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.
AAFP Teams Up With NFL Foundation to Raise Concussion Awareness
More than 1.6 million concussions occur in sports and other recreational activities each year in the United States. Making matters worse, athletes, parents and coaches often are unaware of recommendations regarding returning to play and the need to seek medical attention.
A study published last year in JAMA Pediatrics found that 59 percent of female middle-school soccer players played with concussion symptoms, and more than half of the players reporting concussion symptoms were not evaluated by a physician. According to the Center for Injury Research and Policy, at least 40 percent of concussed high-school athletes return to play too soon. In fact, 16 percent of concussed football players returned to play the same day they were injured.
Concussions can occur even in sports that you don't necessarily associate with head injuries. For example, women's lacrosse is supposed to be a noncontact sport, but the ball travels at speeds in excess of 60 mph. At the recent AMA annual meeting, delegates voted to adopt a measure recommending helmets for girls and women playing that sport.
Like many family physicians, I treat sports-related injuries in my practice and also work as a team physician for the local high school. I often have to educate coaches and parents about the need to hold athletes out of practices and games while they recover. And we've also had to take helmets away from injured football players during games when they were far too eager to get right back into the action.
So how do we raise public awareness about the serious nature of concussions, their long-term effects and the fact that they often can be successfully managed? The AAFP has entered a partnership that will pair the evidence-based medical knowledge of the Academy with the influence of the National Football League Foundation. The initiative will produce three free webinars for family physicians, as well as patient education materials. The AAFP will have full control of all educational materials and will retain final editorial authority over the materials.
The Academy will be able to use the NFL's brand and logo on the patient education materials, which should help get the public's attention. NFL games reached more than 200 million unique viewers last season, when the league averaged 17.6 million viewers per game.
Here is a look at what to expect:
- Sports Concussions 101: The Current State of the Game, July 23, 8 p.m. CDT. This webinar will enable participants to define a concussion, and to identify the signs and symptoms of a concussion during an initial evaluation. The event will be presented by Stanley Herring, M.D., medical director of sports, spine and orthopedic health for University of Washington Medicine, co-medical director of the Sports Concussion Program, and a team physician for the Seattle Seahawks and Seattle Mariners; and family physician Matthew Silvis, M.D., associate professor in the departments of Family and Community Medicine, Orthopaedics, and Rehabilitation, and medical director of primary care sports medicine at Penn States's Hershey Medical Center.
- Sports Concussions 102: If You've Seen One Concussion, You've Seen One Concussion, Aug. 6, 8 p.m. CDT. Participants will be able to analyze the variability of the clinical presentation of concussion, construct an individualized, evidence-based treatment plan and recognize when to seek consultation or referral for a concussed athlete. The webinar will be presented by Jason Matuszak, M.D., the director of the Sports Concussion Center in Buffalo, N.Y., and Yvette Rooks, M.D., assistant professor of family and community medicine at the University of Maryland School of Medicine and a team physician for the University of Maryland Terrapins.
- Sports Concussions 103: Debates and Controversies, Aug. 20, 8 p.m. CDT. This webinar will cover long-term brain health in athletes; rule changes, practice and play modifications, and legislative efforts regarding sports concussions; limitations of protective equipment; and counseling parents about sports participation for young athletes. This webinar will be presented by Herring, Matuszak, Rooks and Silvis.
Patient education materials will be mailed to all active AAFP members in August and also will be posted on FamilyDoctor.org. These materials are intended to help patients understand the definition of concussion and its signs and symptoms, know when to seek medical evaluation, understand concerns about long-term brain health in athletes, and understand the limitations of protective equipment.
As part of the initiative, Family Medicine SmartBrief will publish a special report regarding concussions in August. You can sign up to receive SmartBrief, a daily wrap-up of news that affects family medicine.
Family physicians often are the first line of care for patients of all ages. We’re the first to spot these injuries, the first to treat them and the first to discuss the dangers of concussions with patients. This educational initiative will help family physicians and our patients by focusing on safety, the importance of reporting, evaluation of concussions and return-to-play protocol.
Concussions are a serious public health risk, and this educational initiative is the right thing to do.
Robert Wergin, M.D., is president of the AAFP.
What Patients Don't Know Can Hurt Them
It has been more than five years since the Patient Protection and Affordable Care Act (ACA) became law, but many consumers still remain unaware of one of the law's signature provisions: coverage of preventive services without cost-sharing.
A baby receives the rotavirus vaccine. Many Americans remain unaware that most health plans are now required to cover preventive services, including vaccinations, without cost-sharing.
The White House and HHS recently launched a joint Healthy Self campaign, which is designed to connect Americans to the health care they need and encourage them to take a more active role in their health. Fifty events will be held across the country in August to connect patients with care. The effort includes educating people -- particularly the newly insured -- about preventive services they are guaranteed under the ACA, which survived another Supreme Court challenge last week.
A Kaiser Family Foundation poll conducted shortly before last year's open enrollment deadline, showed that less than half of uninsured Americans were aware that the recommended preventive services most health plans are now required to cover must be provided with no cost-sharing. Those services include:
- blood pressure screening;
- breastfeeding support and supplies;
- depression screening;
- domestic violence screening and counseling;
- HIV screening;
- obesity screening and counseling;
- tobacco cessation interventions;
- well-child visits; and
- well-woman visits.
Considering that lack of awareness about these benefits, it's no surprise that half of the uninsured who were polled said they planned to stay uninsured.
However, more than 16 million people have gained health coverage under the ACA, according to the Healthy Self campaign announcement. That's significant because prevention is the key to true health care. Chronic diseases are responsible for 70 percent of U.S. deaths and 75 percent of our health care costs. Imagine the difference we can make simply by helping patients understand the services they have access to in our practices. If people delay preventive care because of cost concerns, they're more likely to eventually end up spending even more money at urgent care centers and ERs.
So what can we do as family physicians? We can use electronic health records to review what services patients haven't had. Our practices can use phones, email, portals and even social media to encourage patients to come in for preventive care. We also can use acute visits to identify preventive service gaps and schedule follow-up.
It's worth noting that CMS has launched a Web page with resources to help the newly insured understand their benefits and to connect them with primary care physicians who can provide preventive services.
Reid Blackwelder, M.D., is Board chair of the AAFP.
Learning Matters: How Education Affects Health
The recession has been over for nearly six years, and although recovery can be seen in many aspects of our economy -- including employment statistics and housing data -- the same can't be said for our public schools.
At the start of the 2014-15 school year, more than half the states were providing less funding per student than they had before the recession began in 2007. In fact, 14 states have cut per-pupil spending by more than 10 percent. Kansas took things even further, cutting funding for education by more than $50 million during the school year to help cover a massive $400 million budget shortfall.
What many legislators fail to realize is that cutting funding for education now raises health care costs in the future.
Photo courtesy of Reach Out and Read
A physician shares a book with a young patient as part of the Reach Out and Read program. Research indicates that education improves health and increases life expectancy.
How are health and education related? Steven Woolf, M.D., M.P.H., professor of family medicine and population health at Virginia Commonwealth University and director of the VCU Center on Society and Health, recently gave a presentation to the AAFP Board of Directors that illustrated the significant impact education has on health. Based on reports published last year by the Center on Society and Health's Education and Health Initiative, Woolf's presentation focused on how education can increase a person's life expectancy and the quality of that life.
The authors of the report put it succinctly, "Disinvestment in education leads to more illness and higher medical care costs that offset the intended 'savings' of these same budget cuts."
For example, in 2011 the prevalence of diabetes in the United States was 15 percent for adults who did not complete high school. That was twice as high as the rate among college graduates. In the same year, more than one-fourth of adults without a high school diploma were smokers, compared to 8 percent of college graduates. Adults who don't finish high school also can expect to live nine years less than their college-educated peers. And that already sizable gap is widening.
The reasons for the health disparities are numerous, and many should be fairly obvious. Education typically leads to better jobs, more money and many other benefits, including better health insurance, which leads to better access to quality health care. Higher earnings also allow workers to afford homes in safer neighborhoods as well as healthier diets. The median wage for college graduates in 2012 was one-and-a-half times higher than that of high school graduates and more than double that of workers who lacked a high school diploma.
People with lower incomes often live in neighborhoods or communities that present numerous challenges that affect their health, including less access to supermarkets and healthy food choices, less access to green space or other recreational areas, higher crime rates, lower quality schools, fewer jobs and increased levels of pollution.
Low-income areas also often have shortages of primary care physicians and other health care professionals. However, the report points out that people with lower levels of education have worse health than those with more education even when access to care is equal. For example, a 2011 survey of patients in the same health system found that nearly 70 percent of college graduates ages 25-64 described their health as very good or excellent, compared to 32 percent of adults who had not completed high school.
The bottom line is that strengthening schools likely would make our nation healthier and reduce health care spending in the long run. Even if our legislators fail to see the connection between education and health, we can make sure that our patients -- especially children and their parents -- do.
In 2013, 66 percent of U.S. fourth-graders were reading below proficiency levels. Part of the problem is that parents who were not read to as children may not understand the importance of reading to their own kids. In fact, less than half of young children in this country are read to daily, and minority and low-income children are less likely to be read to than others.
So what can we do? Last year, the AAFP entered into an agreement with the Reach Out and Read National Center. That program trains and supports physicians, who give new books to children ages 6 months to 5 years and advise parents about the importance of reading aloud. The program aims to promote early childhood literacy and language development, particularly in low-income families.
Graduation rates -- like immunization rates -- have a huge impact on the health of our communities. Reach Out and Read offers numerous resources for physicians who would like to participate.
Robert Lee, M.D., is a member of the AAFP Board of Directors.
Doctors Need the Straight Dope on Medical Marijuana
Nearly half the states, and the District of Columbia have adopted comprehensive medical marijuana programs, and more than a dozen more have approved use for a limited number of medical conditions. Two states -- Colorado and Washington -- have taken things even further, legalizing marijuana for recreational use.
Of course, none of this changes how marijuana is viewed by federal authorities. The Department of Justice has issued guidance to federal prosecutors, reiterating the agency's commitment to the Controlled Substance Act. The FDA has not approved marijuana as a safe and effective drug for any indication.
Legislators are again impacting the care of patients and the health care delivery system. So where does that leave us as physicians? WebMD polled physicians last year and nearly 70 percent of respondents agreed that medical marijuana can help patients with certain conditions. But physicians were less enthusiastic about making the drug available. Half of the doctors polled in states where medical marijuana is legal supported its legality. In those states still debating medical marijuana laws, 52 percent of doctors supported it.
Hence, although an overwhelming majority of U.S. physicians understand the potential benefits of medical marijuana, roughly half oppose it.
In my home state of Illinois, legislators have legalized medical marijuana. Many patients are asking for it; many have valid reasons, such as cancer or chronic pain. For those who do not, the discussion explaining the reason for denial is lengthy. Illinois, like many states, used model legislation to create its medical marijuana program, and physicians are not required to write prescriptions. Rather, we certify which patients meet conditions that allow them to legally buy the drug at a dispensary.
Sadly, conversations with my patients have highlighted some obvious problems with medical marijuana. I have had patients suffering from chronic pain ask for medical marijuana because they fear becoming addicted to prescription narcotics. They, like many others, don't understand that marijuana can also be addictive. According to the 2013 National Survey on Drug Use and Health, marijuana use accounted for more than 4 million of the 7 million Americans who are dependent on or abusing illicit drugs.
In short, many patients don't know the harmful effects of marijuana. So although there are limited health benefits to medical marijuana, we must also ensure that patients understand the risks.
At last year's Congress of Delegates, the AAFP adopted policy stating that decisions about medical marijuana should be based on evidence-based research and called for further studies into the use of medical marijuana and related compounds. But with new studies being published regularly, it can be hard to keep up on what the latest evidence tells us.
The AAFP can help. The March edition of FP Audio has a clinical topic that will help physicians evaluate current evidence on the use of medical marijuana for the treatment of multiple sclerosis and severe childhood epilepsy. Another edition exploring the topic further is scheduled for July.
The Academy will offer two sessions related to medical marijuana Sept. 29-Oct. 3 at FMX in Denver. An interactive lecture will cover what family physicians need to know about medical marijuana. And during an "Out and About" -- an offsite CME session -- a family physician and a patient will discuss legalized marijuana from the physician and patient perspectives. That session will be followed by a tour of CannLabs, an advisor to commercial, governmental and educational entities focused on the cannabis industry.
State chapters also can play a role. The Illinois AFP is offering its second webinar on medical marijuana and its implications for physicians on April 27. Registration is limited to the first 100 participants, but an archived version will be available. (The event is not limited to Illinois AFP members.)
The bottom line is that medical marijuana is becoming available in a growing number of states. There is a tremendous economic advantage to a state’s economy. Consumer advocacy groups have formed to urge the federal government and the FDA to ease federal restrictions and fund marijuana research. When patients come to us for help, we should know the law governing our actions and what liabilities may exist. And, we should have an informed conversation with our patients about the potential risks and benefits of a drug for which long-term safety for adults and children is not yet truly known. The laws are changing rapidly. Family physicians should become knowledgeable of the laws in our own states regarding the use of medical marijuana. Consult your state medical boards and/or departments of professional regulation for guidance where necessary. The train has left the station.
Javette Orgain, M.D., M.P.H., is vice speaker of the AAFP Congress of Delegates.
Rx for Success: PBS Film Shines Light on Health Care Triumphs
I recently watched a documentary that put a song in my heart and left me inspired by people who decided to take control and make a difference in the world around them -- for their patients, their teams and their communities. I heard stories of family physicians doing what we do best, despite the many hurdles we all face in a fragmented system. I want you to see what is possible.
David Loxterkamp, M.D., is the son of a physician. For two decades, he was a small-town, small-practice family physician much like his father, a general practitioner, had been. About 10 years ago, however, Loxterkamp decided he needed to make a change.
"I realized medicine is too difficult to do it alone," he said. "This is a really hard, emotionally draining job. You really need someone else to help you out."
Loxterkamp assembled a team to help him care for his small community in Maine, where he still makes house calls. His practice now includes other physicians, nurses, a psychiatrist, a psychologist, a pharmacist, a physician assistant, a medical assistant and a physical therapist.
It's hard to argue with their results. The practice's ER visits have fallen 40 percent in the past four years. One-third of the patients enrolled in a smoking cessation program have actually quit, and the blood sugar level of patients with previously uncontrolled diabetes has dropped dramatically.
David Grubin also is the son of a general practitioner, but he did not follow in his father's footsteps. Grubin is a filmmaker whose documentary, Rx: The Quiet Revolution, makes its debut tonight in many markets on PBS. Grubin said his father had lost faith in the U.S. health care system by the time he retired. Physicians, his father said, didn't have enough time for their patients, and he didn't know how to change a system that valued volume over quality.
Grubin's father, however, had never met anyone like Loxterkamp, one of the four examples the film provides of physicians and systems that have found a way to succeed in a dysfunctional, fragmented health care system.
The film, which will be repeated in most markets and also can be viewed online, delivers a powerful message: It is possible to succeed in our flawed, fee-for-service system. Although Loxterkamp practices in a recognized patient-centered medical home, these success stories didn't depend on the kind of incentives often provided in practice transformation pilots.
For example, Grubin visited On Lok, a San Francisco-based program for the elderly, that has been around since the 1970s. Like Loxterkamp's practice, On Lok takes a team-based and patient-centered approach to care.
The innovative program provides care and social activities for the elderly during the day yet allows patients to remain in their homes at night. In addition to medical care, the program provides services like grocery shopping and cleaning to patients who likely would otherwise be in a nursing home.
According to the film, patients in the program are less likely to visit ERs and hospitals and are less likely to be readmitted than those who live in nursing homes.
With the number of Americas older than 65 expected to double in the next 20 years, such services could be in high demand in the near future. And this film could help more patients be aware of -- and expect -- high quality, patient-centered care.
Grubin's travels also took him to Alaska, where native Alaskans were so dissatisfied with an Indian Health Service program that relied on emergent care that the community took control of the local hospital and built a new system with a strong primary care foundation. Team-based care is again a central theme in this story as is telemedicine, which the system uses to connect remote communities with physicians and pharmacists.
Teams and telemedicine also play prominent roles in the success of a program in Mississippi, which has the nation's lowest median household income and the highest rate of obesity. The state, which has one of the nation's highest rates of diabetes, is trying to address these health problems with a program that provides patients a tablet-based monitoring program that allows them to provide a blood sample each morning.
The program goes beyond monitoring with physicians, nurses, dieticians, physical therapists and more providing care and counseling. As one patient told the filmmaker, "You need somebody that cares."
Clearly, Grubin has succeeded in finding such people. It is critical to point out again that these practices were created in the setting of a flawed, fee-for-service, volume-driven, fragmented and dispassionate system. Individuals, sometimes a family physician and sometimes another team member, took control of their lives and situations. They made changes, big and small, with the most important one being that they would remember to care. They have reclaimed their joy of practice by embracing the essence of team-based, patient-centered care. And now they have shared their stories in this film.
These stories give us hope and show us what is possible.
Reid Blackwelder, M.D., is Board chair of the AAFP.
Dear Payers: Unnecessary Visits Waste Patients' Time
One of the biggest health care challenges we face in this country is the combination of fragmented care and the siloing of different systems. I recently was reminded how important this issue continues to be.
During a recent clinic, most of my patients were logged in with notes related to their insurance rather than a medical need for a visit. Some of them were there for health maintenance per insurance, one was for a "diabetic check per insurance," and so on. Oddly, this was a group of patients that I had seen only a few months ago.
I asked these patients why they had come in, noting that I had not expected to see them so soon. (In fact, I had not planned to see them for a year, assuming they weren't ill.) Most of them said they had received phone calls from their insurance companies stating they needed to be seen for a health maintenance visit, but in reality, no such need existed.
Family physicians provide health maintenance during every visit, but we must make sure we code appropriately because, unfortunately, insurance companies often pay more attention to codes than to the actual care being provided.
As I reviewed their records, I realized that in my efforts to care for my patients, I had neglected to care for their charts by indicating an ICD-9 "V" code (e.g., V70.0, "Routine general medical examination at a health care facility") within the timeframe of the insurance calendar. However, each of these patients had indeed had health maintenance evaluations. When I had seen them in November, we had gone through the management of their chronic diseases, any acute issues, their biopsychosocial issues, and we had also addressed their individualized preventive services aspects -- all of the things that we routinely address.
Each patient had Physician Quality Reporting System measures checked and recorded, and I reviewed health maintenance and documented it clearly in the chart; however, as this was just a routine part of what I did, I was billing based on their medical disease management.
Despite their efforts, my patients had been unable to convince the insurance representatives on the phone that they had actually covered all of these issues. In fact, one patient who came to me for a diabetic check per insurance does not even have diabetes, and so this was another issue I documented.
Rather than calling patients -- who reported that they felt "harassed" by the payers -- it would make more sense in a nonfragmented system for insurance companies to call physicians so we can review what care has and has not been offered and provide any necessary information. My hope and ideal would be that all payers look for ways to connect with physician offices or, better yet, implement a system that would note the checkboxes that indicate the appropriate health maintenance measures were indeed done without the V code.
Better and easier communication with payers would benefit patients and physicians and help payers avoid unnecessary costs. Several of the affected patients had Medicare, but when I tried to call that payer I was unable to get a real person on the phone. The patients did not have any related paperwork with them, so I couldn't identify a direct help phone number. So, we covered whatever clinical issues needed some attention. Then, without really requiring anything specifically for the health maintenance, I diligently coded V70.0s and documented the previous discussions in their charts.
The sustainable growth rate formula legislation that passed the House last week includes steps to consolidate performance measures in an effort to decrease administrative burdens. It would be helpful if interoperability existed that would allow immediate tracking when such measures were done anywhere in the health care system. Although we have made some progress, there is still a great deal of work to be done.
One of my favorite quotes lately is, "It is not patient-centered until the patient says that it is patient-centered." Forcing patients to make unnecessary office visits certainly misses the mark.
Reid Blackwelder, M.D., is Board chair of the AAFP.
FP Recommendation Key to Boosting Colorectal Cancer Screening Rates
Each year, more than 130,000 U.S. adults are diagnosed with colorectal cancer, the nation's second-leading cause of cancer deaths. Despite those stark statistics, nearly one-third of adults ages 50 to 75 aren't getting screened as recommended.
In an American Cancer Society survey of unscreened patients, one of the leading reasons respondents gave for not being screened was that they had not received a screening recommendation from a physician. Family physicians are positioned to make a huge difference in closing this gap because we provide roughly 200 million office visits each year to a vast spectrum of patients.
A physician discusses care options with a patient. An American Cancer Society patient survey indicates that a physician recommendation can make a big difference in whether or not patients are screened for colorectal cancer.
So it was no surprise last year when the National Colorectal Cancer Roundtable (NCCRT) -- chaired by family physician Richard Wender, M.D. -- sought the AAFP's support for its 80% by 2018 initiative, which seeks to increase the percentage of adults ages 50 and older who get screened for colorectal cancer to 80 percent by 2018.
It's been estimated that achieving that goal would prevent more than 200,000 deaths because colorectal cancer can be detected early -- when treatment is more likely to be successful -- and even prevented through the removal of precancerous polyps.
So where do we stand? The percentage of U.S. adults who have been screened increased from 56 percent in 2002 to 65 percent in 2010. And as the screening rate has risen in recent years, cancer incidence has dropped in this age group.
Still, much work remains to reach the initiative's goal. College graduates are screened at a rate of more than 80 percent, but disparities exist for many other populations. Patients with less education and income, the uninsured, underinsured and certain minority groups have dramatically lower screen rates and higher cancer rates.
So how do we reach these populations? I recently participated in an event hosted by the American Cancer Society and the NCCRT that looked at the progress made during the first year of the 80% by 2018 initiative. We heard from some of the more than 200 groups that have pledged to help boost the screening rate. Those groups range from individual physician practices to national physician organizations and also include payers, public health groups, national retailers and others. In some communities, family physicians, gastroenterologists, public health officials and others are working to identify unscreened patients and direct them to affordable care.
For example, John Allen, M.D., M.B.A., president of the American Gastroenterological Association, said during the event that a grant from Walgreens had helped physicians in Connecticut identify and screen more than 300 patients. Of those, 46 percent had precancerous polyps.
In Arizona, the state department of health is working with one payer to provide screening information to 200,000 patients, as well as providing related CME to physicians.
Earlier this month -- which happens to be Colorectal Cancer Awareness Month -- Mississippi announced a statewide program that aims to increase screening rates in that state to 70 percent by 2020. Although that goal is lower than the NCCRT's objective, it would be a giant leap for Mississippi, which has the nation's highest mortality rate -- and one of the lowest screening rates -- related to colorectal cancer.
What can we do in our own practices? We can make that all-important recommendation during visits with patients ages 50 to 75, and we can follow up with reminders through mail or email.
We also can be sensitive to what type of test patients are willing to do because although some may be hesitant to have a colonoscopy, they may agree to do a take-home test. Remember that a typical series of take-home stool tests does qualify as screening and should be done annually. However, a single, one-time, in-office stool test does NOT adequately screen for colorectal cancer.
In my federally qualified health center, we are helping eligible patients get coverage through the health insurance marketplace. Although screening is a covered preventive service, follow-up care could require a copay in some health plans.
Family physicians build relationships and trust over time. By making a recommendation and providing reminders, we can help achieve this important, life-saving goal.
Wanda Filer, M.D., M.B.A., is president-elect of the AAFP.
The Folly of Judging Physicians Based on Patients' Foibles
Physicians write nearly 4 billion prescriptions each year in the United States, yet roughly half the patients who come to us for help fail to take their medications as directed. Among older patients, the proportion could be as high as 75 percent.
Patients often suffer the consequences when they don't take their medications as directed, but so, too, do physicians when reimbursement is tied to outcomes and community metrics. This can create an adversarial relationship between a prescriber and a "noncompliant" patient, which is antithetical to the kind of relationship family physicians want to have with their patients.
I recently attended a presentation about minimally disruptive medicine, which means simply health care that is designed to meet the goals of the patient while also considering the capacity of the patient to meet those goals.
This overall concept gets at the issue of noncompliance and whether we should even use that term. Noncompliant conjures up an image of a patient who disregards our advice because he or she doesn't value it, but the truth is that any number of factors can prevent a person from adhering to a prescribed regimen, including insurance coverage, out-of-pocket costs, health literacy, cognitive issues, social problems, transportation and more.
The speaker gave the example of a 55-year-old man who had several chronic conditions, including diabetes, high cholesterol, hypertension and obesity. Due to his multiple conditions, his physician advised him to exercise, but the man had a blue-collar job that caused him back pain. That pain rendered him largely sedentary at home, which exacerbated his chronic conditions.
In addition to his physical health concerns, the man's chemically dependent daughter had moved into his home along with her children to escape an abusive relationship. And on top of everything else, the man was suffering from depression.
The patient said he was simply overwhelmed, was unable to exercise and had little time to make the office visits his physician recommended to keep his conditions in check.
We've all had patients like this. They are aware of their health problems and would like to address them but feel unable to do so. Some are merely treading water. That leaves the physician with the unenviable choice of "firing" patients or continuing to try to help them under the very real threat of financial penalties.
Payers would like patients to fit neatly into a single mold but the reality is that patients need an individualized plan that fits their needs. Progress in addressing chronic conditions -- even if it's just baby steps -- should be valued rather than discounted, and physicians should not be penalized for being unable to force a patient with multiple chronic conditions to make miraculous improvements in the face of a litany of obstacles.
I had a patient whose hemoglobin A1c was 14. We were able to bring that number down to 10, which is a significant improvement. But from a payer's perspective, it wasn't good enough because my community metric is 8.
Using these types of quality measures across the board has unintended consequences, and physicians are being punished unfairly for failing to live up to these expectations. Drawing a line in the sand and saying, "Meet this number," fails to recognize the value of the work primary care physicians are doing to reduce the burden of illness and costs to the health care system if a patient happens to land slightly outside an ideal target area.
Being sick is emotionally, physically and financially hard on patients. We need to look at how we can partner with patients and individualize their therapies so they can make progress toward health goals that make sense for them -- not just for us and certainly not for payers.
Lynne Lillie, M.D., is a member of the AAFP Board of Directors.
Curbing Childhood Obesity Requires Moving Beyond the Exam Room
A concerned parent recently brought her child to see me, worried that the child was underweight. A check of the patient's height and weight confirmed what I suspected -- the child's body mass index was normal. The problem likely is that so many of the child's peers are overweight or obese that the parent's sense of normal was skewed.
Our state, North Carolina, has the fifth-highest rate of childhood obesity in the nation, affecting nearly 20 percent of children ages 10-17 years. Nationally, more than one-third of all children and adolescents are overweight or obese.
|More than one-third of U.S. children and adolescents are overweight or obese.|
The White House recently marked the fifth anniversary of the first lady's Let's Move campaign, an ambitious national program to combat childhood obesity that the AAFP has supported. But efforts to address this epidemic have shown mixed results. In the first two years after the program launched, the obesity rate among children ages 2-5 years dropped nearly 4 percent, but the rate among those 12-19 increased more than 2 percent during the same period. Overall, the rate of childhood obesity was steady at nearly 17 percent.
The Robert Wood Johnson Foundation recently doubled down on its investment in childhood obesity programs, matching the $500 million commitment it made in 2007 with a pledge for another $500 million during the next 10 years.
But what can we as family physicians do in our own communities? When I was president of the North Carolina AFP, our chapter partnered with the state agricultural extension agency to provide nutrition education in family medicine practices. We identified children who were overweight or obese and provided education for entire families in large-group visits. We also worked with the extension office to develop a Web-based resource that included the menus of the popular fast food restaurants in our region. The database allowed users to compare nutrition information of various menu items so that they could make healthier choices when they ate out.
Both of those programs were funded by the state's Health and Wellness Trust Fund, which provided grants with money from the Tobacco Master Settlement Agreement. Although those funds are long gone, family physicians can still find creative ways to help families eat better and increase physical activity. And we can help families beyond the work we do in our exam rooms.
For example, Tommy Newton, M.D., of Clinton, N.C., created a program that rewards elementary students for achieving certain fitness goals. The 10-year-old program, used in schools across the county, has more than 3,500 students enrolled and has been shown to improve children's fitness and self-esteem.
One of the challenges many families face is the lack of a safe place for children to play. Gone are the days (in most communities) when parents felt comfortable allowing their kids to ride their bikes around town -- or even play outside in their own neighborhoods -- without supervision. One of our local communities has addressed that by completing a bike trail that stretches from one end of the city to the other, providing a safe place for families to exercise.
What is your community doing to address this crisis?
Mott Blair, M.D., is a member of the AAFP Board of Directors.
Maternity Care, Solid Team Training Build Strong Bonds
For me, nothing cements my relationship with patients and their families like the birth of a child. It is heart-warming for me to be part of the privileged minority of family physicians who continue to provide maternity care as part of a full-scope practice.
Getting here was no accident. I grew up in rural Washington, and when I was born in the local small community hospital, a family physician was there for the delivery. The same family physician delivered my sister and brother, and he later mentored me during high school when I worked the night shift as a hospital orderly to get a taste of a career in health care.
During my second year of medical school, I was fortunate to find a family physician preceptor for my continuity clerkship who not only practiced maternity care in the hospital but also provided care in patients' homes, working with a certified nurse midwife to provide home births and births in his office-based birthing center.
The experience of following families through prenatal care and then being invited into their homes to assist with a birth had me hooked, and watching those newborns grow and develop during the course of their well-child care set the hook for good.
In the multicultural community my medical school served, it was not uncommon to have multiple generations present for births and well-child visits. The safe birth of a healthy baby often came as a relief to the elder members of the families, whose previous experiences with childbirth had not always been so joyful.
The contrast between taking care of a selected, “low-risk” population of women having home births and my experiences as a medical student on the OB service of a quaternary care university hospital was enormous; I saw that a comprehensive education and residency training program in family medicine, taking care of the highest-risk/highest-acuity pregnancies, was definitely a necessary start on my path to a full-scope practice. Little did I know how much I would miss taking care of the low-risk patients until those first few months of residency in the county hospital, where every patient seemed to have a myriad of medical and social challenges. The vaginal delivery of a healthy, term baby was rare, except for patients who received prenatal care through our family medicine clinic. Although they had many of the same demographics as the rest of our county hospital patients, and many of the same obstetrical challenges, the clinic patients had the advantage of continuity of the team and integrated care of the family.
Now, more than 30 years after residency, I am sitting in the labor and delivery unit, reflecting on the experiences I have shared with the family I am caring for tonight. We have a long history together; this is their second child, coming more than 15 years after the birth of their first. That beautiful baby girl, who has grown into a mature young lady, is here with her dad, helping coach her mom during labor. Between her birth and tonight, there have been three miscarriages, including a molar pregnancy.
The couple had almost given up hope of another child, but tonight, hope comes home to stay. We have time to talk about their first childbirth and the family medicine resident who was there with me. That resident subsequently became a partner in my practice. We reminisce about that stubborn little girl who decided she was going to arrive in the wee hours of the morning. She had a compound presentation that required extra help and effort. Everything turned out fine, but I am reminded how challenging it was to keep panic out of the room that morning until help arrived.
And yet I am confident this evening -- working with another resident -- that no matter what the challenges may be with this labor and delivery, panic will not show its ugly face. How can I be so confident? I sum it up in one simple but profound concept.
A team of experts does not automatically make an expert team. That is one of the tag lines in the “Safety in Maternity Care” chapter I helped write for the AAFP’s Advanced Life Support in Obstetrics (ALSO) program when I joined the ALSO Board years ago. Teamwork training, as simple as it may sound, saves lives. There is a growing body of evidence that simulation and teamwork training specifically regarding obstetrical emergencies saves mothers and babies no matter the setting, whether it be in the regional perinatal center (like the one I am sitting in this evening), a rural hospital in Tanzania or the maternity hospital in Baghdad (where I taught an ALSO course last year).
Tonight’s team is different from the team I worked with nearly 16 years ago; everyone on the labor and delivery unit tonight has been through an ALSO course. Five years ago, after some adverse events that could have been prevented, the obstetricians, family physicians, nurse midwives, labor nurses and mother-baby nurses here voted to require ALSO certification and ongoing maintenance of that certification for every person working on the unit. We are proud that safety has become the focus of our care. Teamwork is integral to everything we do, and this high-risk perinatal center serving a high-risk, multiethnic population has the lowest C-section rate and highest safety ratings of any hospital in our state.
I salute the AAFP’s commitment to ongoing education in maternity care, from the ALSO courses for practicing physicians and other maternity care professionals, to the Academy's Family Centered Maternity Care course, to the Basic Life Support in Obstetrics courses targeted to medical and nursing students, prehospital care professionals and emergency department staffs and, finally, to the international work ALSO and Global ALSO continue to do.
I have to go now. The newest member of the family is about to arrive.
Carl Olden, M.D., is a member of the AAFP Board of Directors.
Health Tech Developers Could Use Physician Input
I always wanted to attend the Consumer Electronics Show, not only to see what all the hype was about but also to find out if there were innovative ideas that could be used to strengthen primary care and help family physicians better meet our patients' needs. Finding ways to improve patient access, care coordination and engagement while achieving the Triple Aim -- better care, better outcomes and lower cost -- may require new approaches and an open mind, and I wanted to see if any technologies were on the horizon as part of those solutions.
I couldn't have picked a better year to finally make it to Las Vegas. The number of biotech and health companies participating in the recent international show increased by more than 30 percent this year.
Photo Courtesy the Consumer Electronics Show
Attendees look at
smart watches on display at the Consumer Electronics Show. More than 50
wearable health and wellness products were on exhibit last month at the show in
More than 150,000 people trekked to the Las Vegas Convention Center to see the latest high-tech gadgets. Exhibitors covered more than 2 million square feet with the latest innovations in automobiles, televisions, headphones and more. I didn't have time to see everything, so I focused on the exhibits that had the potential to improve health and wellness.
What did I see?
How about bike pedals that can track a cyclist's speed, distance, elevation, calories burned and record his or her route?
Or a patch that can monitor a patient's temperature for 24 hours, tracks changes and send alerts to physicians?
Could your patients benefit from a product that tracks calories through a wrist sensor and monitors heart rate, blood flow and fluid levels?
Although there were plenty of innovative ideas on display, the biggest trend was wearable devices. There were dozens of companies hoping to be the next Fitbit. In fact, more than 50 wearable products were being promoted at the show.
Why the glut? Roughly 19 million wearable products were sold last year, and that number is expected to more than triple within the next three years. But as I made the rounds and talked to these companies on the show floor, I had to question how much some of these companies knew about U.S. health care. And were they making a product because it fit a need or simply because they had developed a cool, new technology?
For example, I talked to representatives of the company promoting the temperature monitor. That product is being marketed primarily as a pediatric device. When I asked them, "What about geriatric patients?" they admitted they hadn't considered that possibility.
I talked with multiple foreign developers who were each marketing more than a half dozen gadgets that can monitor a user's temperature, blood pressure, blood sugar, etc., and they each had their own proprietary platform that feeds data into one place. A patient could easily use such a system to send his or her information to a physician. The problem is that a consumer would have to buy all these gadgets from the same vendor because the competing systems aren't interoperable. Sound familiar?
The disconnect between developers and health care was one of the reasons I was glad to see family medicine prominently featured at the show. A panel of physicians representing the Health is Primary campaign hosted a panel discussion that urged increased collaboration among technology companies, physicians and consumers during a presentation about health technology.
According to an AAFP survey released at the event, more than 50 percent of family physicians recommend health and wellness apps to their patients, and more than 40 percent use apps at the point of care.
So what's the problem? Roughly 40 percent of respondents indicated they had reservations about using apps because of questions regarding the evidence or proven effectiveness of these products. With more collaboration that could change because we could help developers make better products to help our patients.
That isn't to say product developers don't have good ideas. I talked with one exhibitor who has developed a new app that helps consumers create appropriate diets for patients with diabetes. The app assists with menu planning, recipes and grocery lists. The developer hopes to make the app free to patients by working with stores and manufacturers to distribute relevant coupons through the app.
Again, I wondered if this idea could go further. Could it, say, help patients with heart disease adhere to a low-sodium diet? The developer hadn't thought of that possibility.
In the short time since the show ended, I've already exchanged emails with a few developers who realize family physicians can help improve their products, making them more beneficial to a wider audience.
I also realized that not only could family physicians help product manufacturers, we could bring our own ideas forward. For example, I know a family physician in Kentucky who has developed an app that allows practices to offer after-hours visits via a smartphone. With ever improving technology, not every visit needs to be face to face.
Tech developers could certainly benefit from our experience. Too often, physicians have been the victims of well-intended technology that was developed without sufficient physician input. Technology should be a tool, not a burden.
Do you have ideas for new or improved tools that could benefit our patients and our practices?
Wanda Filer, M.D., M.B.A., is president-elect of the AAFP.
New AAFP Guideline Adds to Evidence Supporting VBAC
It has been more than four years since the American College of Obstetricians and Gynecologists updated its recommendations for vaginal birth after cesarean (VBAC), stating that VBAC is "a safe and appropriate choice" for most women who have had a cesarean delivery. Still, women are frequently denied labor after cesarean (LAC) because of hospital or practice policies that conflict with evidence-based guidelines.
Fortunately, this hasn't been an issue for me or my patients at either of the hospitals where I provide maternity care. My practice encourages VBAC whenever possible because the overall risks associated with a vaginal delivery are actually lower than the risks associated with a C-section, and certainly with subsequent C-sections. The recovery time is much faster with VBAC, and that shorter recovery contributes to a more positive experience for moms and also makes it easier for them to do other things, such as breastfeeding their babies.
LAC, of course, doesn't always lead to a vaginal delivery. In fact, less than a third of my patients who attempt it are actually successful. The two main challenges have been maternal exhaustion and the inability to help labor along with certain medications.
That second challenge, however, is changing. Although ACOG's recommendation statement offered limited and somewhat conflicting information about the use of oxytocin to induce labor, the majority of research in this area pointed to an increased risk of uterine rupture. Regarding the use of oxytocin to augment contractions, however, "The varying outcomes of available studies and small absolute magnitude of the risk reported in those studies support that oxytocin augmentation may be used in patients undergoing (trial of labor after cesarean)."
For me, that wasn't a strong enough endorsement at the time. But now, the AAFP has published a new VBAC guideline that also supports the use of oxytocin for induction and augmentation of labor.
In fact, the guideline states that "there does not appear to be an increased risk of uterine rupture associated with oxytocin augmentation of labor." It also says that "augmentation of labor with oxytocin is associated with a 68 percent rate of VBAC."
For my practice, this changes everything and provides a new pathway to help my patients who want to try LAC. Having that chance is so important because some moms who want a vaginal delivery feel bad and blame themselves when they have to have a C-section. Having an attempt at vaginal delivery -- even if unsuccessful -- takes away some of that guilt because they know they did everything they could. This aspect shouldn't be overlooked given the importance of mental well-being during the postpartum period.
And when these moms succeed, the joy is immeasurable. They not only have the pride and happiness that is typical of a new mother, but they have accomplished something they previously were told they could not do and achieved the kind of delivery they wanted the first time.
Emily Briggs, M.D., M.P.H., is the new physician member of the AAFP Board of Directors.
Annual Exams? Tailor Visit Frequency to Patients' Needs
Ezekiel Emanuel, M.D., recently offered some interesting advice to the more than 2 million readers of The New York Times. Emanuel, who is an oncologist, said Americans should skip their "worthless" annual physicals.
This message -- conveyed via our nation's largest metro newspaper -- has caused a great deal of concern among primary care physicians, as well as confusion among our patients. As with so many things, significant aspects of this issue are overt, but many more are nuanced.
One of the issues Emanuel raises is the increasing evidence that doing a complete annual physical exam does not improve morbidity and mortality. This correlation is actually fairly well proven. In fact, significant data, including the book Overdiagnosed: Making People Sick in the Pursuit of Health, by Dartmouth professor H. Gilbert Welch, M.D., M.P.H., suggest that reliance on routine complete physicals and indiscriminate use of various labs and screenings actually confer more harm than benefit. Such evidence is the basis of Choosing Wisely, the AAFP-supported initiative that identifies overused tests and procedures and encourages physicians and patients to discuss those options before incorporating them into a treatment plan. The Academy has identified more than a dozen tests and procedures that have questionable value for certain groups of patients.
© 2014 Sheri Porter/AAFPHere I am listening to a patient during an office visit. A recent New York Times editorial against annual exams minimized the importance of the physician-patient relationship.
And although the AAFP does not have a guideline recommending annual exams, we certainly aren't recommending that patients stay home until they have an acute illness. The frequency of visits should be tailored to the patient, based on recommended screenings and conversations between the physician and patient.
It's worth noting that much of Emanuel's argument against annual exams is built on a 2012 Cochrane Collaboration review that considered only asymptomatic patients. According to the CDC, half of U.S. adults have at least one chronic condition, and 25 percent have two or more. Now ask yourself, "What percentage of my patient panel would I feel comfortable not seeing until they had an acute illness?"
Every patient deserves individualized care. Family physicians don't treat the "average" patient. We don't treat diseases, and we don't treat labs. We treat people and families. Accordingly, we have to take the evidence and put it into the context of that specific patient and his or her needs. This can include a patient who feels strongly that he or she should have a screening test or a complete physical even with the awareness that it may lead to a cascade of labs or evaluations that might not be otherwise indicated. Being patient-centered means having these conversations and supporting our patients in their choices even if they go against the evidence.
Emanuel briefly, and grudgingly, acknowledges that an annual exam provides an opportunity to "reaffirm the physician-patient relationship." But in dismissing the exam as having no benefit, he minimizes the importance of that ongoing physician-patient relationship. The annual exam is an opportunity for primary care physicians to strengthen this bond by speaking with our patients and getting to know them better. This helps us provide better care when they ultimately need it and enhances their trust in us.
Establishing this relationship early is critical to yielding the best dividends when people become ill. This trust and caring can only be created in the setting of an ongoing and growing relationship that requires face-to-face visits. The relationship also facilitates the primary care physician's role as a cost-effective coordinator of the patient's health services by making early detection of problems possible.
So what about frequency? Patients should be seen based on their age, their gender, their health care philosophy and needs, their problems and diseases, and multiple other factors. The ultimate goal should be to maintain and nurture the relationship. We should focus on appropriately addressing the patients' concerns, as well as on formulating an agenda based on our understanding of where that patient is in achieving health and minimizing disease. So, not only do we consider what an appropriate screening protocol is for each patient, we also address the all-important behavioral and lifestyle aspects that impact morbidity and mortality.
What we need isn't reliance on an annual physical. Instead, we need to continue to push for changes in our health care system that ensure the care we deliver is focused on prevention and evidence-supported measures that are individualized for each patient. Family physicians are ideal for this role. We must continue to move health care delivery in this direction, and physician payment should reflect the value and power of this relationship and what we provide.
Reid Blackwelder, M.D., is Board chair of the AAFP.
Beating Burnout: Get Involved, Call for Change
During AAFP Assembly last fall in Washington, keynote speaker Dike Drummond, M.D., asked family physicians in a packed ballroom to raise their hands if they had experienced symptoms of burnout. Hundreds of hands -- far too many -- went up.
Although disheartening, the response certainly wasn't surprising. According to a 2013 Medscape survey, more than 40 percent of U.S. physicians reported experiencing at least one symptom of burnout (loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment). A 2012 study in JAMA Internal Medicine found that more than one-third of physicians were burned out.
|More than 40 percent of U.S. physicians experience at least one symptom of burnout.|
Some of the reasons for this crisis -- such as administrative burden, difficulty finding work-life balance, feeling undervalued, frustrations with referral networks, government regulations, and (of course) reimbursement issues -- are shared across different types of family medicine practices. Other factors may vary from practice to practice. For example, employed physicians like me may be struggling with the loss of control over our day-to-day practice. Meanwhile, some small and solo independent practice physicians may be having difficulty figuring out how to meet the latest regulatory requirements with limited staff resources.
In addition to these challenges, physicians face more and more pressure to meet or exceed patient expectations. Patients want to be heard and family physicians want to listen, but in our stressed work environments, we often don't have enough time -- more than the typical 15 minutes – or adequate resources to meet the needs of our complex patients. I've had patients thank me for listening and for being thorough, but how often do we hear that? Based on the current environment, I would say not nearly enough.
A growing number of my colleagues seem discouraged, and it saddens me to hear family physicians say things like, "I don't know if I can do this anymore." Many physicians are responding to burnout by limiting their scope of practice, reducing their work hours, or leaving the practice of medicine altogether. According to a 2012 Urban Institute data analysis 30 percent of primary care physicians ages 35-49 planned to leave their practices within five years. The rate was more than 50 percent among physicians 50 and older. Those numbers should alarm anyone aware of the already glaring shortage of primary care physicians.
Clearly, this is becoming a crucial public health issue. The drivers of burnout are different for each individual physician, but the impact of physician burnout is affecting health and health care delivery for every consumer in the country. If we don't address these drivers and take care of the physicians we have, there will not be enough of us left to care for the health of our nation.
An article published in the November/December issue of Annals of Family Medicine suggested that the triple aim framework -- which calls for better care, an enhanced patient experience and lower health care costs -- needs the additional aim of improving the work life of physicians and our staff members.
So what do we do about it? Individual physicians may be able to help themselves by better managing their stress or by seeking support. But what about change on a broader scale?
I've had my own experience with burnout. When I felt that I needed to get off the hamster wheel, one of the things that helped me refocus was getting involved and advocating for change. I've been involved with the Academy for years through the Congress of Delegates, commission work and the National Conference of Special Constituencies. But the No. 1 issue that prompted me to run for the Academy's Board of Directors last year was burnout. I don't know all the answers to solving burnout, but I know it must be addressed.
The Academy adopted a position paper on the issue last year. And it's worth noting that the AAFP last year created 10 member interest groups to provide a forum for members with shared professional interests. The MIGs provide new outlets for members to make their voices heard.
The AAFP also is working to address many of the drivers that lead to burnout, including payment reform and administrative burdens related to electronic health records.
Finally, we need to remove the stigma from burnout. Physician who need help shouldn't be afraid to ask for it. If you feel burned out, know that this is not a weakness or a character flaw, and you are not alone.
You can help yourself with resources that support personal resilience and time management skills, but you also can tackle the problem on a broader scale by working within your organization to address the drivers of burnout in your practice. And know that the AAFP will continue to work to alleviate regulatory burdens and other factors that contribute to burnout.
Lynne Lillie, M.D., is a member of the AAFP Board of Directors.
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