Rural Recruiting, Retention Proves Daunting
I went to college in St. Louis, med school in Cleveland and residency in the Houston suburbs. If you had asked me back then where I would be living when my training was complete, I never would have guessed a rural mountain town on the West Coast. But this city girl has grown to love rural medicine.
The beautiful scenery, family life and the ability to be present in the day-to-day functions of our home were the main reasons my husband and I first decided to leave an urban environment for a much quieter setting, but my desire to work with the underserved translated naturally to this new setting, as well.
| Here I am talking with patient Gail Ruby during a recent office visit. Unfortunately, I'm leaving my rural practice in California because of the local hospital's lack of support for primary care.
I quickly realized that the struggles related to poverty and access don't discriminate based on location. Many of the same health challenges I saw in med school and residency infiltrate our small community, and my patients can attest to my value as a family doctor in the clinic, the hospital or in the operating room.
With so much that I have gained from being in rural practice, it pains me to have to leave. My contracted hospital has not been able to provide a work environment that supports me as medical director, and I find myself once again giving preference to work over family. That was the problem that led me to move from a big city environment in the first place.
Before I arrived here, there were only two obstetrical physicians covering more than 15,000 patients for 18 months. During the last five years, our community lost four physicians, including three family doctors. I am the only young primary care physician in town, and most of the practicing physicians are nearing retirement. So, as a new physician working in a great community, I am concerned by the ever-demanding needs of a small practice, little support and lack of new hires into the area.
Although my family loves this close community, I find myself sinking deeper and deeper into the inefficiencies of a practice that does not support physician leadership. More importantly, I realize that the hospital recruitment has been ineffective, and my work-life balance has suffered as a result.
Sure, there are alternative practice models, like direct primary care. However, it is difficult to limit a practice panel when a community is already suffering from attrition of physicians. One could open up his or her own solo practice, but the start-up costs and overhead can be prohibitive. Frankly, when faced with $100,000 of debt -- or more -- coming out of residency, it is intimidating to think of incurring even more debt to start a business.
The truth is that in small towns, the local hospital is the main financial resource for recruitment and retention of physicians. Factor in that most new physicians are looking for some kind of employment model, and the cost of recruiting usually cannot be absorbed by smaller practices. Despite the important role of primary care, especially in small communities, I find myself often defending my value -- to the community and the hospital -- as a family physician practicing obstetrics.
The cost of recruiting a family physician is roughly $100,000. But what is the value lost when you lose a family doctor? Research shows that having a family doctor cuts costs in unnecessary testing, reduced hospital readmissions and better continuity of care. We also know that family doctors generate revenue for affiliated hospitals, to the tune of $1.5 million in annual revenue per FTE.
Although doctors and hospitals functioned in a more segregated way in the past, it is now almost expected that hospitals collaborate with physicians in order to provide better population medicine. This is certainly a paradigm shift in focus and priorities, and at least where I live, is not well-received by the corporation that owns my local hospital.
One thing is certain. Traditional recruitment models have not attracted any doctors to my town in at least the last five years. Something has to change.
Leaving my town has real consequences in how medical care will be delivered, especially in relation to obstetrical care. We know that if rural communities lose their hospitals, it is a sentence for increased maternal-fetal deaths, more high-risk deliveries, more inappropriate home births and a loss of economic stability to the community. It also leaves the door open to poor health outcomes for the chronically ill.
So what is the answer? How do we appeal to young physicians and encourage them to invest in these areas? The answer may be much simpler than you think. If you build it, they will come.
Young physicians are looking for a place in which we can thrive both personally and professionally. As I continually stressed to my hospital, new recruits want to know that the people who work in that setting are supported, that innovation is welcomed and that the management or corporation is forward-thinking. We also want to be compensated appropriately for the level of work and expertise we offer. The new recruit wants to be in a place that supports and upholds the importance of the physician's role in the delivery of patient-centered care.
We aren’t afraid to work hard, but we don’t want to do so in vain. Although this is not unique to a rural setting, the financial component is amplified due to lack of resources compared to larger cities with larger markets.
My colleagues here tell me that these expectations represent quite a change in mentality from even 10 years ago, when physicians did not require as much from corporate entities. I’m not completely sure how this shift occurred, but part of the answer lies in the increased demand for data sourcing and the challenge of electronic health systems that do not communicate with one another. Couple that with reduced reimbursement rates for primary care, and we have a good start to answer that question.
Call it a generational change of mind or maybe a realignment of priorities. However you want to label it, this trend isn’t going away. Gone are the days when a person would work without being afforded respect and validation. As innate servant-leaders, family doctors have a tendency to gloss over those business aspects, but I hope our savvy new physicians will push all stakeholders into the right direction. I hope that we will return to a world where a family doctor is able to choose whatever practice model fits his or her lifestyle best, whether that is running a small business or as an employee.
My family will miss the community we have grown to love, but moving is the price to pay in order to have a continued presence in my home. As we prepare to move to another community with a small-town feel, I can definitely say that being part of a rural town has left us with a great impression of family life. I hope that my departure creates the pressure the local hospital needs to revamp strategies that will attract and keep primary care alive in this area. When my family returns to visit, I pray that the medical scene will beat to a different tune.
Marie-Elizabeth Ramas, M.D., is the new physician member of the AAFP Board of Directors.
Women in Leadership Build Support for Other Female Physicians
At a recent family medicine meeting, I took pride in the fact that this year the AAFP president, the speaker of Congress of Delegates and the president of the AAFP Foundation are all women. That's a rarity given that Wanda Filer, M.D., M.B.A., is only the third female president in the Academy's 69-year history.
I believe we’ll see more female physicians on the forefront of leadership in the future. When I graduated from medical school, women accounted for roughly 10 percent of the U.S. physician work force. Today, the number is closer to one-third.
| Women in leadership positions in family medicine include, from left, AAFP President Wanda Filer, M.D., M.B.A.; myself (speaker of the AAFP Congress of Delegates); and AAFP Foundation President Evelyn Lewis&Clark, M.D., M.A.
In family medicine, the trend is even stronger. More than 40 percent of AAFP members are women, and the numbers are higher among our youngest physicians. Fifty-four percent of family medicine residents are women, and 57 percent of our new physician members are women.
As our percentage of membership increases, so does our representation. Three dozen presidents and presidents-elect of our constituent chapters are women. And nearly 50 women serve on AAFP commissions. Female physicians should feel empowered by the changes we are experiencing.
Despite the advances women have made, obstacles remain. A recent Medscape survey indicates that female physicians still earn far less than our male counterparts. Illinois AFP President Alvia Siddiqi, M.D., recently launched our chapter's Women in Leadership Member Interest Group to address such disparities. The group's first event, held in late February, aimed to help women improve their contract negotiating skills.
Siddiqi said the chapter's intention is to "provide an open forum to discuss issues relevant to female family medicine physicians, including contract negotiations, balancing career and family lives, and career development." The group will encourage female physicians to participate in leadership and offer opportunities for mentoring, and personal and professional development through education and other programming.
On a broader scale, Michigan AFP President Kim Yu, M.D., recently started a social media effort to connect female family physicians across the country. Yu launched Physician Moms in Family Medicine on Facebook in January, and the group had 800 members within a few days. It now has more than 1,100.
Only family physicians can join the group, Yu said, because she wanted members to have a place "to ask their questions within the safety of our own specialty."
"It has been eye opening to hear directly from physicians on topics from ABFM certification questions, celebrating when someone becomes an AAFP fellow or delivers a baby, how to deal with threatening patients, interesting or difficult cases, how to teach circumcision to residents, favorite board review courses, info on FQHCs, best CME courses, procedures, or sharing about our favorite conferences," Yu said.
Yu said her goal for the group is to provide a venue where women can find a community to share their joys and difficulties and support each other.
The group is open to women who are not mothers, but Yu said it will keep its name so women know they also can "discuss issues that affect us as physician moms, not just as physicians."
Yu also hopes the group can encourage its members to become more involved in advocacy for their patients and the specialty.
As Women's History Month comes to a close, I'd love to hear what other chapters and groups are doing to provide mentoring and resources for female family physicians.
Finally, I want to remind you that the National Conference of Constituency Leaders will be May 5-7 in Kansas City, Mo. That event, which provides a platform to five AAFP special constituencies -- women, minorities, new physicians, international medical graduates and physicians interested in gay, lesbian, bisexual and transgender issues -- is co-located with the Annual Chapter Leader Forum.
Javette Orgain, M.D., M.P.H., is speaker of the AAFP Congress of Delegates.
Teaching Abroad Helps Grow Family of Family Medicine
I recently returned from Saudi Arabia, my fourth trip there in the past seven years and the first with a new passport. Planning for the trip gave me the occasion to thumb through my old, expired passport and reflect on all the places I have traveled to on behalf of the AAFP's Advanced Life Support in Obstetrics (ALSO) program.
Lots of memories -- joyful and wonderful experiences, frustrating travel disruptions and memorable international colleagues who struggled to provide the best possible medical care under often challenging circumstances.
And yet, in my years of teaching ALSO in resource-challenged countries, I rarely encountered family physicians providing maternity care. In almost every case, the participants in the global ALSO courses were obstetricians or nurse midwives. In many of the countries I have visited, family medicine is not well established, and physicians who provide general medical care in the community rarely interact with hospitals or provide maternity care.
That clearly is changing around the world as family medicine residency programs are established and graduates enter their communities to provide comprehensive, family-centered care across generations.
In decades past, many U.S. physicians generally thought of global medicine as missionary medicine. American doctors, the thinking went, travel to developing countries to provide short-term medical care to underserved populations, often in association with philanthropic and faith-based organizations. But there are incredible examples of dedicated family physicians who contribute their time, energy and funds to support international programs and provide continuity of resources to communities that otherwise would not have health care. Several of my extraordinary community colleagues rank among them.
The AAFP partnered with the Kansas-based non-profit organization Heart to Heart International and the AAFP Foundation to start Physicians with Heart in the former Soviet Union in 1993. In nearly two decades, the project helped provide support, training and mentorship to local family medicine associations and family physicians in the countries of the post-Soviet era. In collaboration with local health authorities and ministries of health, Physicians with Heart developed and conducted family medicine education and training events. The project also coordinated airlifts of much needed pharmaceuticals, medical equipment and supplies, as well as educational materials.
I got started in international and global medicine when Physicians with Heart brought the ALSO course to the former Soviet Union. Today, the Academy continues to support our members in their global health work and initiatives to support nascent family medicine associations, provide basic and continuing medical education, sustain ongoing family medicine residency training, and help support family physicians in countries where the specialty is having difficulty becoming established and growing.
Our Academy members' participation in the World Organization of Family Doctors, or Wonca, has expanded our international horizons even further. The incredible energy and enthusiasm of our young family physicians in Wonca's Polaris Movement for New and Future Family Physicians in North America is wonderful testimony to the realization that we are one global community, all striving to improve the life and health of those we serve.
Many medical school applicants have already participated in global health activities, and many U.S. medical schools and family medicine residency programs have well-established international and global health rotations, areas of concentration and global health tracks. Involvement in global health lets us see and learn more about conditions that are rare in U.S. medical practice. But it also equips us to provide care to underserved communities and multi-cultural populations in the United States, including refugees, immigrants, asylum seekers and other transnational groups.
It is important to remember how much we can learn from our international colleagues. The United States ranks last among the most highly developed nations in life expectancy, penetration of universal preventive health measures and global cost of care. Those countries that have better health care outcomes with lower costs have strong family medicine and primary care communities, as well as proven strategies to ensure primary care access for everyone.
I started this blog talking about my recent trip to Saudi Arabia for a reason. You see, during my second trip to Riyadh in 2011 I was introduced to Abdullah al-Owayed, M.D., a United Kingdom-trained family physician who was the first chair of the first department of family medicine in Saudi Arabia. I was asked to give a talk on the patient-centered medical home (PCMH) to a group of family physicians, all of whom had received their primary care training outside Saudi Arabia. Months after that visit, al-Owayed came to the United States and spent time in my group practice learning about our PCMH journey, and about our practice’s relationships with our local medical school and family medicine residency program.
On his return to Saudi Arabia, al-Owayed established his country's first family medicine residency. Just last month, I had the pleasure of having one of the first graduates from that residency participate in an ALSO instructor course. She is one of the pioneers of the new generation of family physicians in Saudi Arabia, providing maternity care as part of a comprehensive, full-scope family medicine practice.
How can you contribute to family medicine's development abroad? The AAFP has several networking mechanisms that may help you match to your interests and abilities with global health needs and efforts. An AAFP member interest group focused on global health and a number of member-initiated regional groups, as well as the annual AAFP Family Medicine Global Health Workshop, can provide you with resources, member experience and connections for your global health engagement. And the Academy's Center for Global Health Initiatives supports the professional needs of AAFP members who want to be globally engaged.
Carl Olden, M.D., is a member of the AAFP Board of Directors.
Let's Shine a Light on Black Contributions to Medicine
For some, February means an extra day off work for Presidents Day. Many look forward to Valentine's Day each year. Still others see the month as an opportunity to raise awareness of cardiovascular disease in women.
For me, February represents a time to reflect on the contributions of people of color who helped make this country great. In the field of medicine, there have been many black scientists, physicians and technicians who invented, improved or initiated practices from which we benefit today.
HeLa cells are seen dividing under electron microscopy. The cells, originally taken from a young black patient, Henrietta Lacks, without her knowledge, have been used in medical research for decades.
I also think about the people who have contributed to science without even knowing it.
We celebrate Black History Month to highlight stories that have somehow faded into the background of U.S. history. Although we rejoice in the victories of people such as Rosa Parks and Martin Luther King, Jr., there are myriad others whose names most of us would never recognize.
My grandparents lived in Haiti when it was one of the few independent black nations in the world, if not the only one. They reminded me that when they were still children in the early 1900s, walking freely in Haiti, life was far different for blacks a relatively short distance away in the United States.
Until recently, science often advanced on the unknowing backs of minorities. The blister of the Tuskegee syphilis trial conducted from 1932 to 1972, still causes us to flinch today.
It is within this context that I remember Henrietta Lacks. If you haven't read The Immortal Life of Henrietta Lacks by Rebecca Skloot, I strongly recommend it. In 1951, this wife and mother died at age 31 from cervical cancer. Her cells were harvested without permission for study.
Better known as HeLa cells, they were used in the development of the polio vaccine and were the first human cells to be successfully cloned. The cells' replicability allowed them to be mass-produced and distributed all over the world for research. This was done without the knowledge of the Lacks family, whose members were neither recognized nor compensated for this contribution. It was not until 2013 that NIH officials formally recognized the Lacks family for their matriarch's contribution to medical research.
Indeed, the incredible scientific gains made using the cells of this woman stand in sharp contrast to the fact that many of her descendants lacked the means to pay for their own medical care. Such disparities reverberate throughout the black community. They serve as a constant reminder of the chasm between quality and equity. For some, this experience serves as a litmus test for each encounter with a medical professional. Indeed, it's important that we as physicians recognize there's a steep hill of skepticism we need to climb when caring for many of our patients.
One of the reasons why we celebrate Black History Month is that we, as a culture, do not count black history as part of our history. We don't hear enough about the Henrietta Lackses, the Charles Drews or the Daniel Hale Williamses in our collective history classes.
We relish the fruits of many black authors, philosophers and academicians, but there is so much black history that goes unseen by mainstream culture. We aren't taught, for example, about the slaves used for medical experimentation in the antebellum American South.
Some might argue that there are many contributors to our society, from all backgrounds, that go unheralded. Others might retort that all people, regardless of background, should be recognized for their merit. I agree with both perspectives.
However, our institutional systems of learning remain anemic in color. The value placed on contributions to science is determined by our ingrained bias. It is demonstrated by Nobel prizes awarded and NIH grants received. It is displayed by who is prominently recognized in our history books versus who is mentioned as an afterthought.
Ideally, one would have the ability to see value and worth without the tainted spectacles of bias. However, bias is rooted our subconscious and requires methodological maneuvers to surface. We as scientists can all relate to that. As one of my mentors in medical school taught, "You don't know what you don't know."
We are trained as doctors to believe that the history is the most important part of the physical exam. I have come to appreciate the truth of this simple statement. Each patient is the result of generations of history, good and bad. Part of my job is to decode that potential.
Today, I wanted to share a bit of black history -- our black history -- because whether or not you knew the story behind the HeLa cells, chances are that you have benefited from them. I hope that one day our learning experiences will reflect the kaleidoscope of culture and diversity that makes us Americans.
Marie-Elizabeth Ramas, M.D., is the new physician member of the AAFP Board of Directors.
Tales From the Road: Giving Thanks for Family Medicine
In the eight weeks since I became AAFP president, I have visited nine states; Washington, D.C.; and Canada on Academy business. Along the way, I've met with governors, members of Congress, medical students, journalists and many, many family physicians.
Although these are trying times for family medicine, I've seen many things to be thankful for, and I want to share some of those bright spots.
During the recent interim meeting of the AMA House of Delegates in Atlanta, Neil Brooks, M.D., of Vernon, Conn., announced that he was participating in his last AMA meeting. That's significant because the former AAFP president has been representing family medicine in the House of Medicine for more than a quarter of a century, including the past 12 years as a member of the AAFP's delegation.
(Coincidentally, Rep. Joe Courtney, D-Conn., spoke highly of Neil and his wife, Sandi, during a recent meeting with AAFP leaders. Courtney is a co-founder of the new Primary Care Caucus, which seeks to advance public policy that establishes, promotes and preserves a well-trained primary care workforce and delivery system as the foundation of our health care system.)
When experienced physicians like Neil Brooks leave leadership roles, who will take their place? Well, for one, I was impressed by Allen Rodriguez, a second-year medical student from UCLA who was part of our AMA delegation. Student interest in family medicine is increasing, and I try to meet with medical students wherever I go. Students are excited by the idea of family medicine -- taking a holistic approach to caring for people in the context of their community, family and life rather than defining them by their disease state.
The students I have met with (most recently at Virginia Commonwealth) are passionate about addressing the social determinants of health, show great leadership skills and are committed to lifting the profile of family medicine. We recently saw students and residents at Columbia University and NewYork-Presbyterian Family Medicine Residency rally around their programs when those organizations announced misguided plans to divest from primary care. Columbia and NewYork-Presbyterian backpedaled from those plans after a fierce, and well-deserved, backlash.
And, of course, I'm thankful for the family physicians who are out there helping people every day. I've visited several state chapters in the past few years, and one of the things I look forward to on these trips is hearing the inspiring stories of each state's family physician of the year.
In Illinois, I heard about Elba Villavicencio, M.D., of Buffalo Grove, who was nominated by a patient who said "Dr. V" helped her quit using tobacco after 35 years of smoking and also helped her lose weight. Villavicencio trained in Ecuador and practiced in her home country and Colombia for several years before coming to the United States, a move that required not only additional training but learning a new language.
In Iowa, I heard about Mark Haganman, D.O., of Osage, who was praised not only for being a good doctor but also a good citizen. Haganman was humble about accepting the award, but others praised him for going above and beyond what any patient would normally expect from his or her physician. For example, Haganman mowed a patient's yard, not because the patient had asked but because help was needed after a surgery. Stories like that are inspiring, and we need to hear more of them.
Studies tell us that more than one-third of physicians are struggling with burnout. During my speech in Denver at the Family Medicine Experience, I said that we need to look out for each other. I was pleased recently when one of our members took me literally and asked me to call a colleague who was struggling. I made that call last week and offered a sympathetic ear and some mentoring. It's rough out there, and we need to continue to look out for each other.
We also need to continue to share the stories of our colleagues who are doing incredible things in their communities. Doing so helps inform the press, the public, payers and politicians about why primary care matters.
Happy Thanksgiving, and thank you for all that you do.
Wanda Filer, M.D., M.B.A., is president of the AAFP.
Leadership Gives Female Physicians More Control of Career Path
I've worn a lot of hats in my nearly three decades as a family physician. I've been an associate residency program director, founded a health care consulting firm, worked in a federally qualified health center, advised my state's governor as physician general and served as a health correspondent for the region's NBC affiliate -- all while functioning as a family physician and putting our broad training to work.
I never made my gender an issue in any of those jobs, but in my newest role -- president of the AAFP -- I may have underestimated how important it is to some. During our recent Congress of Delegates -- and in my year as president-elect -- a significant number of our female members told me they were inspired to see a woman in my position. These are women who want to make a difference, feel they can be leaders and are seeking opportunities for growth. Fortunately, leadership isn't closed to them at the AAFP. There are five women on our Board of Directors. Three of the Academy's seven commissions were chaired by women this past year. Women also play important leadership roles in our state chapters and at the National Conference of Constituency Leaders.
| I received the President's Medal during my installation at the recent Congress of Delegates in Denver.
I am only the third female president in the long history of the AAFP, but women in leadership is a trend that is growing in family medicine. Forty-two percent of our active members are women, and the numbers are even higher among our younger members, with women accounting for 55 percent of our residents and 56 percent of new physician members.
Forty years ago, there were a little more than 35,000 female physicians in the entire country. Today, the number has swelled to more than 321,000, and women represent nearly one-third of the U.S. physician workforce.
Medscape recently surveyed more than 3,200 female physicians, and what they had to say about leadership, career satisfaction and work-life balance was interesting. (It's worth noting that 15 percent of respondents were family physicians.)
More than half the women said they hold at least one leadership position. Forty-two percent were leaders in their practice, 12 percent were leaders in academic departments, and 12 percent were leaders in a professional organization.
Although we've made progress, there are still notable gaps. For example, none of the respondents were deans or vice deans. And I'm clearly in the minority, because only 4 percent were presidents of professional organizations.
Survey participants were asked why they sought leadership roles, and the No. 1 answer leaders gave was to be a positive influence (70 percent), followed by a desire to make change (68 percent). Those are great answers, but the response that resonated with me was from the 53 percent of female leaders who said it was because they want to shape their own path.
When I get frustrated in my practice with my clunky electronic health records system, meaningful use or any of the other challenges we face, I think about the work we're doing as an Academy, and I know it won't always be this way. Although we may be frustrated by our circumstances, we can use that as motivation to be active agents of change. We can use our stories of adversity -- both our own and those of our patients -- to make good things happen through advocacy.
When we are in control, things are better at home and work. Is it a perfect process? Absolutely not, but doing something about our problems improves situations for ourselves and our patients.
The women surveyed (90 percent of those who identified as leaders and 86 percent of nonleaders) agreed that it is important for women to be involved in leadership. But they diverged on whether or not it was an important personal goal, with 76 percent of leaders saying it was important to them compared with 42 percent of nonleaders.
The most common reason cited for not getting involved was time constraints. Interestingly, when the women were asked if they were happy with their careers and personal lives, leaders were more likely to be professionally satisfied and had similar responses to those of nonleaders about personal life satisfaction despite the added demands on their time.
Of course, timing is everything. I'm the first mom to serve as Academy president, but my daughters are both in their 20s. It's important to consider not only what you can do but when you can do it.
Women who were not in leadership were asked why they chose not to get involved. Some of the reasons they gave are things we should change, including lack of female mentors and lack of support. As women become a larger percentage of the physician workforce, these barriers become totally surmountable. We must help guide our aspiring young leaders (male and female), and we all need to build our own network of support both within and outside of medicine.
Wanda Filer, M.D., M.B.A., is president of the AAFP.
Practice Perspective: Patient Stories Get Attention of Media, Policymakers
One of the most important roles of the AAFP president is spokesperson, and I’ve done a lot of speaking this year.
In the first few weeks of September -- my last month as president -- I talked to reporters about health care apps, ICD-10, meaningful use, vaccination rates, workforce issues and more. On one particularly busy day, I did seven interviews.
As I traveled around the country this year to roughly a dozen constituent chapter meetings, it was clear there is a perception by many of our members that AAFP directors aren’t practicing physicians. But that isn’t the case. Although I traveled about 200 days during my term, I’m still a practicing small-town doc with a solo practice in rural Nebraska. So when members say to me that I don’t know what it’s like dealing with the day-to-day issues of a family practice, I say, “Yes, I do. I do what you do.”
That in-the-trenches perspective has helped me in my role as spokesman and advocate. For example, I know how challenging meaningful use has been and how the many shortcomings of electronic health records are hampering our practices. I’ve talked about it not only with the media but also with Congress.
What I've found is that whether I’m speaking with reporters or legislators, being a practicing physician makes a difference because both groups want to know how health care issues affect patients (their readers and constituents, respectively).
“Do you have an example?” is a question I’m asked on a regular basis. Invariably, my answer is, “Yes, I do.” And I’ve noticed that when I provide journalists with a compelling patient story, it almost always makes it into their articles.
Sharing stories about how patients are affected by things such as access to care or how physicians are being affected by issues such as payment helps inform public debate and, ultimately, shape policy. There’s no better example from this past year than the repeal of the sustainable growth rate (SGR) formula. The AAFP and our members advocated relentlessly for years to have this flawed formula replaced. Thanks to your numerous letters, emails and phone calls, Congress voted overwhelmingly to replace the SGR and move forward with a new model for Medicare payment.
Thank you to everyone who joined us in this battle. Our voice and our stories are being heard and are a powerful force for changes in our health care system. The patient-centered medical home is mentioned in the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act, the legislation that repealed the SGR, largely because of our advocacy efforts.
Of course, our work is not done. We continue to communicate with Congress and federal agencies about many other challenges, including meaningful use.
Some vital programs that support and promote primary care -- including the Agency for Healthcare Research and Quality and the Health Resources and Services Administration -- have been targeted for cuts as Congress looks to reduce federal spending. But rest assured that the Academy is pushing back. You can follow the AAFP’s advocacy efforts on these issues (and others) and get involved in our grassroots movement on our advocacy Web page.
Sharing our stories is a powerful thing.
Robert Wergin, M.D., is president of the AAFP. He will transition to the role of Board chair on Sept. 30.
Building Relationships at Core of Family Medicine, Leadership
It's hard to believe that this will be the last blog I write as an AAFP officer. For me, the past six years on the AAFP Board of Directors have flown by. I have had an incredible journey full of once-in-a-lifetime experiences. However, one of the most important lessons I have learned is a basic one that is a core trait of being a family physician: It is all about relationships.
Although we say this routinely, it is such a profound truth that it can be overlooked in our busy lives. But when we embrace it, it is the fundamental approach to how we do what we do as family physicians.
| Here I am sharing a laugh with Academy members (clockwise from top) Kim Yu, M.D., Jennifer Bacani McKenney, M.D., and Kevin Wang, M.D., during an AAFP event. Building relationships is critical not only in our practices but also in leadership.
It is also the foundation on which health care reform must be built. One of the biggest dangers associated with the fragmented and siloed care many Americans still receive derives from a failure to respect this core principle. In all the discussions about primary care, providers, teams and the latest acronyms, we can lose sight of this basic truth: We care for individual people, and we must do so with teams of people who value the uniqueness of that person.
I have been able to travel the country and meet hundreds of AAFP members in their home states. This constantly reminded me to put our relationships into the right context. You are most "yourself" in your natural environment. As an AAFP Board member, and as an officer for the past three years, I needed to have the full understanding of who you are and how you are affected by all the changes that are happening in our health care system. Conversations, phone calls, meetings, notes, emails and social media interactions all helped teach me about you. This allowed me to better represent family physicians and to advocate more forcefully for our specialty.
My wife Alex and I have been welcomed into so many of your chapters, as well as into many people’s homes. We have broken bread together, enjoyed good drink, engaged in stimulating conversation, played music and sang songs, roasted marshmallows around bonfires, hiked incredible vistas, and enjoyed the peace of friendships all over the country. We have felt like a part of your families, and we thank you for that kindness and hospitality.
Life on the road can be challenging. AAFP officers travel more than 200 days a year. One of the things that keeps us going is the sense of connection and appreciation we feel at the many meetings and events we attend. This support makes it much easier to do the important work of engaging different groups outside of family medicine and making sure they know who we are, what we do and why it matters.
Of course, it helps to have a wonderful message. There is nothing better than seeing the light go on in the eyes of a congressional staffer, a legislator or a health care colleague when they finally "get it."
Although we each have our own perspectives, and our individual chapters may have slightly different challenges and priorities, we really are all singing the same song when it comes to the importance and value of family physicians. We are stronger together.
Accordingly, one of the challenges I'll leave each of you with is to make sure that you don't turn your back on the sacred nature of the relationships you create and nurture. It can be easy when you're frustrated by changes to allow that frustration to overtake the incredible joy that comes with answering the call to service. For those of you who are leaders within our national or state academies and in your communities, I challenge you to also seek out and nurture the relationships you create in those roles. It is critical that we truly represent those who depend on us to take their voices forward.
For those who would like to be more involved in leadership, the Academy offers many opportunities. For example, the deadline is fast approaching for state chapters to nominate members for AAFP commissions. I cannot emphasize enough how invigorating it is to move to the next level of involvement. Please jump in -- the water's fine!
My time on the AAFP Board will come to an end later this month when the Congress of Delegates convenes in Denver. Thank you for the tremendous honor of representing you. Although I will not be contributing in this particular forum any longer, you will continue to hear from me. I'm excited about my role on the Family Medicine for America's Health Board of Directors. I also will continue to serve as the Academy's liaison to the CMS Health Care Payment Learning and Action Network guiding committee.
My time on the AAFP Board has prepared me to take on these roles as we continue to navigate challenging waters ahead. I am confident we are moving in the right direction, and that others are seeing family medicine more clearly, listening to us more openly and believing in our message.
Thanks for being on this journey with me. Thanks for your support. And thanks for making me feel like a part of your family.
Reid Blackwelder, M.D., is the Board chair of the AAFP. His term ends Sept. 30.
Are You the Leader We're Looking for?
Before the end of the year, nearly two dozen family physician volunteers will be selected to serve on AAFP commissions, providing invaluable input regarding issues related to continuing professional development, education, finance and insurance, governmental advocacy, health of the public and science, membership and member services, and quality and practice.
If you've ever wanted to get involved, make a difference or make your voice heard, this could be your chance. The Academy sent a letter to its constituent chapters today seeking nominations for 23 commission slots that will be vacated in December. Interested members should contact their chapters before the Oct. 15 deadline for nominations. To be considered, your chapter must provide a
- letter of nomination,
- typed nomination form,
- passport photo, and
- completed online conflict-of-interest form.
Commission members serve four-year terms and participate in biannual meetings, conference calls, project work and other activities. Commission work can be a stepping stone to leadership in our organization. More importantly, it is an opportunity to influence the direction of the Academy and our specialty.
Photo courtesy of Kim Yu, M.D.
More than 100 Academy members volunteer their time each year and provide input to the AAFP's seven commissions, including the Commission on Membership and Member Services.
As an example of how the commission process works, I visited AAFP headquarters in Leawood, Kan., twice this spring to attend meetings of the Commission on Finance and Insurance that took place during budgeting for the new fiscal year. I was impressed by the diligence with which the organization prepares the annual operating budget and the thoughtful questions that were asked by the 10 family physicians volunteers before they forwarded that budget to the Board of Directors for approval. There is a commitment by all involved to spend your dues money wisely.
It's an intense, time-consuming process. Each Academy division director was given 30 minutes to explain who they are and what they do, explain items of note in the budget related to their division and discuss goals and hiring needs for their areas. Commission members listen and ask questions.
Given the scope and breadth of the Academy (more than 120,000 members and more than 400 employees) and the immense number of activities the AAFP is involved with in advocacy, education, practice advancement and public health, one commission member likened the budget process to drinking from a fire hose. The Commission on Finance and Insurance is tasked with striking a balance between being a good steward of Academy funds while also advancing needed products and services to members.
For example, one of the many projects discussed during budgeting was the recently launched Performance Navigator. The ambitious project combines live learning and online resources in a new tool that can help family physicians satisfy requirements for maintenance of certification parts II and IV, earn up to 113.5 AAFP Prescribed credits, and improve our practices while enhancing reimbursement potential. (Registration is now open for the Nov. 4-6 live course in Carlsbad, Calif.)
This commission's responsibility when considering such projects is to look at the big picture, understand what our resources are and make recommendations to the Board of Directors. The members of our other commissions perform similar tasks, reviewing emerging legislation and regulations for possible comment; lending their expertise in developing clinical policies and preventive services recommendations; providing feedback on proposed CME programs and activities; offering insights on new practice tools and processes; and more.
So here is your chance to make your mark and support our specialty. Contact your chapter. October will be here before you know it.
Wanda Filer, M.D., M.B.A., is president-elect of the AAFP.
Father's Day Flashback: Lessons Learned From Dads
I have been blessed with many father figures in my life, and each one has shared valuable wisdom that has helped me become a better physician, a better leader and a better person. In honor of Father's Day, and fathers everywhere, I want to pay tribute to the special fathers in my life by sharing some of their wisdom.
My great grandfather, Charles Light, was a Mennonite minister. My first memories of him were of a gentle man who lived simply on a farm and enjoyed quilting. He was a member of the Hereford Dairy Project and sailed on that initiative's first trips that brought animals to those living in poverty so they would have sustainable means to provide food and income for their families. He showed me the wisdom of paying it forward.
My great grandpa Otto McBride was a carpenter. My first memories of him were of his wonderful smile, which extended over his entire face and into his eyes. He could create anything with his hands. I still have the cedar chest he built for my grandma to keep my mother’s baby clothes in. He showed me the wisdom of building your own future.
My other great grandpa, Thomas Lloyd, owned his own shoe store in Racine, Wis. My first memories of him were of playing with the hundreds of seashells that he would collect in Florida and bring back home in jars. He showed me the wisdom of appreciating the beauty in nature.
My grandpa Don Beckenbaugh was a salesman in the Midwest who retired and moved to southern California. Six months after his retirement, he was offered a job selling real estate. Six months after that he became a broker who managed a successful real estate business in Laguna Niguel for 20 years. He was also committed to keeping his large family connected, and every time we had a gathering, he would go around the table and make everyone stand up and give a short speech to share what was new in their life. (That was the old-fashioned version of Facebook). He showed me the wisdom of believing in yourself.
My other grandpa, Allen Light, was a salesman who lived his entire life in the Midwest, which allowed me to spend holidays and summer vacations at his home for more than 40 years. He had a great sense of humor and a sharp wit and was an avid gardener and winemaker. He had a strong faith in God and held the importance of family above all other things. He took care of me when I was a baby, and he helped take care of my babies when I became a mom. He always took an active interest in whatever I did in my personal and professional life. When he developed cancer at the end of his life, he taught me what is was like to be a patient. He showed me that the burden of disease cannot break your spirit, but also that it cannot exceed your capability to live with disease. He showed me the wisdom of allowing faith, hope and love to guide your life.
My dad, Bob Beckenbaugh, is a recently retired hand surgeon. He was the first one to introduce me to medicine and show me how physicians can make a difference in the life of others. Dad also taught me to appreciate the power of humor and the importance of having fun. He taught me to laugh and tell jokes and to swim, water ski and snow ski. He even tried to teach me to play golf, but he says I "hit the big ball (planet Earth) more than the little ball (the golf ball)." Most of all, my dad taught me that taking care of other people is the most important service you can do with your life, and that as a physician, patients should always be treated with courtesy and respect. My dad showed me the wisdom of keeping joy in your life and striving for excellence in caring for others.
For the past 36 years, I have been blessed with another dad, my father-in-law Ted Lillie Sr. He is a retired small business owner who cares deeply for his family and strives to help those who are less fortunate then himself. He taught my husband to be a wonderful father, and he has shown me the wisdom of perseverance in the face of adversity.
So this month, I say thank you to all my fathers, and thank you to fathers everywhere who take the time to make a difference in the lives of others.
Lynne Lillie, M.D., is a member of the AAFP Board of Directors.
Vacation? Hardly. AAFP Commission Work Is Tough, but Worth It
I recently returned home from the summer meeting of the AAFP commissions, typically referred to as Summer Cluster by its participants. Such meetings are sometimes called "vacations" by people who aren't involved, but the truth is that they are hard work.
And our hard work is backed up by the hard work of those back home who cover for us.
More than 100 family physicians, residents and medical students volunteer their time to the commissions, which provide input that shapes the direction of the AAFP and family medicine. Members serve four-year terms on commissions, which focus on specific areas, such as advocacy, education, member services, public health, professional development and practice improvement.
Photo courtesy of Kim Yu, M.D.
AAFP President Robert Wergin, M.D., center, speaks during a meeting of the Commission on Membership and Member Services. More than 100 Academy members volunteer their time and provide input to the AAFP's seven commissions.
Liaisons from the AAFP Board of Directors and constituent chapter executives also participate in these biannual meetings, and many of us return home with wry smiles as people ask about the time we spent out of town. Cluster meetings typically are held in the summer and winter in Kansas City (near the AAFP's headquarters), which is known for its climatic extremes. Although it's a fine city, Kansas City in the sweltering summer (or dead of winter) is not an ideal vacation destination.
Here's the long and short of it: When commissioners, Board members, officers and chapter executives are in Kansas City for Cluster meetings, we are working. There is a significant amount of prep work for these meetings, including poring through agendas that often are hundreds of pages long.
Most of us are practicing physicians, and in this era of electronic health records (EHRs), we are never truly away from patient care. Almost all of us have to step out of meetings at some point to take a patient phone call. We consult our EHRs during breaks so we can address urgent patient care needs, and we check in with our staffs. For example, throughout each day of the recent meeting, I made time for various patient care issues. I filled prescriptions, sent portal messages asking for follow-up from six patients on various issues (all sent on one morning, and answered that afternoon), dealt with a patient who had a new problem (which also resulted in a phone call), and reviewed the care of residents I had precepted the day before the meeting started.
In addition to patient care, many of the Board members -- especially officers -- must also find time for media calls (just as we do when we are back home). AAFP President Robert Wergin, M.D., in particular, is essentially on call 24/7 to handle media requests and to dash off to represent the Academy at other events, be it the annual AMA meeting, a White House event or some other important gathering. Not a meeting goes by in which he is not dealing with several phone interviews or email reviews of important media opportunities. These are critical for getting family medicine's message out to the public, and he has done an outstanding job.
I admit that I get so recharged after spending a few days with friends and colleagues at Cluster meetings that anyone could be forgiven for thinking I was coming back from a restful time away. In the end, there is nothing more exciting or rewarding than being able to continue to take care of our patients and our practices, while at the same time doing the important work of the Academy.
Next month, the AAFP will make its annual call on chapters to nominate family physicians to serve on the commissions. I'm grateful for all those who have served because they challenge us as an organization to do what we do even better. But we also owe a debt of gratitude to the people in our practices, communities and, of course, our homes who cover for us and support us, which allows us to do important work for our specialty and our Academy. Thanks to all.
Reid Blackwelder, M.D., is Board chair of the AAFP.
Face-to-Face With Dr. Oz: Benefits of Touting Family Medicine Outweigh Risks
When discussing treatment options with our patients, we consider the risks and the benefits of the various options available. Ideally, we seek choices with benefits that far outweigh the risks.
The same is true for leadership, but sometimes you have to boldly stick your neck out to make your message heard.
| Here I am talking with Mehmet Oz, M.D., on "The Dr. Oz Show." In a show about facing your fears, my segment dealt with the fact that some patients fear going to the doctor. I emphasized that patients need a family physician who can serve as their trusted health adviser.
Earlier this year, I got a phone call from Mehmet Oz, M.D., the cardiothoracic surgeon, author and TV host better known as Dr. Oz. We had met years before when I was working for the local NBC affiliate as a health consultant and reporter. His staff had initiated conversations with the Academy about interviewing me on his show, and now he was reaching out to me directly.
I hadn't jumped at the opportunity, and with good reason. It's been a rough year for Dr. Oz, who was called before Congress last summer because of concerns with some of the products that have been promoted on his show.
"You need to understand that our members aren't happy with some of your advice," I told him. I also let him know that family physicians are spending too much of our valuable time explaining to patients why we don't recommend some of the products and ideas they've seen on his show.
But again he asked me to come on the show to tell his audience about family medicine, and that audience is vast. Each weekday, nearly 2 million people tune in to watch on television, and many millions more watch online.
So here was a risk with a potentially huge benefit. This was an opportunity to talk to millions of Americans about the importance of family medicine and the critical role that primary care plays in health care. I could give this audience, which hasn't always received evidence-based information, a better understanding of who we are and what we do as family physicians.
As I considered it, the conclusion that I drew was that the benefits would outweigh any risks if I could reach viewers who don't have a primary care physician and make them realize that they should. Incredibly, that goal was accomplished before the show was ever broadcast.
The topic of the episode, which aired today, was fear. Specifically, my segment dealt with fear of going to the doctor, which can keep people away from our practices even when they are in dire need of care.
So we talked about why everyone needs a family physician, a trusted adviser who knows the patient and his or her family history. We talked about the scope of family medicine and the fact that we care for people from the beginning of life until the end. We also talked about our ability to help patients set and reach their personal health goals.
One woman in the audience had not seen a physician in more than a decade because of her personal fears and concerns about costs. When we had finished taping my segment, I walked over to her and said, "Can I help you find a family physician?"
"I would love that," she said.
I followed up with her, and -- with help from the New York State AFP -- was able to connect her with a family physician in her area. If nothing else, I know my appearance on that show made a difference for one person already.
We mitigated our risks with Dr. Oz as much as possible. We discussed beforehand things I would not do on the show, found out who the other guests would be, and received a guarantee that there wouldn't be any medical products or services or nutritional or diet products promoted during this episode.
This effort already helped at least one person in the studio audience. My hope is that viewers who see the episode on TV or online will find their way into our exam rooms. Americans need to understand the value and importance of what we do. For people to hear our message, we may have to take a few bold risks.
Wanda Filer, M.D., M.B.A., is president-elect of the AAFP.
Your Opinion Matters; Here's How to Share It
With more than 120,000 members working in a wide range of practice models in all 50 states; U.S. territories; Washington, D.C.; and U.S. military bases around the globe, we won't always have a consensus on issues that affect family medicine. In fact, we often don't.
Although family physicians are different in so many ways -- based on gender, generation, political affiliation and race, to name a few -- we all share a common goal: to provide the best care possible to our communities. It's important that we communicate and work together as members and as an organization to achieve that goal.
Tiffany Matson/AAFPHere I am talking with attendees at the AAFP Leadership Conference. Hundreds of members and chapter staff attended the event last week in Kansas City, Mo.
Sometimes, the Academy receives feedback from members who feel they aren't being heard. Small- and solo practice physicians, in particular, have vented frustrations about the growing regulatory burdens their practices face and their need for help in addressing these obstacles. I understand because I am a rural, small-practice physician, and there are others like me serving on our Board of Directors. And I can tell you we do hear members' feedback.
AAFP officers, myself among them, offered updates on a variety of issues facing family medicine and took questions from members during a May 1 Town Hall meeting during the AAFP Leadership Conference in Kansas City, Mo. We discussed payment reform, workforce issues and more. Members will have another opportunity to ask us tough, direct questions Sept. 27 during a Town Hall meeting at the Congress of Delegates in Denver.
But these annual events are only two examples of ways that AAFP leaders and staff listen to members' opinions. There are many other ways to make your voice heard.
The Academy regularly solicits member feedback through randomized surveys. If you want to make your opinion known, this is an excellent -- and easy -- way to provide input that affects AAFP products and policies. In 2013, the Academy polled members more than two dozen times on various issues, so if you receive a survey, please complete it!
The AAFP also gathers feedback about twice a month through the Member Insight Exchange. This is a growing group of family physicians -- currently, about 600 of them -- who have provided input on a wide range of issues, including AAFP products, Medicaid, health care apps, direct primary care and more. The Academy would like to expand the numbers of members who participate (log in required) and earn incentives for providing feedback.
It's also worth noting that we send a member of the Board to nearly every state chapter meeting. These meetings offer a chance for us to provide updates about what the Academy is doing nationally, but more importantly, they provide an opportunity for us to listen to family physicians from across the country.
Last year, the Academy illustrated its commitment to helping all members have their voices heard when it created a pathway for the establishment of member interest groups. To date, 10 groups -- including one for solo/small practices and another for rural health -- have been created. Many of these groups plan to meet at AAFP Family Medicine Experience (FMX) in September in Denver.
AAFP leaders also are participating in quarterly online discussions with family medicine interest group leaders to answer questions and discuss issues that matter to medical students.
In addition, AAFP leaders and staff have responded to members' questions and concerns posted on the Academy's listservs. Although we don't respond to every comment, the Academy monitors and discusses comments we receive via social media. And you can communicate with me directly through the AAFP President Facebook page and on Twitter @aafpprez.
I want to assure you your voice and input matter greatly. As a practicing family physician, I understand firsthand many of the frustrations of our members. As an Academy, we will continue to work hard on reducing those frustrations so that we can bring the joy of practice back to our lives.
Robert Wergin, M.D., is president of the AAFP.
FPs Have Ability to Inspire, Be Inspired by, One Another
During a recent review course at our local medical school, my practice partner gave a lecture about the patient-centered medical home (PCMH). My partner -- who also happens to be my wife -- was not too keen on making the presentation at first. She doesn't think of herself as a public speaker, but after a bit of encouragement, she agreed to share the story of our journey through practice transformation with an audience of about 250 people. And she was magnificent.
Every practicing physician has interesting and valuable stories that other physicians could learn from, but too often, we don’t seize the opportunities in front of us. Likewise, I think many family physicians fail to realize the value we bring to the health care system. But if our nation is to transition from a specialty-driven health care system to one built on primary care, family physicians must be the change agents in that revolution. We cannot wait for permission or validation from others; if we do not believe in ourselves, who will?
In medical school, we often heard the mantra, “see one, do one, teach one,” which emphasizes student learning through practice. A similar approach of “imagine one, do one, inspire one” could be applied to the changes that are needed in our health care system.
One of the experiences I enjoy most of late is when other physicians come to visit our practice to see what we’re doing. Some come to see what we’ve done with our electronic health record system. Others want to know how a small, rural practice became a recognized PCMH. Still others want to hear about our accountable care organization (ACO).
Being around people who are making changes and succeeding can give us the confidence, courage and inspiration to embark on our own transitions. And that doesn’t have to be a transition to a PCMH or an ACO. A growing number of our members are pursuing other practice alternatives, such as direct primary care.
We can create the change we want to see, but first we have to understand the possibilities. We can’t just sit back and wait to see what happens next. Of course, every family physician doesn’t have to run for a chapter presidency or testify before a congressional committee to consider him- or herself "involved," but we can all share our success stories with our colleagues and work with our staffs to provide the best care possible.
The Academy has pledged to deliver "strong medicine for America." So long as we inspire our family physician colleagues, and allow ourselves to be inspired by others, we will deliver on that promise.
Lloyd Van Winkle, M.D., is a member of the AAFP Board of Directors.
Thomas Wolfe Had It Wrong: You Can Go Home Again
The only doctor who ever treated me while I was growing up was the local general practitioner, so my concept of a physician was someone who took care of everyone -- from birth to end of life -- and was involved in the community. Being exposed to subspecialty care during medical school and residency didn't change my perception of what I was meant to do. I knew I wanted to be a "real doctor."
Photo Courtesy Megan Sonnier
Here I am talking to a patient who -- like many in my hometown practice -- I've known for decades. In fact, he wrote a letter of recommendation for me when I was a high school student applying for a scholarship at the University of Alabama.
Not to gainsay Thomas Wolfe's compelling novel You Can't Go Home Again, but when I left Bibb County, Ala., to attend medical school in Mobile in 1975, that was exactly what I planned to do. I wanted to practice family medicine in my community.
I live in Brent, Ala., and work in Centreville. These neighboring small towns run together and are home to roughly 6,000 people combined. When I look at my patient list in the morning, I often know patients' complaints before I see them because I've already heard about their illnesses, conditions or concerns at church, in the stores or from my nurse.
At the heart of primary care is the idea that patients should have an ongoing relationship with a family physician they know and trust. I have that kind of relationship with my patients because I've lived here most of my life, and I've practiced medicine here for more than 30 years.
There were only two other physicians in the county -- both family physicians -- when I started my practice in 1982. One was another local who had come home to practice. One thing we learned about starting new practices in our hometown is that folks typically fall into one of three groups:
- People who didn't know you before you became a physician or moved to town while you were away at medical school or residency;
- People who knew you before you were a physician and will never come to you for care because they still think of you as a kid; and
- People who knew you before you were a physician and won't see any other doctor because they know and trust you.
Patients should have the right to choose their physician, and I understand that some of my old high-school classmates might be uncomfortable being patients of mine -- particularly women. On the other hand, I've delivered the babies of some of my former classmates, so it works both ways. My patient panel also includes former teachers, coaches and my high-school principal.
My wife grew up in a small town, too, and when I finished residency, we visited a few other communities before we decided where to start my practice. In fact, I had an offer to join a friend's practice in another location. But in the end, we couldn't find anything we liked better than my hometown.
I've built strong relationships in this community. To me, that's part of being a family physician. And I love what I do.
John Meigs, M.D., is speaker of the Congress of Delegates, the governing body of the AAFP.
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