Week in D.C. Creates Opportunities to Advocate for Family Physicians
I recently returned from an extremely busy week in Washington where the Academy's Board of Directors met to review issues that are important to family physicians and our country.
We were able to take advantage of our location to advocate for family medicine on Capitol Hill during the meeting. Despite a government shutdown caused by a snowstorm -- which was predicted to hit D.C., but did not -- many of our elected leaders were able to meet with their representatives. AAFP President Jeff Cain, M.D., director Dan Spogen, M.D., and I met with Senate Majority Leader Harry Reid, D-Nev., (pictured below) to deliver our messages about payment reform -- including the need to repeal the sustainable growth rate (SGR) -- graduate medical education (GME) funding and other critical issues.
Although the Board agenda was filled with a few days' worth of discussions on such topics, this trip also presented an opportunity for me to speak for family physicians in other venues, as well. I actually arrived days before the Board meeting to represent you at some intriguing events.
I attended a press conference organized by the National Commission on Physician Payment Reform. This group was convened by former Senate Majority Leader Bill Frist, M.D., R-Tenn., and Steven Schroeder, M.D., of the University of California-San Francisco, to devise ways to directly address payment reform. The commission made a dozen recommendations, including eliminating the SGR and replacing fee-for-service with a new model based on quality and value.
It's worth noting that the AAFP convened a task force two years ago that made similar suggestions last year.
At the press conference, I applauded the work of the commission and recognized that it supported the AAFP's recommendations to CMS and other bodies on specific ways to steer payment away from a strict fee-for-service model. I also had a chance to talk with a reporter from the British Medical Journal whose subsequent article referenced the AAFP's work, as well as the commission's report. The more we all work and move suggestions together with one voice, the more likely changes are to happen.
Next, I represented the AAFP at a special meeting called by aides to first lady Michelle Obama. We met in her office to discuss the needs of our service men and women and military veterans. I was able to highlight the AAFP's commitment to this special group through the Academy's Joining Forces website.
of the critical needs identified were improving coordination of medical records
between the Department of Defense and the U.S. Department of Veterans Affairs
(VA) system and addressing the needs of our women veterans. In addition,
providing mental health services is a huge need for our veterans. For both of
these groups, family physicians are ideally suited to help. Several physician
organizations -- including the AAFP --
Finally, the AAFP also participated in another effort involving the first lady, the Building a Healthier Future Summit. That dynamic, three-day event brought together more than 1,000 representatives of private and public sector groups to fight childhood obesity. The AAFP was invited based on our Americans In Motion -- Healthy Interventions (AIM-HI) fitness initiative.
Michelle Obama spoke at the summit, and representatives from supporting organizations -- including the AAFP -- were on stage to be recognized. You will be pleased to know that afterwards there was a lot of recognition of the "distinguished-looking" representative from the AAFP. (During my speech in Philadelphia at the Scientific Assembly, I did promise that my beard would not be ignored -- or forgotten.)
These are exciting times. Thank you for the opportunity to represent you and our patients in so many different venues. Wherever I go, people are talking about the importance of primary care. Our task is to make sure they also recognize the vital role that family physicians play in delivering it.
Reid Blackwelder, M.D., is the president-elect of the AAFP.
Growing AAFP's Media Outreach: Responding to CNN
If you want to deliver your message to a large audience, sometimes you have to be nimble.
A recent Friday afternoon found me on a rare day off, skiing in Breckenridge, Colo. So did the AAFP public relations staff, who tracked me down via my cell phone. I was on a chairlift when they asked if I could fly to New York to participate in a prime time panel discussion about health care on CNN.
The cable network needed an answer within a half hour.
My answer, of course, was "Yes!"
By Monday, we had plane tickets. Tuesday, I arrived in New York, and Wednesday, I was on the set, under the lights, in makeup. The Academy's public relations staff had me prepped. We had done our homework, and I was ready.
Our panel with Sanjay Gupta, M.D., was set to discuss ways to improve our nation's fragmented, inefficient health care system and followed broadcast of "Escape Fire: The Fight to Rescue American Healthcare." The award-winning documentary details how our nation spends $2.7 trillion a year on health care, but with a deeply flawed system that rewards quantity over quality, and focuses on the treatment of disease rather than preventing it.
Filming for our panel lasted nearly half an hour, but CNN's edits brought the segment down to six minutes. In those few minutes, however, my goal was to make two important points:
- patients are healthier when they have two things: insurance coverage and access to a usual source of primary care; and
- effective primary care results in higher quality and lower costs.
For those precious few minutes, I had dropped everything and canceled my clinics on Tuesday and Wednesday. Was it worth it? Absolutely. More than 500,000 people were watching CNN on Sunday night when the program aired twice. It will be broadcast twice again on March 16.
The coverage by CNN is a national event, continuing an important conversation about what is wrong with our health care system. It also points the way to solutions that value family physicians and primary care.
The opportunity to talk to America through a national media outlet doesn't present itself every day, but the AAFP is getting, taking advantage of and even creating such opportunities more and more. Our public relations staff doesn't just respond to media requests; it is proactively reaching out to reporters with story ideas.
That staff has helped raise the profile of the importance of family medicine through the relationships it has built with the media. The number of on-message outcomes in print and online articles, radio and television broadcasts has increased 114 percent since 2008.
In any given week, the AAFP president routinely speaks to reporters for six to 12 interviews on topics ranging from health care policy to clinical issues. When the Supreme Court ruled on the Patient Protection and Affordable Care Act last June, Board Chair -- then President -- Glen Stream, M.D., M.B.I., did 10 interviews in one day. And that's not even the record. Former AAFP President, Ted Epperly, M.D., once logged 11 media calls in one day!
Again, you have to be nimble to get your message across.
Media mentions of the AAFP in the nation's top 20 markets have increased 330 percent in the past five years, including a 17 percent bump last year. Our media outcomes in the dozen consumer outlets we track -- such as Reuters and NPR -- have increased more than 50 percent since 2008, while our reach in trade publications also has increased steadily.
The hard work of the Academy staff, and our elected leaders, has given family medicine a respected voice in national discussions about health care.
Jeff Cain, M.D., is President of the AAFP.
Delivering an Important Message for Family Medicine
The AAFP Board of Directors met with members of Congress and congressional staff March 6 to discuss issues important to family medicine, including physician payment and graduate medical education. In this video interview with AAFP News Now Washington Correspondent James Arvantes, Carlos Gonzales, M.D., of Patagonia, Ariz., talks about making his first Capitol Hill visit as an Academy Board member.
Carlos Gonzales, M.D., is a member of the AAFP Board of Directors.
Signs of Primary Care Success
When a company or an industry
becomes truly successful, one of the first real signs of that success is a new
level of criticism aimed its way.
Recently, one of our neurosurgeon colleagues wrote a post critical of primary care that appeared on the Neurosurgery Blog. It then was picked up by the Association of American Medical Colleges' blog Wing of Zock.
In the blog, Robert Harbaugh, M.D.,
does a grave disservice to family physicians, medical students, and our country
by misrepresenting and attacking primary care medicine.
Unwilling to let his message stand
unopposed, I worked with the AAFP's public relations staff to craft a response
to Harbaugh's blog as posted on the Wing of Zock blog, and we are very happy that
they posted it.
As our country begins to move toward investing in primary care as an effective way to bend our unsustainable cost curve of health care, we can expect increasing push back from those who either do not understand the real effectiveness of primary care or who stand to lose in this important transformation.
Our Academy will respond forcefully
to these outliers, for the health of our patients, our practices and our
Primary Care Needs Are No Myth
In "The Primary Care Shibboleth: Debunking the Myth," Dr. Robert E. Harbaugh (a neurosurgeon) does a grave disservice to family physicians and medical students who value the professional satisfaction, intellectual challenges and career-long patient relationships of primary care.
Dr. Robert Harbaugh, M.D., is misinformed.
Primary care should be the critical foundation of our health care system. A wealth of published, credible data supports the value of primary care and prevention:
- Health care systems with a strong primary care sector are associated with reduced health care costs and improved quality of care.
- Primary care physicians decrease health care utilization through effective preventive care and enhanced coordination of care.
- Patients who have a family physician as their usual source of care have lower total medical care costs.
Harbaugh wrote, "The United States has a relatively high concentration of primary care physicians and a relatively low concentration of (sub)specialists compared to the OECD (Organisation for Economic Co-operation and Development) average of all countries." Unfortunately, this statistic is skewed by counting all of "internal medicine" as a primary care specialty, erroneously including medical subspecialists as primary care. The truth is the ratio of primary care and subspecialty care proven to produce the best outcomes is now out of balance in the United States and threatens to get worse. Currently, less than 20 percent of medical students who enter internal medicine residencies go on to practice primary care.
Harbaugh asks if anyone believes that by investing more in primary care, we can prevent people from getting sick and save money. It may come as a surprise to Dr. Harbaugh, but not only do our nation's health care policy experts acknowledge the value of investing in primary care, but so do many of the nation's top business executives.
Harbaugh misses the point of primary care by describing it as "a brief meeting with a physician who tells patients what they already know." Primary care's strength is in continuity, the relationships formed with patients over years that allow early detection and intervention in medical illnesses. Family physicians are trained in effective behavioral change methods proven to make a difference in the health of their patients. Investing in primary care and the patient-centered medical home reduces overall system costs by reducing unnecessary hospitalizations and unnecessary emergency department visits.
Overall, Harbaugh fails to acknowledge the very real cost and patient safety differences in primary, secondary and tertiary prevention. His example from his own practice is the carotid endarterectomy, an example of tertiary prevention. Indeed, if a patient had access to a primary care physician to help control blood pressure, smoking cessation, and prescribe statins when necessary, the patient might even avoid the need for this procedure with its associated high costs and surgical risks.
Furthermore, we cannot hide from the truth. Primary care is among the lowest paid physician specialties in the United States, a travesty given the overall value that primary care brings to our patients, communities and the health care system. This huge income disparity has a profoundly negative impact on our country's future workforce. The average medical student today has more than $161,000 in education debt after medical school. Data increasingly show that debt and earning potential are swaying student specialty choice.
To close the gap in medical student specialty choice, the Council on Graduate Medical Education's 20th report recommended that primary care physicians be paid at 70 percent of subspecialists' pay. When our Canadian colleagues faced a similar decrease in primary care student interest 10 years ago, they increased the mean salary of family physicians and now have more medical students entering family medicine than ever.
Harbaugh interprets the data narrowly and quite selectively. The professional societies representing primary care have never advocated "robbing Peter to pay Paul" by increasing payments to primary care physicians at the expense of surgical specialties and other subspecialties. The AAFP's position has always been that savings from preventing avoidable emergency department use, hospitalizations, readmissions, procedures and tests will more than pay for improved payment for primary care.
Harbaugh says patients are the priority, and we couldn't agree more. If we are to address the toughest challenges in medicine, we must respect the value and expertise of all our medical colleagues -- primary care and subspecialists alike. By bringing physicians together, we can have a profound and far-reaching impact on medicine. But most importantly, we can do what is best for the health and well-being of our patients.
Jeff Cain, M.D., is the president of the AAFP.
Residencies Face Barriers to Teaching PCMH
I believe that the patient-centered medical home (PCMH) is the future of primary care. The model has been proven to provide cost effective and high quality health care, and some payers are beginning to recognize its value.
At the University of Nevada School of Medicine, where I am chair of the department of family medicine, we have developed curriculum for students that includes required reading, faculty lectures and shadowing faculty. It's working out well for student education.
But in Nevada, and elsewhere, teaching the PCMH model to residents remains an issue that needs a solution. It's a looming problem for residencies because, starting in 2015, the Accreditation Council for Graduate Medical Education (ACGME) will require residencies to teach population management. Although population management sounds big and broad, the reality is that PCMH is the most likely model to fill that accreditation requirement.
According to an estimate by the Association of Departments of Family Medicine (ADFM), one-third of residencies already are teaching PCMH, one-third are working to implement it into their training programs and one-third have made no progress in implementing it.
That leaves many programs with a lot of work to do in the next two years. Unfortunately, adding curriculum with no new resources amounts to an unfunded mandate. How will these programs adjust?
The good news is that help may be on the way. For years, the AAFP, and a coalition of other primary care groups, has been urging the Health Resources and Services Administration (HRSA) to study the development of PCMH curriculum in primary care residencies. A pilot project, funded by HRSA, is expected to start this spring at four universities (encompassing a total of 12 pediatric, family medicine and internal medicine residencies).
The goal will be to develop a unified curriculum that could be deployed in any of our nation's roughly 1,000 primary care residency programs.
Of course, the lack of standardized curriculum is just one barrier to making a residency program a PCMH. Population management is impossible without a robust electronic health record (EHR) system, and some programs just aren't there yet.
It's estimated that implementing an EHR in private practice costs roughly $80,000 per full-time equivalent physician. Here in Nevada, we have six departments in Las Vegas and four in Reno. The cost to implement our new EHR is estimated at $6 million. For some training programs, the cost will be even higher.
Grant money has helped some residency programs move forward with EHR implementation, but others lack the resources to take that step, which is a shame because the PCMH is good for patients. It stresses preventive care, engages the patient and encourages a healthy lifestyle. It also benefits payers by lowering costs, improving care and leading to better outcomes.
We can talk to our residents about PCMH, and we can teach them about things such as team-based care. But without an established curriculum and robust EHRs, residents are only getting a taste of what the PCMH is all about.
And those who don't learn the PCMH in residency will be forced to learn it as new physicians. Surely, there is a better way. We need a consistent method of teaching PCMH at all levels of education.
Payers stand to reap the benefits of physicians who practice in the PCMH model. So payers should recognize that teaching students and residents in this model is costly and do what they can to help facilitate that training.
Docs Seeking Strong Connection to Patients Could Find it in Rural Practice
I was sitting in a meeting in Austin, Texas, 90 miles from home, when one of my patients was injured by a piece of metal that blew off a roof. My nurse called and said that this older gentleman's head needed stitches. I asked her to refer him to the nearest emergency room, which is about 20 miles from my office.
"He says if you won't do it, he's going home," she said.
Such is life for a family physician in a small, rural community. Patients can be incredibly loyal, especially when you have been around for a while. I couldn't let that patient go home with a three-inch laceration on his head, so I drove the 90 miles home, treated him and drove back to my meeting.
Rural Texas, like many small towns and farming communities around our country, desperately needs primary care physicians, so I'm happy to precept six or seven medical students each year at my clinic in Castroville.
Most of them come from the University of Texas Health Science Center in San Antonio specifically because they want to experience rural practice. They see things here they likely would not in an urban or suburban primary care office because, by necessity, I do more urgent and emergent care than my big city peers.
I was the only primary care doc in town when I opened my clinic 27 years ago. Today, Castroville (population 3,000) has a county health clinic and an urgent care that is open on the weekends. But people still come to me with chest pain, strains, sprains, fractures and just about everything else a full scope practice could expect.
My nurse, Donna Winters, and I both grew up in this area, and I've known her since we were kids. Donna and my office manager, Cheryl Fournier, both have been with me for more than 25 years, and I suppose we've seen it all.
One day, Donna pulled me out of an exam room, although I was with a patient.
"Come with me right now," she said.
She led me to another exam room where a female patient was on the table writhing in pain.
"I have appendicitis!" the patient said.
Donna looked at me and shook her head.
"No, she doesn’t," she said.
The patient, in fact, was about to give birth. It was a breech delivery, but we managed it right there in the office, and both the mother and child did fine. That's not the way it would have happened on the third floor of a professional building in San Antonio, but you have to be prepared for anything in a small town.
One day, a man came in with a sack and said, "I've been bit by a snake. I killed it, and it's in this sack."
I told a staff member to put the sack in the nurse's station sink, and I went in to an exam room to look at the man's wound. I discerned that it was not a rattlesnake bite and went back to the nurse's station get a look at the snake. The sack, however, was now empty.
Like I said, prepare for everything.
When the medical students come here, I encourage them to consider rural practice. I tell them it can be a wonderful life experience, but I tell them the negatives as well as the positives.
In a town this small, you have to know that everyone is going to know your business. I've never had an unlisted home phone number. People don't abuse it, but they will call if they need something important. Occasionally, I have had people show up at my door.
If that level of connectedness makes you uncomfortable, small-town practice probably isn't for you.
I never have to ask medical students if they are going to practice in a town like mine. My patients do that for me.
"Are you going to do this?" they say. "We need docs in small towns."
I tell students that I love being a small town family physician. Hopefully, they will witness some of the moments that make me feel that way.
I recently lost a patient to esophageal cancer. When the chemo stopped working and things started to go badly, I worked with him and helped him make decisions about end-of-life care. After he passed, his widow asked me when I was planning to retire.
"I'm not," I said.
"Good," she said, "because when my time comes, I want you to do for me what you did for my husband."
When things like that happen, you go to bed at night thinking, "I'm doing the right thing."
I meant what I told that woman. I have no plans to retire. I see 30 to 40 patients a day. I hired a second physician several years ago, and together, we have more than 6,000 patients. I hope to grow the practice so that I can scale back my hours as age demands it, but as long as my mind and body are fit, I plan to keep doing what I love.
Hopefully, there will be someone to take my place when I can't do it any longer. Employed physicians account for 60 percent of the AAFP's membership, and less than 20 percent of our members are solo docs. Neither trend bodes well for our rural communities.
Before I opened my practice in 1985, seven banks turned down my request for a start-up loan. The eighth bank I visited made it possible to build and open a practice. Today, it's even more difficult for young physicians to get started.
But not impossible.
If a new physician interested in rural medicine could find one or two like-minded colleagues, the expenses, and risks, of starting a new practice could be shared.
If you can make it work, it's an amazing life.
Lloyd Van Winkle, M.D., is a member of the AAFP Board of Directors.
Feeling Detached: Lessons from Being a Patient (Again)
It's good to be back in Washington advocating for family medicine. And it's good to see the Capitol again, though my view today is a bit cloudy.
You see, my last visit here ended in an unexpected manner. Not because of a bad meeting or difficult legislators but because of my own health. As I was leaving the White House on Jan. 3, I noticed a new, large floater in my field of vision. By the time I was driving home that night in Colorado, I was seeing flashes of light.
Uh, oh. This was no thunderstorm. As you know, these are potentially symptoms of a detached retina.
After calling my family physician and an ophthalmologist, I was seen emergently and initially diagnosed with a posterior vitreous detachment in my right eye that later progressed to a retinal tear.
Frankly, I was scared. Our eyes are so important to what we do as physicians, not to mention in our everyday lives.
It's said that life teaches us lessons. If we don't learn them the first time, those lessons will be offered again. For me, it had been more than 15 years since I found myself playing the extended role of patient after an airplane crash. That accident eventually led to the loss of both legs below the knees, so I'm no stranger to being on the receiving end of health care.
But once again, I was reminded of how fragile we are and how quickly life can change. In a matter of days, I went from visiting the White House, seeing patients and teaching residents to being a patient in the operating room of my own hospital. Post op meant lying flat on my back, at home alone in a dark house. I went from being on the front lines of our advocacy efforts to being told that I could not read, use a computer, exercise or work.
Like my retina, I was feeling detached.
Fortunately, I have great colleagues at the AAFP who were able to handle my Academy duties, and I have other great colleagues who were able to handle my clinic and teaching duties in Colorado.
I ate even better than normal, as friends, family and colleagues circled the wagons to bring food, entertainment, and good cheer to the house. To keep my mind engaged, they even brought books on tape!
It's funny how sometimes we get so caught up in our lives that we take things for granted. I'm used to being a caregiver. I'm the guy who shows up to offer help. Once again, it was hard for me as a physician to be vulnerable, give up my role as caregiver, and be in a position to ask for help.
The good news is that I'm expecting to recover my vision in time. And I'm back to work, advocating for family medicine in Washington. This week I'm here talking to lawmakers about graduate medical education and the sustainable growth rate formula.
Sure, life offers all of us curveballs. But for family physicians, these setbacks also can remind us of how our lives and our work are so important and so intertwined.
I hope that you can take a moment this week to look around to really "see" your life, family and friends, patients, and those who appreciate you.
Today, I am grateful for the care of my family physician, our subspecialist partners, and to be back in the game for you in Washington, where together we can see and work toward a better future for our patients and our practices. Even if for this short time, I need a little help with accommodation (pun intended).
Jeff Cain, M.D., is the president of the AAFP.
Chapter Meetings Shine Light on Constituent Issues
It's good to be home.
In less than three weeks, I have been to Fort Myers, Fla., for a leadership symposium; to San Diego for the Family Medicine Working Party (the biannual meeting of seven family medicine organizations); to Lake Tahoe, Nev., for the Nevada AFP's annual meeting; and back to Florida for the AAFP Foundation's annual meeting with its corporate partners.
Although all of these trips were important, the Nevada event stands out for me. It was our first constituent chapter meeting of the new year and just my second as president-elect. Each year, AAFP Board members make it to as many chapter meetings as we can. These events present wonderful opportunities to talk face to face with members, many of whom don't have the chance to travel to Academy events outside their own states.
(Here, my wife, Alex, and I talk with Nevada AFP chapter executive Brooke Wong and members Donald Farrimond, M.D., and Tom Hunt, M.D.)
To do our jobs as elected leaders, we need to hear the concerns and issues of family physicians across the country. In 2012, Board members made it to 43 chapter meetings. (Former Board members, such as Past President Ted Epperly, M.D., filled in at six others.)
During chapter meetings, Academy leaders give an update on what the AAFP is doing on a national level regarding a wide range of issues. But we're also there to listen.
What do you need?
What does your chapter need?
Although family physicians share common issues -- the need for fair payment being the obvious example -- some problems are unique to states and regions, and perspectives vary from one state to another. These meetings offer an opportunity for our national and constituent organizations to connect and for you as an individual family physician to shine a light on problems that need the Academy's attention.
The AAFP represents more than 105,000 physicians nationwide. Members' needs are many and diverse. We don't always agree. But there can, and should, always be dialogue on important topics. These interactions inform the Board's discussions about topics of critical interest to family medicine as we work to represent all family physicians.
These meetings also offer a chance for chapters to point out successes that might be replicated by our colleagues elsewhere. Bright spots and solutions to common problems must be shared.
I'm scheduled to attend chapter meetings in Idaho, New Hampshire, New Jersey, New Mexico, New York, Tennessee and Washington this year. Don't be shy. Let's talk.
Reid Blackwelder, M.D., is the president-elect of the AAFP.
Preparing for Match Grueling but Rewarding
Sadly for us mere mortals here in the real world, there is no Harry Potter-style sorting hat to magically place every medical school graduate into the residency program that would be an ideal fit for both the resident and the program.
Instead, we have the Match.
So last week, I, along with more than 16,000 other fourth-year med students, started ranking my list of potential destinations. The questions we face seem endless, but here are a few of the big ones:
- What specialty will I select? (OK, I know the answer to that one, but some of my peers may still be struggling with it.)
- What region of the country will I live in? (And how is the weather there?)
- Who will train us and mentor us once we get there?
- What job options will I have when I'm through?
have until Feb. 20 to finalize our
lists, and then the system starts churning out potential iterations before
finally selecting the one with the most successful number of matches on March 15.
In the end, it's an algorithm -- not a hat -- that will determine how we are dispersed across the country. So it's up to the applicant to do as much homework -- or road work -- as possible before making those rankings. The average medical student interviews with 14 residency programs.
I spent the entire fall on the road, including a four-week rotation on the psychosis floor at Western Psychiatric Institute and Clinic in Pittsburgh and another at St. Vincent de Paul's Family Health Center, a medical clinic for the homeless in San Diego. (Here I am spending a day with residents from that center and its mobile medical clinic.)
In addition to those "auditions," I had 13 interviews in places such as Anchorage, Cincinnati, Denver and Seattle.
I want to work with homeless populations with coexisting physical and mental illness, so I interviewed with four of the five combined family medicine and psychiatry programs in the country. Each of these combined programs offers only two spots, and they each interview nearly two dozen candidates. No pressure.
And on top of that, I have primary care policy and advocacy interests. Sorting out how these family medicine and psychiatry programs compare to categorical family medicine and combined family medicine/preventive medicine programs was a challenge.
But it has been a great experience. Some of my interviews were spread over two days. That gave me time to feel out the programs, meet the residents, faculty and staff. It also gave me time to think about some more important questions, such as "Do I fit in?" and "Does this program fit me?"
That's really what it comes down to. My advice to younger medical students is to spend as much time as you can with residents outside the interview setting. Can you see yourself working and learning alongside these people?
Take time to evaluate where you belong. Reconnect with your mentors when you return to school and analyze what you saw. Who and what do you hope to be, and which program gives you the best chance to reach those goals?
Comparing residency programs isn't like comparing apples to apples. It's more like comparing apples to oranges AND bananas. There are so many innovations and training opportunities, it is an interesting time to pick your ideal residency program.
For example, a combined family medicine and psychiatry residency program I visited had its continuity clinic in a homeless shelter.
A P4 (Preparing the Personal Physician for Practice) family medicine residency provided time for interns to learn necessary skills and bond during month-long "chautauquas" and allowed second- and third-year residents a half a day a week to focus on their areas of interest.
Another P4 program, which has a combined family medicine/preventive medicine residency, had a focus on health policy and practice management, and some graduates move on to become medical directors at federally qualified health centers while others are involved in state and federal policy.
It was energizing to see innovative family medicine residency departments as well as so many impressive applicants excited to make a difference for patients and our healthcare system.
What other advice do I have for students who will go through this process next year and beyond? Enjoy it. Plan in extra time, if possible, and experience the cities you visit.
There were only four hours of daylight when I was visiting Alaska's Family Medicine Residency, but I managed to cram in some cross country skiing and a dog mushing excursion.
I was towed out of a snow bank by a farmer with a tractor while leaving Iowa City. (I couldn't pass up buying cheese curds in Kalona the day after a blizzard.)
I went sight-seeing in San Diego, including a trip to the Cabrillo National Monument (pictured here). I also stumbled upon -- completely by accident, I swear -- a game of nude beach volleyball.
You never know what you might find if you don't get out and look. Here's hoping you find what you're looking for in the Match.
Aaron Meyer is the student member of the AAFP Board of Directors.
Asking Tough Questions About Abuse Can Save Lives
It was more than 20 years ago, but some patients you never forget.
I was not the primary care physician for this new baby girl, but I was on call when her mother brought her in for a well visit. I had treated the mother, her husband and their other children before during sick visits. They seemed like an average family.
During our last visit, the mother and I talked about typical new baby topics -- car seats, breastfeeding and immunizations. What I didn't know at the time was that this young woman was desperately looking for a way out of an abusive relationship.
I was a new physician, just three years out of residency. Although I asked important questions about the child's health and safety, I didn't know to ask the mother about her own safety. Back then, we didn't know that homicide -- not bleeding, blood clots or infections -- is one of the leading causes of death in women in the first year after childbirth.
Now we know.
That woman wanted to find a better, safer place for herself and her children, but a short time later she was dead. The baby's father killed the mother, their older children and two other family members before a failed attempt to take his own life. The infant survived.
I remember my practice partner -- who was their primary care physician -- crying while dictating notes from their files. She stopped the recorder and said, "This family could have made a difference."
For me, they did.
I wanted to learn more. What could I have done differently? What was the dynamic in that family that led to this horrible act? Could it have been prevented?
The U.S. Preventive Services Task Force has published new recommendations that call on physicians to screen all women of childbearing age for intimate partner violence and to refer them to intervention services, if needed.
It's good advice. We can save lives with the right information. I have seen an extraordinary number of positive outcomes when a physician understands the dynamic of what his or her patient is living with.
One excellent screening tool is RADAR, which prompts physicians to follow these steps in a private setting:
- Routinely screen female patients;
- Ask direct questions;
- Document your findings;
- Assess patient safety; and
- Respond, review options and refer.
The recommendation to screen all women of childbearing age is a good one. I have heard disclosures about abuse from politicians, judges and colleagues. It's worth noting that men and children also are at risk. Sadly, abuse happens all the time in every community, and you never know who might need help.
A variety of conditions could raise a red flag. If a patient is experiencing things such as anxiety, chronic pain, depression or eating disorders, go upstream. What is causing those problems? Don't be afraid to ask difficult questions when you are alone with the patient, such as
- Are you safe?
- What happens when you argue?
- Are you afraid to go home?
This is something family physicians can, and should, do. And just a few minutes of our time can make an unbelievable impact in the long term.
So what do you do when a patient is willing to confide in you? Telling him or her to "just leave" an abusive relationship is not the answer. Know the resources and shelters in your community. Often, I've taken a patient to a private place in my practice, dialed a shelter for them, started that important first call and then left the room so that the patient could talk in private.
We can help our patients with a better outcome and better quality of life. But we have to be willing to start the conversation.
Wanda Filer, M.D., M.B.A., is a member of the AAFP Board of Directors.
Dedicated Medical Students Drawing Peers to Family Medicine
Each year, seven student leaders chosen from our network of Family Medicine Interest Groups (FMIGs) come to the AAFP's offices in Leawood, Kan., for orientation before beginning their new roles.
When our five FMIG regional coordinators, national FMIG coordinator and Student National Medical Association liaison to the AAFP met with Academy leaders and staff in January 2012, AAFP EVP Doug Henley, M.D., challenged them to boost student membership to 20,000. They delivered, helping boost our student membership by 3,500.
Dr. Henley raised the bar to 21,000 when seven new student leaders recently met in Leawood. The task of increasing student membership will become more difficult because a growing percentage of students already are members. To date, 20 percent of medical students have joined our ranks.
So how do the FMIGs grow student interest in family medicine? Each regional coordinator is responsible for keeping in touch with the more than two dozen medical schools in his or her region, as well as with FMIG student leaders on those campuses. They find out what those groups need help with and make sure they are aware of various opportunities, such as funding sources, scholarships and AAFP programs.
It's no coincidence that student attendance at the National Conference of Family Medicine Residents and Medical Students increased by 10 percent in 2012.
The work of the student leaders broadens the AAFP's scope and complements the work of staff members in the Academy's Medical Education Division, who work with FMIG faculty advisers on those same campuses.
A recent survey of those faculty advisers showed that interest in family medicine is increasing among students in 41 percent of FMIGs and is steady in 44 percent. Less than 4 percent reported declining interest.
There are at least 147 FMIGs at our nation's allopathic medical schools, up from 113 just five years ago. Also encouraging is that 10 of the AAFP's 11 target schools (those without a department of family medicine or those that have had a department of family medicine for less than three years) now have an FMIG.
I personally work with our local FMIG every year in Colorado by teaching students how to present Tar Wars, the AAFP's tobacco-free education program for fourth- and fifth-graders. Tar Wars is popular with med students and strengthens their interest in community health and family medicine.
I was able to meet with our national FMIG leaders, via Skype during their recent meeting n Leawood, and I was impressed by their energy, enthusiasm and commitment. They are (left to right in the photo above) Simon Tesfamariam, of Duke University School of Medicine, Student National Medical Association Liaison to the AAFP; Kristina Zimmerman, of The Commonwealth Medical College, FMIG Network Region 3 Coordinator; Catherine Louw, of the University of Washington School of Medicine, FMIG Network Region 1 Coordinator; Kenetra Hix, of the University of Tennessee Health Science Center, FMIG Network Region 5 Coordinator; Lauren Kendall, of the University of Illinois at Chicago, FMIG Network National Coordinator; Mustafa Alavi, also of the University of Illinois at Chicago, FMIG Network Region 2 Coordinator; and Mark Prats, of the Uniformed Services University of the Health Sciences, FMIG Network Region 4 Coordinator.
FMIGs are on the front line of our family medicine revolution. Good luck to you all.
Jeff Cain, M.D., is president of the AAFP.
As Flu Reaches Epidemic Proportions, Protect Yourself and Patients
During the past three months, hospitals in my home state of Illinois have admitted 150 patients to intensive care units with influenza-like illness. Six of those patients died. During the same time last year, Illinois had two hospitalizations and no deaths from the flu.
Closer to home in Chicago, six area hospitals were recently on bypass, in part because of the spike in influenza illnesses. And, we're not alone. The CDC said Jan. 11 that 47 states are reporting widespread influenza activity, and 24 states were reporting high influenza activity. In Boston, officials have declared a public health emergency after the number of reported influenza cases in the city jumped 10-fold over last season's total.
CDC officials have said this could be the worst flu season in a decade. We already have reached epidemic levels, and we've still got a long way to go.
So, what are we going to do about it? I got my flu shot. Have you got yours?
The CDC's Advisory Committee on Immunization Practices (ACIP) recommends that all health care workers get vaccinated annually against the flu. The AAFP adopted policy two years ago supporting mandatory influenza vaccinations for health care workers. At least 10 other medical organizations have adopted similar policies, and numerous employers -- including mine -- have taken a similar stance.
Still, the CDC estimates that fewer than 65 percent of health care workers are vaccinated against the flu, leaving our patients, colleagues and families at risk.
A hospital in Indiana recently made news when it fired eight employees who refused the vaccine. That state already has reported 21 deaths from influenza this season. So many health care workers -- from front desk staff to nurses and physicians -- come into contact with patients. Those who refuse immunizations are denying the proven safety and efficacy of the vaccine and jeopardizing the health of our most vulnerable patients.
Low flu vaccination coverage among health care workers has led to outbreaks in hospitals and long-term care facilities. Conversely, health care workers who are immunized help reduce the transmission of influenza and prevent illness and death as well as lost work days among staff.
According to a 2010 AAFP immunization survey, 94 percent of family physicians said they are immunized against the flu each year. Ninety-seven percent of respondents to the 2011 survey said their staffs were routinely immunized against the flu, so we're well on our way to ensuring our patients don't get the flu in our offices.
For those of you who are not vaccinated, however, flu season typically lasts into March, so it's not too late to be vaccinated. You also can help improve vaccination rates in your patients by encouraging them to get immunized and also by dispelling myths -- such as you can't get the flu from the vaccine.
Some of your patients may refuse the vaccine because they are fearful of needles. But the flu vaccine also is available in a painless nasal spray, as well as an intradermal shot with a needle that is 90 percent shorter than those used for intramuscularly administered vaccines. Patients whose insurance offers them a choice should be made aware of those options.
It's not too late for your practice to increase the rate of vaccinations in your community by decreasing barriers to your patients getting vaccine. You can offer extended nurse visit availability or create campaigns -- alone or in partnership with local public health agencies -- that target your patients as well as the most vulnerable in your area.
If your practice is not providing vaccinations -- or if you have exhausted your supply of vaccine -- make sure you know where to refer patients and staff in your community. There are vaccine shortages in some areas, according to the CDC.
More than 90 percent of the influenza viruses that the CDC have analyzed match the viruses included in the 2012-2013 influenza vaccine. The agency said people who are immunized are 62 percent less likely to need medical care for the flu than those who are not. Although that level of efficacy is less than what we see in many other vaccines, staff and patients should be reminded that the flu vaccine still is the best way to protect themselves and their families. After spending a day with sick patients, don't take the flu home to your loved ones.
Finally, the CDC has a Web page devoted to flu resources for health care providers, including information about diagnostic tests, antiviral recommendations and surveillance. The AAFP also has a Web page devoted to immunization resources.
Protect yourself, your patients and your family. Get immunized.
Ravi Grivois-Shah, M.D., M.P.H., is the new physician member of the AAFP Board of Directors.
Time for a National Conversation About Gun Violence
Growing up in the Pacific Northwest blessed me with a love, and respect, for the outdoors. I am an avid cyclist and experienced skier. I also grew up with guns, and I own sporting guns to this day.
At the same time, my hospital -- Children's Hospital Colorado -- has served as a treatment center for wounded kids after two of the most horrific shootings in our nation's history: the Columbine High School massacre in 1999 and the more recent attack at a movie theater in Aurora, Colo. Twelve students and one teacher were murdered at Columbine, and 12 people were killed in the theater shooting. Seventy-nine others were wounded in the two incidents combined.
Children from my practice, as well as children of my friends and practice partners -- were at the theater on that horrible night in July.
It's time that we, as a country, recognize gun violence as a major public health issue. According to the CDC, more than 31,000 Americans were killed with firearms in 2009, rivaling the number of those who died in traffic accidents. The number of Americans killed by guns in one year on U.S. soil is more than four times the total of U.S. deaths from the wars in Iraq and Afghanistan combined.
Following the recent school shooting in Connecticut, the White House formed a task force to develop policy to prevent these tragedies and reduce gun violence. On Jan. 3, I participated in the first of a series of stakeholder meetings when HHS Secretary Kathleen Sebelius, White House staff members and others met with representatives from groups representing health care professionals and public health organizations.
The causes of this problem are complex, and there is no simple solution. The White House and HHS are expected to meet with a wide variety of those involved in the issue, including mental health experts, law enforcement, gun owner groups and youth advocacy organizations, to listen to their analyses and recommendations.
As family physicians, we focus daily on prevention to improve the health of our patients. Today, we need to help our country focus on prevention that addresses all of the causes of violence in our communities.
Our country needs better mental health care, including improved access to care, substance abuse counseling and coordination with primary care. These points were made loud and clear during the Jan. 3 meeting.
The need to address violence in media -- from
television and movies to video games and music videos -- also was part of our
discussion. Studies have shown that children exposed to media violence are more
likely to cause harm to others. The Academy has a position paper on
We also talked about firearm safety. Guns are not the only source of violence, but gun safety clearly needs to be part of the conversation and part of the solution. Our Academy has long standing policy -- endorsed and upheld by our Congress of Delegates -- supporting legislation requiring trigger locks and safe storage of firearms, as well as policy opposing ownership of assault weapons.
Family physicians need to be able to have appropriate medical conversations with our patients about gun safety, and researchers need the ability to study gun safety. Currently, state and federal laws restrict their ability to do so.
The White House has asked the Academy for input, and we shared with them our policies related to violence, including media violence, gun safety and improving mental health care.
I recognize the diversity of our membership and the fact that there are strong feelings on both sides of the issue when it comes to guns. Yet, all family physicians are advocates for decreasing violence in our communities. This is an opportunity for family physicians to be heard as strong advocates of prevention during the development of national policy that will affect the health and safety of our patients.
Jeff Cain, M.D., is the president of the AAFP.
Technology Brings New Meaning to Being There for Patient
As families gather and celebrate the holidays, I am reminded how things change and yet stay the same. We look forward to folks coming home, but travel is getting harder. Sometimes, we need to reach out through texting, tweeting, Skype, FaceTime, Facebook and other virtual methods. They may not seem as intimate, but they allow distant connections to be maintained and even grow.
Family medicine is all about nurturing relationships.
How we care for our patients is also being affected by social media technologies.
I recently experienced a powerful example of how modern technology let me be
there during a difficult time for one of my families, although I actually was
Serving on the AAFP Board of Directors takes me away from home and my practice frequently to attend meetings. A few weeks ago, I was sitting in the Academy's boardroom in Leawood, Kan., when one of my residents back home in Tennessee texted me a question from the emergency room about a patient. My resident did not know I was away, and she asked if I was available. I texted back to say "no" … and "yes" and would do what I could remotely. Due to the Health Insurance Portability and Accountability Act (HIPAA), I asked only for my patient's initials. Because of my relationship with my patients, with just that information, I knew exactly who the resident meant, and suspected I knew the problem.
The 91-year-old woman with altered mental status who was the subject of the resident's text has been my patient for about seven years. I first met this dynamic, independent, well-educated former teacher when she started to slow down. Sadly, her cognitive function was doing the same. I diagnosed her dementia while she still understood the devastating losses ahead of her. I worked with her four children, who all live in different states, to help everyone cope with the huge changes. We communicated by phone, e-mail, home visits and appointments over the years. As her disease progressed beyond what they could do at home, I coordinated care as she moved into an assisted living facility one month ago.
Just before I left for Kansas City, her daughter had e-mailed about one of her meds at the facility, and I had noted a discrepancy that I addressed. But now my resident was seeing her for confusion. With that information only, we quickly went through the possibilities, including a stroke, infection and trauma, but I suspected that the medication might still be wrong. Ultimately, that was indeed the problem. That text conversation allowed me to direct my patient's care quickly and efficiently through my resident, saving time and unnecessary investigations.
During our Scientific Assembly in October, the Academy asked, "What is your best moment as a family physician?" Nearly 300 family physicians responded with tales of delivering babies, helping patients make important changes and offering hope to those who needed it.
My story is a different kind of feel-good moment, but it points out how relationships and technology can grow together. The impact we make in people's lives is profound. We need to be there for our patients and families even when we can't be there physically. My knowledge of my patient's situation and willingness to use e-mails, texts and calls made a difference for her and her family, from the beginning of her disease through this latest ER crisis.
So, what is your best moment as a family physician?
And what will you do in the New Year to make a difference for your patients?
Reid Blackwelder, M.D., is President-elect of the AAFP.