working from 2015 through 2019 and will complete a number of projects each year. There are three ways family physicians can serve as project team members:

  • Experts -- Physicians with a specific type of knowledge, experience or expertise who can help accomplish a task or achieve an objective.
  • Influencers -- Physicians who think work on a particular project is vital and sign on to help influence others about its importance, especially as objectives of the work are achieved and consequences for action become clear.
  • Mobilizers -- People who have passion and interest in working on a project whether or not they have specific experience or expertise in the subject matter.

Advisory group members will be asked to lend their perspectives on issues through online discussions, surveys and other channels.

We realize that not everyone who is interested in participating on a tactic team will be able to commit the time needed to serve as a project team member or an advisory group member. That's where the communicators come in. They will be kept informed of tactic team activities through regular updates and will have opportunities to participate when their schedules permit.

Additionally, we will ask communicators to tell people who might be interested about opportunities to engage with Family Medicine for America's Health.

If you would like to participate on a tactic team in one of these roles, please let us know by completing this questionnaire. You'll find more information about the tactic teams -- including the projected time commitment for various roles and a frequently asked questions document -- in the survey.

You have a unique opportunity to help shape the future for family medicine, family physicians, our patients and our communities. Thank you for considering these positions, and I look forward to working with you!

Reid Blackwelder, M.D., is Board chair of the AAFP and the Academy's representative to the Family Medicine for America's Health Board of Directors.

Wednesday Aug 05, 2015

Students, Residents Show Their Passion for Family Medicine

You have to admire the passion and dedication that students and residents showed last week during the AAFP's National Conference of Family Medicine Residents and Medical Students.

That passion was evident in the debates about public health, education and other issues heard during the student and resident congresses. And it was evident in the expo hall where students, looking for the next stop in their training, met family medicine residency program representatives who made the case for why their programs stood out from the hundreds of other programs represented in that same expo hall.

But you also could see the passion and dedication simply in the lengths that some attendees made in getting to -- or trying to get to -- Kansas City, Mo.

Photo courtesy of Warren Yamashita

Warren Yamashita, a student at the University of Southern California's Keck School of Medicine, presents his research poster at Los Angeles International Airport after his flight was delayed. Yamashita was bumped from three other flights and could not make it to the AAFP's National Conference of Family Medicine Residents and Medical Students.

Take, for example, Courtney Hudson, D.O., M.B.A., a second-year resident at the Crozer-Keystone Family Medicine Residency Program in my home state of Pennsylvania. Courtney was participating in the new Family Medicine Leads Emerging Leader Institute, so she had to be in Kansas City early Wednesday morning. Her work schedule was jammed in the days before leaving. On Monday, she worked a cardiac outpatient clinic in the morning before moving on to the primary care outpatient clinic in the afternoon. She then worked the overnight shift -- with five admissions -- at the hospital before attending lectures Tuesday morning. Her 30-hour shift finally ended with a trek to the airport, and she made it into Kansas City late Tuesday night.

In addition to the Emerging Leader program, Courtney worked her residency program's booth in the expo hall and served as an alternate delegate in the National Congress of Family Medicine Residents. She made it home late Sunday night -- just hours before heading back to work on Monday.

I asked Courtney if the trip was worth the effort, and she said she wouldn't have traded it for anything. She also said that immersing yourself in the event is the best way to get the most out of it.

Poor Warren Yamashita wasn't as lucky. Warren, a student at the University of Southern California's Keck School of Medicine scheduled to present his research poster in the expo hall at the conference, saw his flight from Los Angeles delayed. He was subsequently bumped from three alternative flights and could not make it to Kansas City. Waiting overnight at the airport for the city's buses to resume running, Warren engaged in a long conversation with some airline employees and others about families, economics and health care.

Although Warren was unable to present his poster at National Conference, that didn't stop him from presenting it at 2 a.m. in the terminal at the Los Angeles airport. During the past two years at USC, Warren has worked to increase health care access by training interdisciplinary health professional students to act as insurance educators who provide consultations regarding Medi-Cal, Covered California and My Health LA to consumers at community health fairs. His poster chronicled those efforts.

Warren, who won a scholarship from the California AFP to attend the conference, asked AAFP staff to post an email about his experience and photos of his impromptu airport poster presentation because he wanted to contribute "to the spirit of the conference" even if he couldn't be there in person.

These are just two stories out of the thousands that could be told by students and residents who worked National Conference into their hectic clinic and lecture schedules. Total attendance last week was more than 4,200, and the event continues to grow each year.

I came to my first National Conference four years ago. I had just finished my first year of medical school, and although I was pretty sure family medicine was what I wanted to do, I told myself I was going to keep an open mind. Then I arrived at the convention center, and I was blown away by the atmosphere and inspired by the speakers. I felt connected, like I had found my people.

I keep coming back because the passion for family medicine that the students, residents and faculty share at this event is inspiring and energizing. Every year I take home something new because the conference's workshops -- and the issues debated in the congresses -- change to reflect the issues that are important to students and residents.

Warren said he hopes to make it to National Conference next summer.

Me too.

Kristina Zimmerman, M.D., is the student member of the AAFP Board of Directors.

Tuesday Jul 28, 2015

Physician Burnout: The AAFP Is Winning Battles For You

I have long been concerned about the impact of physician burnout on the health of our colleagues, our profession and ultimately our patients. Most of us realize that the issues of physician burnout are complex and involve factors related to personal resiliency (which can be addressed at the individual level), practice management (which must be addressed at the system level) and regulatory burdens (which must be addressed at the legislative level).

We all know burnout is a huge problem at a time when primary care physicians already are in short supply. Earlier this year, I wrote a blog noting that more than 40 percent of U.S. physicians experience at least one symptom of burnout (loss of enthusiasm for work, feelings of cynicism and a low sense of personal accomplishment). In that post, I wrote about the importance of managing stress, seeking support and removing the stigma associated with burnout.

Since then, additional blogs and editorials published by AAFP News have addressed personal resiliency. One blog post discussed the need to provide residents with resources to recognize, treat and prevent burnout. And we also have confronted the issue of physician suicide.

 AAFP President Robert Wergin, M.D., testifies about electronic health records during a Senate Health, Education, Labor and Pensions Committee hearing.

Although I am glad to see the increased awareness of burnout, I remain dismayed that many of the conversations about issues related to burnout reflect a sense of hopelessness. It is disheartening to realize the sense of frustration of some members who think the Academy isn’t willing or able to help. That being said, I can appreciate that our members on the front lines of primary care may be so busy in practice that they are unaware of all the activities that the AAFP is undertaking on our behalf.

The Academy is, in fact, working to change many of the drivers that lead to burnout, including payment reform and administrative burdens. Here's a look at the progress we've made on some critical issues this year.

Meaningful Use

The AAFP repeatedly called on CMS to ease the administrative burden associated with meaningful use. In April, CMS included two changes the AAFP advocated for in a proposed rule regarding stage 2 -- shortening the attestation period to 90 days and making requirements related to secure messaging with patients more attainable.

In March, the agency published it proposed rules for stage 3. The Academy pushed back, arguing that implementation should be delayed. Last week, the Senate Health, Education, Labor and Pensions (HELP) Committee agreed, and its chairman, Sen. Lamar Alexander, R-Tenn., called for a delay in enforcement of stage 3 requirements, which are scheduled to take effect in 2017.

The HELP committee has heard from both AAFP President Robert Wergin, M.D., and family physician David Kibbe, M.D., M.B.A., in recent months. Wergin spoke about the burden of electronic health records and the need for interoperability at a March hearing, and Kibbe spoke this month about business practices that impede information sharing.

The Academy also has seized opportunities for public comment and written letters to federal agencies in recent months regarding meaningful use stages 2 and 3 and the Office of the National Coordinator for Health Information Technology's interoperability roadmap. All of this correspondence has stressed the need for improvements in interoperability.

Finally, the Academy's Alliance of eHealth Innovation is conducting a study on the benefit and burden associated with meaningful use and is expanding its work on improving health IT usability and implementation.

SGR
For years, family physicians fought for the repeal of the Medicare sustainable growth rate (SGR), the faulty formula that repeatedly threatened to cut physician payments. On April 14, Congress finally passed the Medicare Access and CHIP Reauthorization Act, repealing the SGR formula. The law will provide needed payment stability in the Medicare program with several years of modest payment increases for physicians. The law also funds for two years the Children's Health Insurance Program, the National Health Service Corps, the Teaching Health Center Graduate Medical Education program and the federal community health centers programs.

The Academy will continue to communicate with HHS and CMS as they develop new payment models.

ICD-10
CMS announced this month that it will provide greater flexibility -- a one-year grace period from claims denials and audits -- during the transition to ICD-10 billing codes. The AAFP was one of numerous medical organizations that had written to CMS in March, urging further testing and risk mitigation.

Advance care planning

CMS recently released its proposed 2016 Medicare physician fee schedule. It discusses the establishment of advance care planning codes -- which the Academy has advocated for -- that would pay physicians for our expertise and time in assisting patients and their families with advance care planning services.

VA changes

The Department of Veterans Affairs (VA) announced in March that roughly twice as many military veterans will be eligible to see a physician who is not affiliated with the VA under a new standard for measuring the distance from a veteran's home to the nearest VA facility. The AAFP pushed for that change while also expressing continued concerns about VA payment rates being less than Medicare rates.

HPV testing

This spring, CMS proposed -- at the Academy's behest -- covering HPV testing in conjunction with a Pap smear test (once every five years for asymptomatic Medicare beneficiaries 30 to 65 years old who wish to extend the screening interval).

I know many challenges and frustrations remain. The increasing complexity and administrative burdens being placed on family medicine have been piling up for years. The Academy is committed to stopping this landslide.

The AAFP is continually communicating with Congress and federal agencies to ensure they know about these important issues. Legislators and policy makers must understand that transforming health care will require a strong family physician workforce, which in turn requires improving the health and wellness of our colleagues, and our practices, by decreasing the regulatory and system burdens that cause physician burnout.

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

Friday Jul 17, 2015

California's Vaccine Victory Holds Lessons for Other States

In politics and culture, California does not often align with Mississippi and West Virginia, but I feel proud to stand with those states in declaring solidarity on eliminating nonmedical vaccine exemptions.

Even before an extensive measles outbreak erupted from the so-called Happiest Place on Earth earlier this year, many states sought to tackle the issue of vaccination exemptions, and those attempts have only intensified since then. In California -- the epicenter of that outbreak -- the battle over S.B. 277 culminated in a victory for public health advocates over a small but vocal anti-vaccine contingent, including some noted celebrity opposition.

In California and everywhere else these battles have been waged, childhood vaccination should have been a motherhood-and-apple-pie issue, yet debate about requiring vaccines and removing personal and religious exemptions elicited visceral reactions from both sides of the ideological divide.

Surely, such heated discourse couldn't be focused solely on refuting the science and evidence behind immunizations. Even Jenny McCarthy has backpedaled somewhat from her earlier anti-vaccine statements that, arguably, set childhood immunization efforts back a decade. No, what this debate really boiled down to was the notion of preserving individual rights at the cost of placing others in harm's way.

Throughout its history and in virtually all areas of public discourse, our country has tried to carefully balance the needs of individuals against the greater societal good. Nowhere has this been more evident than in our protection of individuals' religious freedom. In this case, one of the primary arguments to remove religious exemptions to vaccines is completely consistent with this goal. After all, no major religion in the world (we're not talking about Scientology here) is against vaccination; we can rely on our pastors and priests, rabbis and imams to agree on this point.

So, we're back to personal freedom. The crux of anti-vaccine supporters' argument against removing the personal/philosophical exemption stems from a fear that the government is dictating -- and, thus, overruling parental control of -- children's health care matters. But consider this perspective: The California law allows an exception to the vaccine mandate for home-schooled children, which, in essence, preserves parents' right to decide whether their children will participate in a community-sponsored benefit or opt out of that process.

Moreover, this law continues to allow medical exemptions as determined by a physician, so we can and will continue to discuss this important issue with our patients. In fact, Gov. Jerry Brown cited the continuation of the medical exemption as the sole reason he signed this bill into law. To some, this clause may appear to allow a loophole for vaccine-hesitant parents to go doctor-shopping. And, no doubt, there still will be some physicians ready to cast doubt on the science of vaccines, but they will continue to be in the minority. Ultimately, the decision will be in the hands of the physician and the child's parents after an evidence-based discussion that takes place behind exam room doors.

One last thought: Perhaps sensing the inevitability of passing this legislation, opponents of the California bill vilified its primary author, Sen. Richard Pan, M.D., a practicing pediatrician -- and good friend -- who represents the state's 6th District. Fortunately, Dr. Pan wisely built a coalition of citizen groups and medical organizations -- including the California AFP -- that worked together to overcome this opposition. For those of you familiar with Sen. Pan, you know he has been a stalwart champion of primary care and public health, even winning CAFP's Champion of Family Medicine award in 2013

My challenge to you, my fellow family physicians, is to take up this public health banner and run with it: no personal exemptions, no religious exemptions. Three states down, 47 to go.

Jack Chou, M.D., is a 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.