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Wednesday Dec 07, 2016

Time to Lift 16-Hour Limit on First-year Residents

The AAFP is supporting a proposal that would increase the number of consecutive hours first-year residents can work from 16 hours to 24 (plus the possibility of four additional hours for the completion of care of an individual patient).

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Friday Nov 11, 2016

Lead by Example: Train Students to Report Medical Errors

Ninety percent of medical students reported observing adverse events in a recent study, but only 51 percent reported them. This conundrum is not new; more than a decade ago, a case study concluded that medical students' value in ensuring patient safety is often overlooked. Gary LeRoy, M.D., writes that this has to change.

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Tuesday Nov 08, 2016

Don't Let Implicit Bias Shape Physician Workforce -- or Patient Care

A study at Ohio State University College of Medicine revealed implicit white preference by the admissions committee. This is significant because black, Hispanic and American Indians and Alaska Natives are underrepresented among medical students. However, AAFP student Board member Lauren Abdul-Majeed writes that many admissions committee members were mindful of their individual results when interviewing medical school applicants the following year. Consequently, that class was the school's most diverse ever.

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Tuesday Sep 27, 2016

Meeting With Mentor Underscores Importance of Relationships

A meeting with the mentor who introduced her to family medicine nearly 40 years ago highlighted a week that left Wanda Filer, M.D., M.B.A., feeling like she had been "immunized against burnout."

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Tuesday Jul 12, 2016

Try PROBE Tool to Help Stave Off Burnout

When a friend of a friend of mine committed suicide recently, it hit me harder than I would have imagined. I didn't know the man and knew little about him other than that he was an emergency medicine resident and a member of the gay, lesbian, bisexual and transgender community.

When I learned of his tragic passing, I went back and read something he had posted on social media a couple of years ago that stood out as particularly poignant: He wished he could be more proud to be a gay physician and support others who struggle with self-doubt.

Roughly twice as many physicians experience emotional exhaustion as do adults in the general working population.

The pressures of our profession can be stifling, especially for folks who are hesitant to be open about who they really are. Although each of us faces our own set of circumstances and personal needs, the rate of emotional exhaustion among physicians is about twice that of the general working population. Some theorize that too much empathy can induce compassion fatigue, leading to irritability and uncompassionate treatment of those closest to us. Unfortunately, the consequences of burnout are steep. We lose a doctor a day to suicide. But with proper tools and vigilance, we can help foster wellness and prevent medical student and resident burnout, depression and suicide.

Simultaneously, we can't ignore the many systemic failures that contribute to burnout, including disrespectful behavior that erodes empathy, curricula that don't emphasize social responsibility and engagement, and the unwieldy demands of electronic and paper nuisances.

As our vernacular shifts from a mutually exclusive "work-life balance" to a more holistic "work-life harmony," future physicians can find ways to mediate and integrate multiple commitments while bolstering our resolve. One of the paradigms I came up with recently is the acronym PROBE, which stands for Prioritization, Reflection, Organization, Burnout prevention/mitigation and Expectations. The elements of PROBE may help physicians recognize mild to moderate burnout and do better for themselves, their colleagues, and their patients by exploring some of the suggested tools. However, I would implore anyone who is experiencing severe burnout to set aside any perception of the condition as "a weakness" and to promptly seek the help of other professionals.

  • Prioritization -- Pamela Vaccaro, M.A., outlined the idea of the 80/20 rule, which states that 20 percent of your efforts provide 80 percent of the results, in a 2000 Family Practice Management article. She recommended engaging in activities that advance your overall purpose in life. I would suggest this includes developing a shared vision of the future with those closest to you.
  • Reflection -- Simply by checking in, you can bring awareness to a difficult moment. Apps such as Headspace may help with increasing the regularity of this process, and the MySelfCare.org quiz might help you gauge compassion fatigue. My fellow AAFP Board member Lynne Lillie, M.D., wrote an excellent post on mindfulness meditation a few weeks ago. Progress can be made by monitoring and measuring what you're doing. Debriefing with fellow residents, a partner and/or faculty are great ways to decompress after tough situations. My residency holds monthly sessions (based on Balint group structure) during which residents share patient stories and tips for dealing with stressful situations. Surgical residents at Stanford University developed a comprehensive Balance in Life program that includes faculty mentors, healthy food, stress management and social events.
  • Organization -- One's (digital) house is a reflection of one's inner mind, so working to relieve a cluttered inbox, keeping a repository of readings (e.g, on Google Drive, Dropbox, or using the free AAFP app for podcasts and FP Essentials issues), and learning time-saving tricks to use in your electronic health record system can all help you to be more efficient in your day-to-day tasks. This, in turn, may have the egosyntonic effect of giving you more time to enjoy the pleasures in your life.
  • Burnout prevention and mitigation -- The Resident Doctors of Canada recently released a Mental Health Continuum pocket card for personal burnout awareness and mitigation that details a spectrum -- healthy > reacting > injured > ill -- with each category listing actions to take and coping skills (e.g., visualization, goal setting, positive self-talk, tactical breathing) to use. The AMA's STEPS Forward collection has an online module highlighting six key aspects for resident wellbeing and the AAFP maintains a list of burnout resources. Finding what works for you in the moment is crucial to avoiding pent-up frustrations that can inevitably release in very unhealthy ways.
  • Expectations -- These can be set unreasonably high, leading to unattainable goals. Talking with those with experience in this area may help in setting reasonable expectations, and you may uncover some wise advice for how to avoid pitfalls. It's also important to guide expectations of family members and friends so you don't disappoint them. Whether it's a new job, a new rotation or a new project, setting your own goals can help you come away with a sense of self-growth.

Hopefully, this acronym will help you PROBE the issue of wellness in a systematic way and lead you to contentment in this healing profession. We have a long way to go to prevent the devastation of burnout in our profession; let's work together and take care of our own.

Richard Bruno, M.D., M.P.H., is the resident member of the AAFP Board of Directors.

Tuesday Jul 05, 2016

Breaking Point Offers Med Students Chance to Grow

Saying goodbye to people you care about is rarely, if ever, an easy task. "See you soon" didn't really work on our last day of medical school because we had no idea when -- or if -- we might be reunited. Although we celebrated our graduation, we said our farewells slowly. As the night progressed, each goodbye hug seemed to last just a little bit longer than the previous one.

The past five years in medical school (I spent an extra year to get a master's degree in public health) taught me not only about my future profession, but also a lot about myself. As I transition to the next chapter of my life, I often think about how the people around me have impacted my personal growth.

Johns Hopkins University School of Medicine students, including me, celebrate our graduation May 16 in Baltimore.

The most distinct memories that come to mind are of the happiest, most lighthearted moments of medical school. My classmates and I have numerous memories we all look back on and laugh at: the awkward times we practiced physical examination on each other while trying to maintain personal space, the random food adventures we managed to pull off at the last minute or the study sessions filled with ridiculous mnemonics.

But medical school was not all joyful times. I grew more during the times of stress, during the times I allowed myself to be vulnerable. Instead of associating these memories with shame, failure or rejection, I have learned to embrace them as wonderful learning opportunities.  

The clearest defining moment of growth occurred on my medicine rotation during third year, but I never thanked the classmate who helped me through it for being so supportive during my lowest point in school. As my medicine attending was providing me with feedback on my morning patient presentation one day, she called me insensitive. I was shocked. I racked my brain for reasons, but I couldn't figure out why. My attending said I labeled the patient as a drug addict by overemphasizing the patient's heroin use, which she thought wasn't relevant to the patient's chief complaint. But actually the patient's drug use was the root cause for her presentation. My failing was that I had not made a strong enough case to clarify the connection. Tired, stressed and frustrated that I had not explained that it took me hours to get the patient to open up and confide in me, I surprised even myself when I broke down and cried in front of my attending and classmate.

As medical students, we constantly had to prove that we were worthy of becoming physicians. Residents and attendings constantly evaluated our performance on each rotation. We continually felt stress and the need to shine during morning rounds, and we mentally prepared for a series of followup questions. Simultaneously, we needed to learn the particular style each attending had while digesting the most up-to-date, evidenced-based guidelines or research studies relevant for the field. The pressure on medical students quickly builds. Ultimately, most of us reach a tipping point and we learn how much we can handle before we shut down.

My attending's reaction to my tears caught me off guard. Her stoic exterior immediately melted into a more maternal response as she recognized my distress. She had seen it numerous times in the past, among both students and residents. We spent the next hour discussing the stressors I had encountered on this rotation and clarified expectations. Although the following two weeks did not get easier as our team cared for incredibly sick and complex patients, this became my most memorable rotation because our team grew as a unit. The attending ensured we had a safe learning environment by deconstructing the traditional team hierarchy. Thus, she alleviated several layers of stress and allowed us to focus more on providing quality patient care.

Despite ending inpatient medicine on a positive note, I did not share my powerful experience with anyone until several months after the rotation ended. I still felt embarrassed about crying in front of my entire team. Slowly, my brave friends shared times they, too, broke down on a rotation. Looking back now, we realized how these moments of vulnerability enabled us to gain incredibly valuable experiences for both patient care and personal growth. During these low periods, we grasped and validated our passion for medicine. We had physically and mentally invested in the care of our patients, and we had to understand that we had this safe space to make mistakes and learn from them.  

Although I am sad to leave an incredible group of friends, I am also excited to start residency. Instead of constantly feeling the pressure to prove myself, I know I can focus on my personal growth as a family physician. I look forward to the joyous, comical memories I will share with my cointerns. Instead of trying to wish vulnerability goodbye, I hope to embrace it to grow into a stronger, more compassionate family physician.

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

Tuesday Jun 28, 2016

Give Back: Making a Plea for Family Medicine Preceptors

"This is so cool!" my medical student says as we run from the clinic to the ER.

I agree. It is only 50 yards or so, but my heart is beating hard -- not because of the distance, but because of the urgency of the nurse's phone call. We were called out of a well-child exam to examine a patient with chest pain and hemodynamic instability.

"I had no idea family docs did so much," the student says.

My clinic has a rotation for medical students, and we also make time for pre-med students, such as Isaac Mitchell (left) of Northwest Nazarene University.

I hear this from many medical students, who often don't realize the full scope of family medicine, especially as practiced in small communities like mine. When I look at my practice through the eyes of a medical student, it tends to shake me out of my complacency and makes me appreciate the incredible diversity of what we do. It really is cool.

This is a plea for more community preceptor sites. We need medical students to experience family medicine away from academic medical centers. If students don't see what we do and where we do it, how can they possibly choose to become community family physicians themselves?

Bringing medical students into your community and clinic is incredibly rewarding and useful. My practice has been accepting medical students for years, and it has become an integral part of our practice.

After 20 years, my practice fits me like a glove. It is easy to become comfortable and even blasé about the day-to-day care my community needs. Mentoring medical students keeps me on top of my game, especially with a generation of medical students who fact-check most of the things I tell them. Indeed, I use them to stay abreast of the latest in medical research, both by keeping me interested in pursuing the literature and by having them teach me. They question everything, which makes me do the same.

I enjoy seeing them realize the incredible breadth of knowledge required in family medicine, as well as the complexity of an office visit, and I tease them about whether they think they're smart enough to be a family physician.

I also explain that they are only seeing the tip of the iceberg when it comes to a patient's history. I spend a lot of time talking about who is related to whom and what unspoken stressors are present -- the whole backstory of why the patient is in the exam room.

I used to worry that my patients would object to having medical students in the exam room, but I have rarely seen this. Rather, most enjoy being a part of medical education.

I often hear patients ask students why they are doing a rotation in our clinic in Valdez, Alaska, although it often comes out as, "Who did you piss off to get assigned here?"

When students answer that they had to beat out 10 of their peers to get the opportunity, my patients leave with a thoughtful expression. The rotation is competitive because we don't have enough community preceptors.

I get it. Teaching medical students does take time, especially if you do it right. But I see my role as not only teaching about family medicine, but also about work-life balance, good relationships, a good medical team approach, a healthy diet and exercise. We take students on adventures to model the concept of work hard, play harder. I freely admit that my partner, Michelle, is an enormous part of this.

The medical students earn their keep, though, seeing patients when it is busy and being an integral part of the health team. Like all family physicians, I have many patients who are complicated and require more time than I can give. I have found medical students are able to address many of the social determinants of health that complicate care, as well as spend the time that many of my patients need.

Given our isolated location on the Alaskan frontier with limited resources and hours away from a tertiary care center, the students often play a critical role. On one occasion, a school bus carrying teenage skiers hit a semi truck on an icy road. Our medical student became an essential part of a system completely overloaded by a mass casualty event.

Another student assisted me in an emergency cesarean delivery of twins during a snowstorm. Students have helped me with severe hypothermia cases and often do a better job than I do on counseling teenagers about health issues.

More than 32,000 medical students are AAFP members, and many of them will gather to learn and share their enthusiasm at the National Conference of Family Medicine Residents and Medical Students, July 28-30 in Kansas City, Mo. They all need our assistance and expertise. There is a shortage of family medicine rotations, made worse by competition with students of nurse practitioner and physician assistant schools, many of which pay clinic sites to precept their students.

These medical students are our future, and they need places to experience the full range of family medicine. I know they won't all go into family medicine as a specialty, but I do expect them to treat family physicians with the same respect as they would members of whatever specialty they ultimately choose. I want them to understand the value of family medicine and how they will work with family physicians if they choose another specialty.

Most importantly, these students remind us who we are as family physicians and why we do what we do.

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


Wednesday Jun 22, 2016

AAFP Award for Excellence in GME: And the Winners Are …

Native Americans account for just 0.3 percent of U.S. physicians, but Hailey Wilson, M.D., overcame those long odds to achieve her goal and now works at a federally qualified health center that serves a largely Native American population.

David Tran, M.D., the son of refugees, also beat the odds to become a physician, overcoming homelessness and the loss of his father during college.

Jerry Abraham, M.D., M.P.H., has served in leadership roles for his county medical society and state medical association board, and this month was a member of the AAFP delegation to the AMA House of Delegates in Chicago.

I could go on about the winners of the AAFP's Award for Excellence in Graduate Medical Education, but the curricula vitae of the 12 honorees -- along with their personal statements and letters of recommendation -- take up some 166 pages of degrees, honors, volunteering, leadership roles, publications and other accomplishments.

The Academy's commissions are tasked with making selections for several awards the AAFP gives in recognition of exceptional service and commitment to family medicine, and it has been my honor this year to serve as the board liaison to the AAFP Commission on Membership and Member Services. At our recent summer meeting, commission members finalized the selections for the aforementioned award, which is given each year to a dozen second-year family medicine residents. The honor, supported by a grant from Novo Nordisk, recognizes outstanding residents for their leadership, civic involvement, exemplary patient care, and aptitude for and interest in family medicine.

Every member of the Commission on Membership and Member Services reviewed each of the more than 100 applications we received. It was an extraordinary time commitment to be sure, but every reviewer echoed a sense of incredible appreciation of the quality and diversity within our specialty. It was difficult to select 12 winners from the numerous exceptional candidates who applied with the support of their residency program directors.

As I thought about writing this piece, I reflected on how much our Academy and its members have influenced the medical school admission process, the selection process for family medicine residents, and the support for new physicians and emerging medical leaders.

Those medical schools with a strong commitment to family medicine and primary care include family physicians on their admission committees. They look for candidates who have connections to rural communities, an interest in a broad spectrum of practice, premedical experience working with diverse populations and underserved communities, and who have been exposed to family medicine. They seek candidates who demonstrate a breadth of knowledge and experience, as well as a desire for lifelong learning that will prepare them for the incredible variety of interactions that characterizes the practice of family medicine.

The medical students who are part of a family medicine interest group and student members of our Academy have demonstrated an early commitment, and extraordinary pre-doctoral faculty across our country are instrumental in encouraging and facilitating the journey of those students toward a family medicine residency program.

Family medicine residency programs apply similar selection criteria, sifting through the myriad of applicants for each of their residency slots, and extending invitations to those whom they feel will fit well into an established health care team that cares for a broadly diverse population. Many residency programs have a special commitment to a specific underserved population and eagerly seek applicants who have special experience and interests that will better prepare them for a future practice serving those communities.

This year's award applications included extraordinary examples of commitment to underserved populations and research, as well as compassion, communication and knowledge-based decision-making. I applaud the commission members who made the difficult selection process work.

The winners will be recognized at a special breakfast on Sept. 22 during the Family Medicine Experience in Orlando, Fla. At last year's award ceremony, I sat with the parents and residency program directors of two incredibly humble individuals who spoke not of themselves or their accomplishments, but instead described how much the mentorship they experienced from practicing family physicians meant to them.

When I read about the 12 individuals who will receive this year's Award for Excellence in Graduate Medical Education, I appreciated how successfully family physicians have influenced the premedical education of our high school and college students, the pre-doctoral education of our medical students and the training of our family medicine residents. Behind each and every individual who receives this award are the thousands and thousands of family physicians across our country who make a difference every day in caring for our patients, their families and their communities. You make it possible for us to recognize a few exceptional family medicine residents. We all should take pride in the impact each of us has in growing the future of family medicine.

Here are the winners:

  • Jerry Abraham, M.D., M.P.H., University of Southern California Family Medicine Residency Program at California Hospital;
  • Margot Brown, M.D., Santa Rosa Family Medicine Residency;
  • Stewart Decker, M.D., Cascades East Family Medicine Residency;
  • Daniel Gordon, M.D., Memorial University Medical Center Family Medicine Residency;
  • Christina Kinnevey, M.D., Sutter Health Family Medicine Residency;
  • Adam Kowalski, M.D., Carl R. Darnall Army Medical Center Family Medicine  Residency Program;
  • Catherine Moore, D.O., Mercy Family Medicine Residency;
  • Charles, Salmen, M.D., University of Minnesota/North Memorial Family Medicine Residency Program;
  • David Tran, M.D., Long Beach Memorial Family Medicine Residency Program;
  • Juan Carlos Venis, M.D., M.P.H., Indiana University Health Ball Memorial Hospital Family Medicine Residency;
  • Hailey Wilson, M.D., Swedish Cherry Hill Family Medicine Residency; and
  • Jason Woloski, M.D., Penn State Milton S. Hershey Medical Center Family Medicine Residency.

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

Wednesday Apr 27, 2016

Keeping a Promise to Share What I Know

When we take the Hippocratic Oath we pledge, among other things, to share our knowledge and teach the next generation of physicians. Like a lot of promises, however, this one isn't always fulfilled.

I was a volunteer community preceptor for a decade in my small town, which is near the University of Wisconsin School of Medicine and Public Health. Three afternoons each semester, or six times a year, one first-year medical student and one second-year student would come spend time in my clinic.

Here I am answering a question from Tyler Grunow, a first-year medical student at the University of Wisconsin School of Medicine and Public Health, between patients. I have been a volunteer community preceptor for more than a decade.

My role was to help students develop history taking skills (illness, chief complaint, past history, family history, current meds, etc.), practice physical skills (such as listening to the heart and testing reflexes) and understanding the doctor-patient relationship and why it's valuable.

It sounds simple enough, and yet our specialty finds itself in a situation where far too few family medicine practices are willing or able help. I get it. A few years ago I was chair of an AAFP commission while also serving on the local board of health and working full time. Something on my overloaded schedule had to go, so I took a break from precepting.

It was a mistake.

While I was on that break I was asked to talk about precepting during a panel discussion at a family medicine conference. One of the questions, ironically, was how do you find time to help students and meet all your other commitments.

I was reminded of a student named Scott, who came to visit my clinic for the fourth time on a particularly busy day. I told him before we got started that he could shadow me that day but that I wouldn't have time for didactic learning.

I felt guilty because I didn't stick to our usual routine, and at the end of the afternoon I apologized. "I hope you got something out of that," I said.

He looked at me surprised.

"Dr. Schwartzstein," he said, "that was our best session yet. I learned so much from watching you interact with patients. It was wonderful."

Scott had learned by observing. He got a sense of the doctor-patient relationship and how it is at the core of what we do. Family medicine is about relationships, and he saw how I interacted with my patients and the level of comfort they had with me.

As I told that story at the conference, I realized precepting wasn't something I could give up in good faith. And I realized it wasn't something I had to give up to maintain productivity. I can do this.

So the med students are back in my clinic, three afternoons a semester, six times a year. Physicians are pressed for time, and many likely think med students will slow them down, hurt their productivity or force them to work late. The reality is that it shouldn't be that big of a burden. In fact, students can add value to a practice.

I find out what students are studying before they visit. If, for example, it's cardio, I make sure they get to listen to patients' hearts. I start by asking if there something specific they want to get out of a visit, and if there is I try to help them with that particular interest.

I try to answer questions between patients or at the end of the day. I ask, did you learn anything today? And I'm eager to hear their answers. Students have different perspectives about new ways to do things, and their questions keep me on my toes.

In addition to teaching when we have students in our clinics, we are recruiting future family physicians. While they no doubt notice the administrative burdens and imperfect EHRs and ask about that, I am careful in how I address those issues. Despite these challenges, I still love being a family doctor, and I am careful to talk about, and show students, that love as I see patients with them.

A long time ago during med school graduation I pledged that I would share what I learn. Now, and until I retire, I will follow through on that promise.

Alan Schwartzstein, M.D., is the vice speaker of the AAFP Congress of Delegates.

Tuesday Mar 22, 2016

Lessons Learned From the Match

Since my previous blog post about my experiences along the residency interview trail, I’ve been touched by the number of friends (many who I hadn’t spoken to in years) who reached out with either words of encouragement or requests for advice regarding my journey to pursue family medicine.

My vision of providing quality health care for all was shaped by a family physician who founded a mobile clinic for his community’s underserved -- primarily homeless -- population. It's a vision of care that isn't limited to the confines of a four-walled clinic. It's primary care that improves the physical and mental health of the community I serve.

My medical school doesn't have a family medicine department, but I was one of three Johns Hopkins students who matched into family medicine. Here I am (second from left, Swedish Family Medicine Residency) celebrating with Adi Rattner (far left, Boston University Medical Center), and Rhianon Liu (right, Sutter Medical Center of Santa Rosa) after opening our letters. Family physician and faculty adviser Nancy Barr, M.D., also is pictured.

I continued to clarify this vision throughout medical school and searched for family medicine residency programs that could further structure my growth. On March 18, I learned which program I matched into, along with more than 3,100 other new family medicine residents. This was the seventh year in a row that the number of students matching into family medicine has increased.

Match Day is not only a pivotal life event that celebrates the latest class of future physicians leaping forward, but also a day of inspiration for all medical students. I recall peering down onto the second floor atrium of our medical school building, watching the prior graduating students open their envelopes simultaneously. It has been exhilarating to watch people’s expressions change as they learn their destiny. This year, it was my turn to be the one jumping up and down, face plastered with a giant smile, hugging friends nonstop as we all learned of our futures.   

Medical students are energized by fourth years who match into a specialty of their personal interests, and they’re optimistic that they, too, can achieve their aspirations.

But despite all the excitement exuded by the graduating seniors, this special day may also elicit stress. Questions immediately arise.

"How can I be a strong applicant like him/her?"

"What activities should I get involved with?"

"Who should I be working with, and who should I be asking to write letters of recommendation for me?" 

Without a family medicine department, medical students at my institution relied heavily on upperclassmen, outside mentorship, and the AAFP website for answers. Here is some of the most high-yield advice I received:

  • Schedule a family medicine rotation in your third year. Family medicine isn't a required clerkship at every medical school. I was fortunate enough to rotate at a nearby hospital as a third-year medical student, which allowed me to gain exposure to family medicine early on. Primary care is delivered in so many ways, so consider experiencing it in a setting you're interested in -- rural, urban, underserved, community hospital, and many more. Each setting may also have specific clinical interests such as sports medicine, maternal care, geriatrics and others.
  • Attend the National Conference of Family Medicine Residents and Medical Students. Due to family medicine's broad scope of practice, this conference benefits students of all specialty interests. First and second years gain a better understating of what family medicine is and the bright future it holds. Third and fourth years explore hundreds of residency programs and identify potential programs they want to apply to.
  • Strolling Through the Match provides a great overview of the residency application process, and it’s free! Ask your Family Medicine Interest Group or local state academy for hard copies.
  • Get involved with the AAFP. The Academy offers incredible opportunities to work closely with inspiring family physicians and future leaders of health care. Positions range from the student level -- such as FMIGs -- all the way up to sitting on the Board of Directors at the national level. I started out as a member of my state academy, served on an AAFP commission and later ran for the Board. I've learned so much and loved every minute!  

When people ask me if family medicine is the right fit for them, I first ask what inspired them to pursue medicine. Was it a specific mentor, patient or experience? Furthermore, how did they initially envision practicing medicine, and how has that vision changed throughout medical school? I also refer people to a great article that answers frequently asked questions about the importance of family medicine.

Throughout medical school, I often reflected on the family physician who shaped my perspective on medicine. As a third year, I realized I truly liked every rotation, but I often saw patients admitted for conditions that could have been prevented if they had a primary care physician. The holistic, full-scope care delivered on my family medicine rotation demonstrated to me a strong future for primary care, and I wanted to be a part of it.

On March 18, I nervously scrambled to FaceTime my parents while counting down until the clock struck noon, and then I opened my sealed envelope. I'm honored to announce that I will be joining my No. 1 program, Swedish Family Medicine Residency at Cherry Hill in Seattle!

Many thanks to my family, friends, mentors, and everyone I have met in family medicine for their unwavering support. I have been so fortunate to be blessed with these great opportunities to grow as an individual as well as a future physician. I hope my personal story will inspire students to achieve their dreams, too, and show them it isn't a one-person journey.

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

Tuesday Feb 23, 2016

Finding Right Fit Key to Match Process

"I'm going into family medicine."

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Monday Nov 02, 2015

Med Students, Schools Must Safeguard Peers' Mental Wellness

My friend was brilliant. He graduated valedictorian of his high-school class and was salutatorian of his undergraduate department. He had other gifts, too, including a phenomenal singing voice that would put Sam Smith to shame.

He also had bipolar disorder, which recently led him to take his own life.

For some students at our medical school, the news of his suicide was shocking. For those closer to him, it was almost understandable.

 Nearly one-fourth of medical students meet depression criteria.

Starting from day one, medical school students are constantly exposed to a host of new and stressful experiences. Support from family and friends can make a big difference, but this type of encouragement may be limited for those who are in a completely new environment far from home. Too often, we try to process these situations in isolation, or we may try to cope in potentially harmful ways, such as through excessive alcohol consumption.

According to a study on mental health in medical students published in JAMA: The Journal of the American Medical Association several years ago, 14 percent of students surveyed at the University of Michigan Medical School had moderate to severe depression, and another study suggested that nearly one-fourth of med students met depression criteria. More shocking, more than one in 10 students (11.2 percent) surveyed in a study assessing burnout reported experiencing suicidal ideation in the previous year. Third- and fourth-year medical students reported higher rates of suicidal ideation than did first- and second-year students. 

Although medical students are at particular risk for experiencing mental health issues, we’re unlikely to seek help. One commonly cited reason is stigma. Earlier in our lives, we were somehow molded to react uncomfortably to topics such as depression, schizophrenia, substance use or suicide. Medical school culture then builds high expectations in which weakness is not accepted. Some of us think that disclosing a mental health condition would lead us to be viewed as incompetent.

Even when students decide to seek help, we face additional barriers. Oftentimes, our busy class or clinical rotation schedules prevent us from scheduling needed appointments. And even if we do have free time, getting an appointment with a therapist may take weeks, and it may be a few months before a psychiatrist is available.

Another friend battling depression sought help and found that the institution’s student mental health resources had a three-week wait. She decided to go to the emergency department that day to contract for safety.

Addressing student wellness has become a priority for medical schools. Initially, most schools focused on increasing access to post hoc, therapy-oriented services for individuals who develop mental disorders or significant distress. But in recent years, comprehensive wellness programs are increasingly being implemented to counteract or balance the negative experiences students may face.

My institution established a college advisory program modeled after Vanderbilt University School of Medicine’s wellness program. Students are divided into four colleges (similar to the Hogwarts houses in the Harry Potter books). Within each college, we are further divided into "molecules" of five students with one faculty member who advises us on wellness and provides career counseling throughout medical school.

We meet with our faculty advisers after each clinical rotation to reflect on experiences from the past eight weeks. The most recent discussion focused on personal growth. A third-year student tearfully spoke about the insecurities he faced on his first rotation. He thought he constantly disappointed his team because he hadn’t met clinical expectations. He didn’t realize the expectations of writing complete progress notes on every patient before rounds and providing sign-out to the night team were beyond the scope of a medical student. Furthermore, his team regularly criticized his oral presentations. Hearing fellow third- and fourth-year classmates relate to his experience and offer advice on future rotations seemed to comfort the student, but the fact remains that he should have been supported earlier in his clerkship.

Additional measures taken to improve student wellness have included a dramatic move from assigning grades (honors, high pass, pass, fail) to using a simple pass/fail system. During the preclinical years, most lecture days end by noon. This provides students time to pursue extracurricular activities that range from conducting research to playing intramural sports to visiting family.

Yet even with these changes in place, my classmate struggled with his mental illness. He refused to seek mental health services and attempted to self-medicate. Ultimately, his strongest support was a small group of classmates who, despite his initial resistance, constantly reached out to him during both his highs and his lows. When he first expressed suicidal ideation, our classmates brought him to the emergency department. When he had his first manic episode, those classmates called police for help. They went through so much with him, and now that he has passed, they are the ones left hurting. Their mental health cannot go unaddressed, nor can the mental health of my classmate’s family and loved ones.

This sad experience offers a strong reminder that we future physicians are not invincible. It is acceptable for us to show weakness and to seek help. After all, if we cannot care for ourselves, how can we care for our patients?

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

Wednesday Sep 30, 2015

Medical Students, We're Only Looking for the Best

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Wednesday Aug 26, 2015

Former 'Orphan' School Embraces Family Medicine to Drive Progress

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Wednesday Aug 05, 2015

Students, Residents Show Their Passion for Family Medicine

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

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

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

Photo courtesy of Warren Yamashita

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

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

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

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

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

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

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

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

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

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

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

Me too.

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

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