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Thursday Jul 17, 2014

Is Anybody Out There? Tell Us What You Think

It has been nearly three years since the AAFP launched the Leader Voices Blog with the goal of improving communication between Academy leaders and members.

During that time, we've posted more than 200 blogs on a wide range of topics affecting family medicine. We've let you know about Academy meetings with legislators and meetings with payers. We've talked about the challenges facing small practices and a host of clinical issues.

AAFP directors -- who come from small private practices, big group practices, academia and everywhere in between -- have shared deeply personal stories about where they practice and why. We also have shared stories of our own personal health crises.

And we've seen spirited debate on some controversial topics, such as gun violence.

Although this blog's readership numbers have been steady, the online conversation has grown quiet. We missed a few opportunities to respond to comments earlier this year, but we're committed to doing better going forward. Some of you, no doubt, grew frustrated with a technical issue we experienced this spring with our comments field. That problem has been resolved.

To paraphrase past AAFP President Glen Stream, M.D., M.B.I. -- who had the vision to use this tool to create a two-way conversation between leaders and the members we are elected to serve -- we're listening. And we value your feedback.

The landscape in medicine remains quite active and rapidly changing, and your Academy remains engaged on your behalf. This blog is an opportunity for all members to not only hear what the AAFP is doing, but to be heard by sharing your opinions in the comments field. Tell us what you think -- good or bad -- about the issues we face and how the Academy is addressing those issues.

Start today. We’re listening.

Michael Munger, M.D., is a member of the AAFP Board of Directors.

Monday Jul 07, 2014

Inside the Affordable Care Act: One Patient's Story

Whether folks thought it was a good piece of legislation or not, the Patient Protection and Affordable Care Act (ACA) is the law of the land. And recent polls show that roughly two-thirds of Americans favor retaining and, perhaps, modifying the health care reform law rather than repealing or replacing it.

A Bloomberg National News poll published in June found that 66 percent of respondents favored letting the law stand or retaining it with modifications. A month earlier, a Kaiser Health poll found similar results with 59 percent favoring keeping and improving the law.

By far, most people who responded to the Kaiser poll (60 percent) said the law had no direct impact on them, while 24 percent said the law had hurt them, and 14 percent said it had helped them. Nearly one-third said they knew a previously uninsured person who was able to get insurance because of the ACA, while less than one-quarter said they knew someone who had lost coverage.

I'd like to share the story of one of my patients -- we'll call him John -- who was helped greatly by the ACA.

John was a healthy child growing up in my hometown in Nebraska before he contracted polio at age 3 in 1952 (three years before the polio vaccine was introduced). The disease left him temporarily paralyzed from the neck down, and his parents were told that he would never walk again.

John proved the physicians wrong, and he did walk. But he has suffered for decades from an array of complications, including severe scoliosis, muscle wasting and restrictive lung disease.

As an adult, John could easily have qualified for disability, but he learned a trade, opened his own business and raised a family. His health insurance costs were high, but manageable, and he looked forward to saving more money for his retirement once his children were grown and out of the house. But John's health care insurance costs increased dramatically in the 1990s, and he suffered the consequences, at times, of not being able to afford coverage. In the past 20 years, John has paid more than $200,000 in premiums alone.

Before the health insurance exchanges opened this year, his deductible was $6,000, and his premium was more than $1,300 a month. When the exchanges opened, John went online and found a plan that cost him $32 a month. His deductible dropped to $450.

"It completely changed my life," he told me.

John's new plan was through CoOpportunity Health, one of nearly two dozen Consumer Operated and Oriented Plans set up nationwide under the ACA; this particular health care cooperative started in Iowa and Nebraska with funding provided through HHS. The Iowa AFP and Nebraska AFP were instrumental in securing that funding and making the plan available through the health care exchange.

The new plan lowered John's costs for medications and treatments, including the oxygen he uses at night. In addition to me, John has a respiratory specialist in another town. His out-of-pocket cost to see that physician had soared to $400 per visit on his old plan, so John hadn't seen that subspecialist in years. After he enrolled in the new plan, John made a long-overdue (and affordable) visit to that doctor and found out about new tips to help his breathing that he could have learned a lot sooner if he'd had ready access to affordable care.

The ACA may be far from perfect, but this one example shows its potential. The Academy is working to support the provisions of the act that help family physicians and their patients and is continuing to advocate for change where it's needed.

As for John, he's in his 60s and still running his business, but the money he is saving on insurance will allow him to finally start saving, in earnest, for a well-deserved retirement. John tells me that he feels as though a huge burden has been lifted from him, and the new insurance plan is literally helping him breathe easier.

Robert Wergin, M.D.,  is president-elect of the AAFP.

Wednesday Jun 25, 2014

Follow the North Star: Global Health Is Focus of New Wonca Group

A growing number of medical students, family medicine residents and new physicians are interested in pursuing global health experiences. In fact, more than 30 percent of U.S. medical students completed a global health rotation in each of the past four years.

Polaris, the new and future physicians movement for Wonca North America, was one of the topics discussed when I attended the winter meeting of the College of Family Physicians of Canada's Section of Residents. 

In the United States, we are fortunate to have structured, well-developed clinical rotations and residency programs for our family physicians-in-training, but in many other countries, recent medical school graduates are often faced with the prospect of building their own family medicine experience. To address this need, the Europe region of the World Organization of Family Doctors, or Wonca, formed the first new physicians organization -- referred to as a young doctors' movement -- in 2005 to focus on networking and providing a platform to connect physicians across borders. Other Wonca regions have since followed this example -- all except the North America region.

The 2013 Wonca World Conference in Prague triggered renewed discussions about establishing a new and future physician movement in North America. Members of the AAFP, the College of Family Physicians of Canada and the Caribbean College of Family Physicians have worked together to establish the movement's framework, including its charter, name, logo and a governance structure. On May 19 -- World Family Doctor Day -- Wonca North America announced the creation of its new and future physicians movement, Polaris, to provide an avenue for the exchange of ideas and actual observational experiences in different countries.

Polaris is not simply a platform for launching medical mission work. Rather, it is a comprehensive forum for global health. In many of the discussions leading up to its formation, the difference between mission work and global health was emphasized, and organizers envisioned one possible goal of the program to be changing the perspective that medical missions are global health to the reality that medical missions are only a small part of global health.

Although mission work is often how physicians gain global health experience, family doctors practice in all parts of the globe, and the vast differences that exist among medical systems, available resources, patient populations and disease processes offer amazing learning opportunities that can enhance physicians' work in their own communities and offices.

A global view of patient care is becoming more necessary as both our demographics change and our health systems adapt, and family medicine is the natural home for that viewpoint. Two-thirds of family medicine residency programs now offer international rotations or electives, and even those without formal programs teach the skills and population management competencies needed to work in any community, which produces physicians who have interests and/or abilities well-suited for global health delivery.

Aside from skills development, simply connecting with family doctors in other countries provides a perspective that often helps open our eyes to new solutions and processes we can then use in our own programs and offices. For example, I was fortunate to be invited to attend the winter meeting of the College of Family Physicians of Canada's Section of Residents, where each residency program in Canada is represented. Polaris was simply a glimmer of an idea at that point, but the collaborative effort it represented was well-received.

Canada's postgraduate medical education system is much like that in the United States, but even so, these residents shared our interest in developing a more comprehensive patient approach. Canadians have rural patient populations that make some of our rural sites in the United States appear metropolitan. Not surprisingly, their medical education curriculum includes impressive didactic and skills sessions to meet the needs of students and residents who plan to work in remote settings. I came back to my residency program with ideas for improving our own training based simply on talking with Canadian residents. Imagine the progress we could make in our training if we were able to experience the many cultural variations and nuances that characterize family medicine across continents.

WONCA's young doctors' movements have already established exchange programs to enable their members to participate in observational experiences. Polaris could provide an infrastructure for setting up exchanges to and from North America.

      Polaris is still being developed, and much remains to be decided. So if you are a family physician who is interested in global health -- whether you're a seasoned veteran or someone looking for a first global health experience -- take advantage of the many upcoming opportunities to be part of the discussion

  • At the National Conference of Family Medicine Residents and Medical Students, Polaris will be discussed during the global health networking session, which is scheduled for Aug. 8 in Kansas City, Mo.
  • Attendees at the Family Medicine Global Health Workshop scheduled for Sept. 11-13 in San Diego, can see a presentation by representatives of the Vasco da Gama Movement, which is the European group for new and future family physicians. The event also will feature a networking session where Polaris will be a topic of discussion.
  • An international networking session also will be held during this year's AAFP Assembly, which is scheduled for Oct. 21-25 in Washington.

Kimberly Becher, M.D., is the resident member of the AAFP Board of Directors.

Wednesday May 28, 2014

Patient Portals: Useful Resource But Expensive Mandate

To spend money on a patient portal, or not to spend money on a patient portal right now: That is my dilemma.

I am in a three-physician family medicine practice. We have no physician assistants or nurse practitioners. Our small practice held off on buying an electronic health record (EHR) system, waiting for the Veterans Administration to release VistA (Veterans Health Information Systems and Technology Architecture) to the public domain. That system initially won many awards when fully supported, but licensing of proprietary modules is required for it to function correctly. Thus, we were forced into the commercial marketplace. 

Our path took us to the EHR system that we have used for the past eight years. These have been expensive and emotionally taxing years. Our original trainer, sent by the vendor prior to implementation, gave us some bad information and advice. (Although the company eventually fired him, they still charged us for all the time he spent "helping" us.)

Last year, our server was hacked, causing it to crash. Three weeks and tens of thousands of dollars later, we were back up and running.

We have worked hard and diligently to do the right things. Before the words “meaningful use” even entered our lexicon, we participated with our local Medicare Quality Improvement Organization on a project involving colonoscopy, Pneumovax administration, mammography and flu vaccinations in our patient population. We finished either first or second among the practices for meeting goals set by Medicare.

Meaningful use stage one was our next project, and we successfully fulfilled that government mandate. Meaningful use stages two and three, as well as National Committee for Quality Assurance recognition for transforming to a patient-centered medical home, will be our next projects. All three require upgraded hardware and software, which we acquired after our server crash pushed us in that direction.

We also are considering the addition of a patient portal, which is a requirement of meaningful use stage two. I understand the importance of fluid patient communication, but the cost of complying with this requirement seems steep.

Initially, our vendor was going to charge $5,000 per physician, plus training and a per-use fee. A "use" could include an email, an appointment or a payment received through the portal, and there would be no way for us to limit a patient from inundating us at our expense. That price -- before the server crash, at least -- seemed unfathomable.

The vendor later decreased its asking price by roughly $8,000 to initiate, but the per-use fee and training costs still remain.

What to do? Could we run a parallel program on a free EHR with a free patient portal? Should we spend the kind of money that the vendor is charging? A patient portal has the potential to reduce the number of phone calls we handle, but it also could result in more electronic messages that require responses. Can we, and should we, charge our patients for electronic access to help defer the cost?

What is the return on investment of implementing a patient portal? A Kaiser Permanente study showed that outcomes for patients with diabetes and/or hypertension improved within two months with the use of secure patient-physician email. Another study involving Kaiser patients showed that those who enroll in a patient portal that allows secure messaging with physicians, access to clinical data and self-service transactions are more than two times more likely to stay with a practice than patients who do not use such online resources.

A study in JAMA: The Journal of the American Medical Association found that patients with online access to their medical records increase their use of clinical services.

Still, I'd like to hear from my fellow small-practice physicians on this issue. I'd like to hear about your experiences in this brave new world of constant access and costs associated with electronic data. I look forward to learning people’s thoughts and, hopefully, coming to peace with a definitive decision.

Have patient portals helped your practice, and have they been worth the expense?

Rebecca Jaffe, M.D., M.P.H., is a member of the AAFP Board of Directors.

Tuesday May 06, 2014

Member Interest Groups to Provide Forum to Share Interests, Connection to Academy

I am really energized after attending the Annual Leadership Forum and the National Conference of Special Constituencies(NCSC) last week in Kansas City, Mo. These concurrent gatherings represent one of the most dynamic and innovative events the AAFP hosts.

The Annual Leadership Forum is a great opportunity for chapter-elected leaders, aspiring leaders and chapter staff from all over the country to attend practical and informative sessions and to network. It is one of the keys to helping our emerging leaders at the state level connect with each other and with the national Academy.

NCSC, originally the National Conference of Woman, Minorities and New Physicians, was created 24 years ago because certain member groups were underrepresented in Academy leadership. Over the years, constituencies for international medical graduates and physicians interested in gay, lesbian, bisexual and transgender issues were added.

Delegates write resolutions during the National Conference of Special Constituencies, held last week in Kansas City, Mo. During the event, the AAFP announced new opportunities for family physicians to form member interest groups.

In nearly 2 1/2 decades, NCSC delegates have written many resolutions that have challenged us as an Academy to creatively meet the needs of our members, as well as to improve the health of our patients. This year's conference was no different.

What is different, however, is the next stage in the evolution of this event. Prior to last year's Congress of Delegates, the Board of Directors convened a task force to explore the best way to create value -- including having a voice in the AAFP -- for all members. The task force made a series of recommendations to the Board last week. The Board approved all of the recommendations, and the Academy is moving forward with some exciting changes.

We have member groups with unique needs that are looking for ways their issues can be directly addressed, and a year ago, those members and the Congress challenged the AAFP to do a better job of recognizing the Academy's diverse membership.

The Academy has existing groups representing emergency medicine physicians and rural family physicians that have met for some time. However, our solo and small-practice physicians also are seeking a stronger voice, as are members who practice hospital medicine and those who are exploring direct primary care. There likely are many other groups, some of which we have yet to hear about.

So, here are some of the exciting changes we will see.

Next year -- the 25th anniversary of NCSC -- this annual meeting will again occur in Kansas City, Mo. However, it will be renamed the AAFP Leadership Conference for Current and Aspiring Leaders. The event will have two tracks, the Annual Chapter Leader Forum and the National Conference of Constituency Leaders. The groups will continue to meet in concert. Those of you who have attended in the past know that many of the leadership sessions presented during the forum have been scheduled at times when NCSC leaders also were able to attend. We'll continue this practice, which truly demonstrates our dedication to developing all of our leaders.

We anticipate that these member interest groups will become forums for our AAFP active members to share their mutual interests and address common concerns. We are setting in place a mechanism to begin requesting designation as a member interest group that will allow groups to really focus on what they hope to accomplish. They will be challenged to come up with a name for the interest group, first-year officers, at least 50 active members who support the application, interest group objectives, a description of how the interest group will further the AAFP's strategic priorities and a schedule of proposed first-year activities along with long-term goals.

Each member interest group will be connected with an Academy staff member and with the specific AAFP commission that seems most appropriate for that group.

The groups that presented resolutions 204 and 205 at last year's Congress -- which addressed the unique needs of family physicians in solo and small-group practices -- already have been given information on the application process for forming a member interest group, and we expect them to quickly move forward.

After one year, member interest groups have the option to petition the Board to transition to a member constituency.

Now, please bear in mind that because this is hot off the press, a link to the application is not yet posted online, but we will make an announcement in AAFP News when it becomes available.

Also important to note, a bylaws amendment from the Bylaws Work Group will be submitted to the Congress of Delegates that the member constituency seats to the Congress that currently exist be continued and not be reviewed by the Congress until 2020.

All of these recommendations build on the history of success and innovation that the Annual Leadership Forum and NCSC have always had. I look forward to seeing you in Kansas City next April for the 25th anniversary of this inspiring and energizing conference.

Reid Blackwelder, M.D., is president of the AAFP.

Wednesday Apr 23, 2014

Regional Meetings Offer AAFP Chapters Chance to Share, Learn, Lead

You might already know that each fall, the AAFP's State Legislative Conference offers a national venue for family physicians, constituent chapter leaders and staff to come together to discuss state health policy issues and share best practices for tackling legislative challenges. And during the Annual Leadership Forum each spring -- the 2014 meeting convenes next week, actually -- chapter executives and staff from across the nation gather for leadership training and to trade advocacy tips and other insights with their counterparts in other states.

But what you may not know is that you might be able to find this same sort of interaction -- albeit it on a smaller scale -- within your own region.

I recently had the honor of serving as the AAFP Board of Directors' liaison to the Multi-State Forum in Dallas. There are a number of such events that gather several Academy chapters throughout the year. These events are different from state chapter meetings, but they do have some similarities.

Regional meetings for AAFP chapters offer an opportunity for leaders from several states to come together and share their challenges and solutions. Here I am with California AFP President-elect Delbert Morris, M.D., during the Multi-State Forum in Dallas.

Perhaps the most important thing to recognize is that “All politics is local.” For the AAFP, this means that big impacts start with the state chapters. I encourage each of you to consider how you are getting your messages out, and whether you have considered becoming a more active part of your state chapter to best advocate for your patients, your practice and your community.

Our chapters have many different venues for addressing the kinds of issues that may seem to be unique to individual states. Multi-State is an annual gathering in Dallas of the Arkansas, Arizona, California, Colorado, Iowa, Illinois, Kansas, Missouri, Nebraska, New Mexico, Oklahoma and Texas chapters.

Similar meetings include:

  • Ten State Meeting: This event is held in February at rotating sites and involves the Connecticut, Illinois, Indiana, Kentucky, Massachusetts, Michigan, New Jersey, New York, Ohio, Pennsylvania and Wisconsin chapters.
  • The Southeast Forum: Held in August at rotating sites, this meeting involves the Alabama, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, South Carolina, Tennessee, Virginia and West Virginia chapters.
  • Western States Forum: This forum is meets each year to review resolutions slated to go to the AAFP’s Congress of Delegates and involves the Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, New Mexico, Nevada, Oregon, Utah and Washington chapters.

Typically, chapters select up to five members -- often those involved in leadership positions -- to represent their states at these regional meetings.

Unlike state chapter meetings, CME is not a main focus of these events, although there may be some sessions offered that provide educational credits. The most important aspect of these meetings, however, is for everyone to come together and share. This includes a focus on state legislative challenges and issues. In these sessions, chapter representatives discuss legislation in their states that may impact family medicine or that have been a focus of their chapter's advocacy efforts, including bills the chapters supported and those that generated concern.

Right now, many topics dominate our discussions nationally, such as physician payment, graduate medical education, malpractice and scope-of-practice issues. What is interesting is that at these group meetings, these issues are seen quite differently depending on the state that is presenting about them.

From my perspective, the most important benefit of these gatherings is the opportunity to share best practices. Most of these sessions offer a chance for chapter representatives to talk with one another about what successes they have had in different arenas. One of the biggest challenges for our national organization is how to help connect the chapters. In one important way, we need to make parallel in our organizations what we are asking for in our advocacy efforts. And we need to be sure that we are not duplicating our efforts. The more we can share opportunities, solutions and processes with each other, the better off we all will be.

Some of the other benefits of attending these meetings include the presentations they involve. For example, at Multi-State, we heard from Marci Nielsen, CEO of the Patient Centered Primary Care Collaborative, as well as our own Shawn Martin, AAFP vice president of advocacy and practice advancement. These speakers provided an outstanding framework for some of our discussions. In fact, these discussions preceded a recent JAMA article on the patient-centered medical home (PCMH) that suggested that the PCMH may not produce the outcomes we hoped for. However, we had a chance to consider more recent data than what was included in the article. This demonstrates the ability of these meetings to be on the cutting edge of important discussions.

These meetings also offer an opportunity to meet leaders from around the nation. Many future AAFP Board members and national officers saw some of their early involvement at these meetings and were able to hear the critically important broad view of issues that national leadership requires. But it is also important to note that the representation at these meetings often includes members who may not attend national meetings. These are state leaders who are essential to the function of our chapters. When I go to these sessions, I often meet people who are part of the national delegations, or who come to other national meetings; however, I am also blessed to meet many other family physicians who are working hard in their state chapters to make a difference for their patients, their state and their member colleagues. Ultimately, I leave these meetings feeling energized and optimistic about family medicine.

I am hopeful that you will discover the opportunities that are available to make a difference. Of course, you are involved now as you provide care for your patients and negotiate the challenges that you face every day. But I hope you realize there are also opportunities at the state chapter level to get involved beyond your practice. Step up and contact your chapter executive and move forward in your local leadership. From there, the next step as a chapter leader is to come to some of these larger gatherings where you can work with other family physicians to change things for the better. I look forward to seeing you at one of these meetings.

Reid Blackwelder, M.D., is president of the AAFP.

Friday Apr 18, 2014

Tedious Paperwork, Government Regs: Why I Still Love Being a Physician

Today I had a busy day with a full schedule of patients. I struggled to chart my patients' complex histories in an electronic health record that has given me none of the efficiencies it promised.

I lost my lunch break to an administrative meeting, leaving me no time to get caught up from a hectic morning.

I filled out prior authorization forms for medications that a patient has already been on for six months. I completed more forms and insurance paper work than I care to remember and bemoaned the low reimbursement we are being paid for our visits.

I came home hoping to squeeze in time with my family but knowing that I also had hours of catch-up charting to do. 

When I left clinical medicine for a year, I discovered that I wanted, and needed, to come back.

This is a typical day for me, and I'm sure other physicians can sympathize. There are a lot of reasons to feel frustrated as a doctor right now, and a recent article written by an internist in The Daily Beast outlines how difficult the job can be at times.

But I still love being a doctor, and -- despite the challenges, the paperwork and the burdensome regulations -- I know I'm not alone.

Next month will mark 10 years since I finished medical school and started my journey as a family physician. After residency, I worked at a federally qualified community health center, seeing patients from a wide range of cultural and socioeconomic backgrounds. It often seemed like my patients' problems were bigger than my prescription pad because I couldn't cure the poverty that was at the root of their medical conditions.

I thought I could do more for my patients outside of the examination room than inside, so I left clinical medicine. I spent a year in the federal government as a White House Fellow. In one sense, it was a breath of fresh air: no insurance forms, no call, no charting or EHRs and no worries about whether or not the sustainable growth rate (SGR) was going to be fixed. In addition to gaining a better understanding of how the government works, I also had the opportunity to work on issues such as breastfeeding, hunger and poverty at a national level.

When I started the fellowship, I didn't know if I would return to clinical medicine, but it didn't take me long to realize how much I missed seeing patients. I found myself seeking out clinical experiences, asking anyone with the sniffles if they had other symptoms or if they were taking any medications.

After a year away, I was excited to jump back into patient care. Providing primary care to patients is truly my calling.

I have to admit, I'm a glass half-full kind of person. Although I recognize all of the problems we face in medicine, I also see so much to be excited about.

The Daily Beast columnist pointed out that the majority of medical students typically pick high-paying subspecialties. She also wrote that primary care physicians are the janitors of the medical profession. How nice. The fact is that the number of medical students choosing family medicine has increased for five years in a row, and the number of U.S. medical graduates picking our specialty also is increasing.

It's true, however, that payment -- one of the AAFP’s top legislative priorities in Washington -- remains an immense challenge, both to our practices and to building student interest in family medicine. In a recent MedScape physician survey, family physicians ranked near the bottom of the physician salary scale, yet we had one of the most positive responses when respondents were asked if, given a chance, would they would chose a career in medicine again.

So what do we have to be optimistic about?

I am encouraged that for the first time there is a bi-partisan, bi-cameral proposal for a long-term SGR fix. (Congress hasn’t got the job done yet, but there is still hope.) And CMS, with input from the Relative Value Scale Update Committee (RUC), continues to address overvalued procedures, which shifts money within the Medicare fee schedule to other services, including those commonly done by primary care.

Last year, CMS created two new codes to cover transitional care management, and next year the agency plans to add a code for chronic care management. These new codes should benefit primary care physicians.

I also am hopeful about the prospect of alternative payment models that may actually reimburse physicians based on the value of care that we provide and not the number of people we see (a backwards system that incentivizes physicians to do more and increases medical costs). In addition, more and more practices are operating outside of the insurance framework altogether by providing direct primary care. This option is affordable to patients and puts the patient back in the center of the cost equation.

I am intrigued by the fact that technology and telehealth have the potential to revolutionize how we see patients and provide comprehensive care. Patient portals and virtual medical visits offer opportunities to reduce office visits and increase patient satisfaction.

It has been a joy to see so many patients who are now able to access care with me because they have insurance through the Medicaid expansion created by the Patient Protection and Affordable Care Act.

And for all of the political drama that health care reform has created, it also has opened up a real conversation about the strengths, weaknesses and future directions of health care in the United States for the first time in decades.

But the real reason I still love being a doctor is my patients. So although I could look at today as a tedious mess of charts, forms and administrative haggling, instead I see it as a tapestry of patient experience. I will soon forget the paperwork, but I won't soon forget talking with my patient as we learn her cancer may have returned, or congratulating my patient who lost 20 pounds and dropped his cholesterol by 50 points, or helping a couple start the process of adoption after a long battle with infertility.

In the Medscape survey, the average salary of all physicians was more than $200,000. Eight subspecialties had averages of more than $300,000. Yet when asked what the most rewarding part of their jobs was, only 10 percent of physicians cited money. The top response was "being good at what I do" at 34 percent, followed closely by relationships with patients (33 percent). "Making the world a better place" was third at 12 percent.

So what do I say to physicians who are burned out or dissatisfied? Perhaps it's time to look at other job options? Or maybe it's time to just take a break. When I left clinical medicine for a year, I discovered that I truly love it. It confirmed for me that I wanted, and needed, to go back.

But to do so, I had to do it in a way that was sustainable for me and my family and still allow me to enjoy patient care. That decision sparked my interest in joining the AAFP Board of Directors because I want to help make the world of medicine better for family physicians.

The profession of medicine truly is a calling to help others. I came into it knowing that sacrifices would occasionally have to be made and that patients would often have to come first. If one is in it for money or accolades, he or she likely will be disappointed. I find joy in being able to help my patients navigate their lives in sickness and in health so that they can get back to the joy of living.

Kisha Davis, M.D., M.P.H., is the new physician member of the AAFP Board of Directors.

Wednesday Apr 09, 2014

A Well-Deserved Honor for AAFP President

When I was first elected to the AAFP Board of Directors four years ago, I was fortunate to find a mentor waiting for me.

Reid Blackwelder, M.D., would often give me pointers about how I could be more effective in contributing to the Board's deliberations. Sometimes it was an encouraging email, or he might pull me aside to say, "You made a good point on this issue, but you need to be more succinct."

AAFP President Reid Blackwelder, M.D., second from right, recently was honored by the Tennessee General Assembly for his work as a physician, educator and advocate. State Sen. Joey Hensley, M.D., far left, sponsored the resolution. Tennessee AFP officers Kim Howerton, M.D., and Lee Carter, M.D., also were on hand for the presentation.


Well, I'm working on that, and Reid has been a great role model. His criticism has always been constructive, and he has helped me grow, learn and develop my own leadership style. It's no surprise because he's helped mentor countless others, including the more than 1,400 medical students he's taught over the years at East Tennessee State University's (ETSU's) James H. Quillen College of Medicine.

ETSU medical students have named him Mentor of the Year and Family Medicine Attending Physician of the Year multiple times, and he's also received the Dean's Teaching Award. The AAFP awarded him the Exemplary Teacher of the Year Award in 2008.

He also has been honored by the
Tennessee AFP for his exceptional leadership and outstanding service to that organization.

Whether he is teaching, talking with his patients or lobbying on Capitol Hill, it all comes back to communication. Reid is easy to talk with and is a good listener as well. The same skills have served him -- and the Academy -- well in working with the media. He has been quoted in or contributed to more than 670 articles or broadcast features during his tenure on the AAFP Board.

His cumulative body of work recently led to the Tennessee General Assembly passing Senate Joint Resolution 536, which recognized Reid's "exceptional work as the president of the American Academy of Family Physicians," his dedication to teaching, and his advocacy efforts on behalf of physicians and patients. It also recognized him for dedicating his professional career to improving the lives of others.

I can't think of anyone more deserving of the honor, and I'm proud to call Reid my colleague, mentor and friend.

Currently, we have three candidates for four positions on the AAFP Board of Directors. Our speaker, John Meigs, M.D., recently pointed out on this blog the process of nominating candidates and the need for a deeper pool of candidates I can only say that anyone stepping into these leadership roles will find it a tremendous personal growth experience, and they will gain a new friend and mentor in Reid Blackwelder. Congratulations, my friend, on your well-deserved award.

Robert Wergin, M.D., is President-elect of the AAFP.

Tuesday Apr 08, 2014

Don't Accept Limits on Your Family Medicine Opportunities

With our broad, extensive training, family physicians have opportunities beyond working in family medicine practices. Family docs are working in geriatrics, sports medicine, long-term care facilities, urgent care clinics, hospice care, and as hospitalists, administrators, researchers and more.

It's that diversity that draws some medical students to family medicine in the first place.

When I travel around the country to state chapter meetings, I hear from a lot of family physicians who love what they do. Occasionally, I also hear from members who say they feel trapped.

That was the case recently when I spoke to a colleague who had done research and developed a business plan that would expand primary care services for her health system. The idea, she thought, would improve outcomes and generate new revenue streams.

Her employer, however, was thoroughly disinterested.

Disappointed and disillusioned, she told me she felt stuck in her job because she had signed a two-year restrictive covenant agreement, or noncompete clause, when she was hired. That agreement excluded her from working in other family medicine clinics within 50 miles of any facility owned by her employer, which has locations in multiple counties in her area.

In my opinion, she was so close to her own situation that she had lost perspective. I told her to think about the diversity of her training and reminded her that family medicine is the No. 1 specialty for which recruiters are hiring. We are only trapped if we accept limitations others try to put on us.

These days there are incredible career opportunities across a wide spectrum because primary care is the backbone of our health care system. Family physicians are in high demand. In fact, there were more than 300 new job postings on the AAFP's CareerLink website during the first seven days of this month.

If you're feeling burned out or resentful, it's time to step back and consider what you might be able to do differently. Personally, I've left a job when I wasn't being compensated fairly and was unable to change unsatisfactory circumstances. When advocating for change within your system doesn't work, it's appropriate to consider other opportunities. Don't sell yourself short.

One of my colleagues recently made the decision to leave New England and move to a new opportunity in South Carolina. After more than 20 years of dealing with the same payers, she was ready to try something new.

That brings us back to the issue of restrictive covenants and whether physicians should be signing them. The AMA adopted principles two years ago that discourage physicians from entering employment agreements that contain noncompete provisions or other restrictions on future employment.

Personally, I've refused to sign restrictive covenants twice. Both times, I was told it was standard operating procedure. Both times, I let them know it was a deal breaker for me, and the employers backed down.

If an employer isn't willing to hire you without placing restrictions on your future, maybe it's not the right place for you. It's important to be able to walk away on your own terms, and there will always be other people who will hire you.

With a shortage of primary care physicians, our health care system can't afford to lose our training and expertise. If you're feeling burned out or trapped, you always can reach out to your colleagues or mentors for perspective and advice. Getting involved with your state chapter and national family medicine activities can expand your professional network.

Remember, there are always other options. With training as a family physician, you are invaluable, and you can find professional satisfaction in other settings where you can provide the expert care our nation needs.

Wanda Filer, M.D., M.B.A., is a member of the AAFP Board of Directors.

Wednesday Apr 02, 2014

Candidates Wanted: Four Spots Available for AAFP Board

If you've ever thought about running for the AAFP Board of Directors, now might be the perfect time to do it. As of today, we have fewer candidates than the number of spots available in an election that is just six months away.

Each year, the AAFP Congress of Delegates elects three family physicians to three-year terms on the Academy's Board of Directors. Between meetings of the Congress, the business and affairs of the Academy are managed by and under the direction of the Board. The Board appoints commissions, committees and other work groups as necessary. Directors also serve as liaisons to the Academy's seven commissions and serve on the Board's various subcommittees.

The Congress of Delegates will select new directors in October in Washington. To date, there are only three candidates for four positions on the AAFP Board of Directors.

It has been my privilege and pleasure to serve on the Board of Directors for the past six years. This has been a tremendous opportunity for me to learn more about the inner workings of the AAFP and also to benefit from the knowledge, experience, expertise and dedication of the Board members and Academy staff with whom I have had the opportunity to work.

I have come to appreciate the reasoned discussion and debate of the Board as issues are introduced and all points of view considered as the Board tries to reach consensus on the issues we face.

I came to the Board with my rural background and 30 years of private practice experience, and I hope that I have been able to contribute in some small way. I always have felt that I have learned far more than I have contributed. I have gained a broader understanding and deeper knowledge on so many subjects and issues, which has helped me to gain a broader perspective and to make me a better resource for my colleagues back in my practice, community and state chapter.

I would encourage anyone who has the time, dedication, drive and commitment to family medicine to consider running for the Board of Directors. For me, this has been an intensely rewarding and enriching experience that has carried over into the other aspects of my professional and personal life. I am more dedicated than I have ever been to family medicine and more convinced than ever that our health care system needs a strong, vibrant, respected and resourceful primary care workforce to deliver the cost effective quality health care that our patients and our country need and deserve.

So who is ready to step forward?

In nine of the past 10 years, AAFP chapters have nominated at least five candidates for three Director positions. In the 20 years I have been attending the Congress, I have never seen an uncontested election.

However, chapters have nominated only three candidates for the election that will take place in October at the Congress of Delegates in Washington. Complicating the matter is the fact that Director Clifton Knight, M.D., has accepted the role of AAFP vice president for education. He will resign his elected position on the Board, with one year remaining in his term, when he begins his new job in May.

That leaves us with three candidates for four spots. So what happens to the candidate who comes in fourth, assuming more candidates come forward? The candidate receiving the fourth-highest majority vote total would fill Knight's unexpired term and would be eligible to be a candidate seeking election to a full three-year term during the 2015 Congress of Delegates in Denver.

Due to the additional vacancy, the deadline for receipt of candidate information for the candidates' website has been extended to May 30 with the site going live June 13.

That leaves potential new candidates plenty of time to be competitive with the three existing candidates. Campaigning typically begins at the Annual Leadership Forum and National Conference of Special Constituencies, which will be held May 1-3 in Kansas City, Mo.

Chapters are encouraged to nominate qualified and interested individuals to run. Candidates for AAFP offices must be officially nominated by their chapters and must submit an official announcement letter and candidate photograph to EVP and CEO Douglas Henley, M.D.

With a diverse, national organization of more than 110,000 family physicians, medical students and residents, we need diverse representation -- not only of genders and ethnicities but practice types and locations. This is an excellent opportunity for family physicians to represent our organization.

You can read the campaign rules on the AAFP website.

John Meigs, M.D., is Speaker of the AAFP Congress of Delegates.

Wednesday Mar 19, 2014

Academy Tools Could Ease EHR Burdens

Editor's note: During the AAFP's Scientific Assembly in San Diego, a panel discussion on practice transformation generated far more questions than the panelists could answer in the time allotted. This is the fifth post in an occasional series that will attempt to address the issues members raised -- including challenges associated with electronic health records systems -- during the panel.

Two years ago, my practice implemented an electronic health record (EHR) system. The initial results weren't pretty. Transitioning from paper to electronic files takes time, and my productivity plunged.

But I worked at it, learned the system and my productivity has improved. Although my patient volume has not yet returned to pre-EHR volumes, my clinic is running much smoother than it did initially because my staff and I have adapted. We have embraced this change, and the benefits have been numerous.

  • We qualified for meaningful use stage one incentive payments, and we are working on stage 2, including the launch of a new patient portal. Those incentive payments helped offset the investment in the EHR and that initial dip in clinic volume.
  • My practice previously had one full-time equivalent devoted to pulling and filing paper charts. Now, that information is at my fingertips whenever I need it.
  • Our clinic system is spread across three communities, so one of the big benefits of the electronic system is being able to access records -- including labs and X-rays -- securely from any location, including our ER.
  • A medication reconciliation process has made us more aware of what drugs patients are taking, which helps us avoid medication errors, interactions and duplications.
  • We are developing disease registries that will allow us to track our patients, improve follow-up care and provide better care for patients with chronic conditions.

Health care isn't going back to paper records. This is where we are headed, but qualifying for meaningful use incentive payments can be challenging. That's why the Academy has included a step-by-step guide to meaningful use stage one in its new PCMH Planner, an affordable, subscription-based web tool designed to help practices -- particularly small practices -- transform to the patient-centered medical home model. A guide to stage two is expected be available in the PCMH Planner by the end of March.

The Academy created the PCMH Planner at the request of small practices that were asking for help with practice transformation. I recently saw a demonstration of the Planner, and it is an effective, evidence-based way to start the process of transforming a practice. The Planner also includes Practice Foundations for PCMH, a step-by-step guide to quality improvements and other tasks that should be completed before you begin practice transformation. PCMH 101, which covers the basics of becoming a medical home, will be available later this month, and PCMH 201, which offers more advanced topics, is expected to be available later this spring.

What else is the Academy doing to make EHRs easier to use and more effective? The Congress of Delegates has asked the AAFP to create a clinical data repository that would provide data to family physicians in way that is clinically relevant.

In a 10-practice pilot, we've created registries related to diseases, procedures, medications and lab results and provided the participating practices with analytics and comparison data against their peers. The system is capable of identifying potential gaps in care and patients who should be prioritized for outreach. It also provides revenue and cost efficiency metrics.

Although this is only a pilot, evidence to date indicates that it is working. We have found that the clinical data repository is technically feasible and capable of generating value for practices. The repository also could act as a national specialty registry, which would ease the reporting burden on family physicians by allowing us to report data to a single source.

A decision on how this concept might be rolled out to Academy members as a product likely will happen this summer.

And what about interoperability? When our patients leave our practice and go to another -- for a subspecialist consultation, for example -- my EHR won't necessarily be able to communicate with the subspecialist's EHR. This is a major flaw in our health care system, and the Academy continues to push the Office of the National Coordinator (ONC) for Health Information Technology and EHR vendors on this important issue. Unfortunately, vendors have little motivation to fix it because they want customers to buy their proprietary, unique products. It doesn't help that large health care systems aren't in the habit of sharing information with competing health care systems. Thus, interoperability likely remains at least five years away.

Meanwhile, the Academy is one of the sponsors of the nonprofit DirectTrust, which accredits services that allow physicians to exchange encrypted patient information through secure servers. You can read more about the direct exchange process here

The AAFP is working to develop resources that save us time and money and reduce our reporting burdens. I'll keep you updated on our progress in these efforts.

Robert Wergin, M.D., is President-elect of the AAFP.

Friday Mar 14, 2014

For This State Chapter, It Truly Is a 'Family Affair'

One of the characteristics that truly defines family physicians is that we recognize everything is about relationships. We certainly understand this when to come to our patients.

I worked with a medical student recently, and she was impressed by how much I knew about patients I hadn't seen for months. I told her that it's because we family physicians know our patients, and we value their stories. This is how we help take care of folks and how we put everything into context. It's one of the things that make family physicians special.

Nevada AFP executive director Brooke Wong is her chapter's sole staff member, but her entire family helped the chapter's annual meeting run smoothly. Here, daughters Alexa, 9, and Kendall, 3, along with Bear Farrimond, 5, assist Jeffrey Ng, M.D., with a raffle drawing.

We walk our talk in so many other ways, too. This relationship aspect is something I see regularly, and thoroughly enjoy, as I travel around the country and talk with Academy members. One of my responsibilities -- it's an opportunity, really -- as AAFP president is to attend state chapter meetings. Often, I am there to install new officers, provide educational opportunities and update members on what the AAFP is doing for them.

But I think what I am really doing is reinforcing the power of relationships. The connections I am making are phenomenal. Many of the physicians I see at chapter meetings are people I have met at other meetings because we often travel the same paths. However, each state chapter also has physicians who are not involved at the national level. These are the dedicated family physicians on the front lines who are often coming together for their own networking and education.

Behind all of this activity are the chapter executives who do outstanding work for their members. These are truly compassionate and remarkable individuals who help each chapter be the best version of what it can be.

I recently traveled to South Lake Tahoe, Nev., for the Nevada AFP's annual meeting. I was invited to the chapter's meeting last year, but I had to cut that trip short to make an unplanned, but very important, other meeting. I was thrilled that the Nevada AFP asked me and my wife, Alex, to come again this year. We were eager to get the full experience this time.

What was remarkable is that you would never know that this actually is a small chapter. A large number of people attended the very well-put-together CME sessions in a beautiful location. However, what was most powerful to me was how much of a family affair this event was. The moment I arrived, executive director Brooke Wong welcomed me into her bustling command center.

Brooke is a staff of one, but her family provided plenty of help to make the meeting run smoothly. Her young daughters helped with a silent auction. Her husband, Conrad, provided IT support and took photographs. He was everywhere, making sure that the CME came off without a hitch and documenting all of the events.

At registration, Brooke's mother and father greeted people with a smile, offered chocolate and signed attendees up for all of the various events.

As soon as we walked in, we were part of the Nevada AFP family. There is truly no better example of the power of relationships than what occurs at these chapter meetings.

Thanks to all of the chapters I've had a chance to visit, and I look forward to those coming up. It is an incredible opportunity, and I value being a part of each of your families.

Reid Blackwelder, M.D., is president of the AAFP.

Wednesday Mar 12, 2014

Barriers Impede Telemedicine's Potential

Editor's note: During the AAFP's Scientific Assembly in San Diego, a panel discussion on practice transformation generated far more questions than the panelists could answer in the time allotted. This is the fourth post in an occasional series that will attempt to address the issues members raised -- including payment for telemedicine -- during the panel.

We know that telemedicine, the use of technology to deliver care at a distance, has the potential to expand access to care in underserved areas, reduce ER visits and save patients time. Questions remain, however, about how we can best expand telemedicine's use in primary care.

Telemedicine already is used in subspecialty care, including dermatology and radiology. But in our current fee-for-service model, can telemedicine be integrated into primary care without significantly increasing health care costs?

Kimberly Becher, M.D., left, the resident member of the AAFP Board of Directors, accompanied me on a trip to Capitol Hill while I was a visiting scholar at the AAFP's Robert Graham Center for Policy Studies in Family Medicine and Primary Care. I interviewed more than a dozen representatives of federal government health agencies and congressional staff about telemedicine for my project.

I recently spent a month in Washington researching telemedicine and the barriers to its expansion as a visiting scholar at the Robert Graham Center for Policy Studies in Family Medicine and Primary Care. Participating in the Larry A. Green Visiting Scholars Program was an invaluable educational experience, and I acquired skills that will help me for the rest of my career. The Graham Center staff provided me with in-depth training on research, including how to plan a project from beginning to end, proposal writing, information and data gathering, manuscript writing and more.

The training actually started months in advance as I worked with Graham Center staff to define what my project would be so that I could hit the ground running when I arrived in Washington for one month of intense work.

I picked telemedicine as my topic, in part, because the Graham Center was already in the midst of a research project on the subject. Funded by a $200,000 grant from WellPoint, the project produced a literature review, a report from the meeting of an expert panel, and -- coming later this year -- a survey of AAFP members about our knowledge and use of telemedicine.

It is hoped that the member survey results and my manuscript will be published in peer-reviewed journals. The Academy also intends to share the report from the expert panel.

For my project, I interviewed 14 representatives from government health care agencies and congressional staff to gauge their understanding of telemedicine and to identify barriers to its expansion in primary care and what is required to move beyond those barriers.

Barriers, it turns out, are not in short supply. One of the biggest issues is payment because of the constrained rules that exist in the current payment systems. There are certainly ways that telemedicine can be integrated into care delivery now, but I hope with alternative payment models on the horizon -- where physicians are paid based on quality and value -- we will see more physicians use it to deliver care at a lower cost for their patients.

Reimbursement for telemedicine services vary widely by payer and state. Ten states require Medicaid coverage of telemedicine, and 43 states require Medicaid coverage for some telemedicine services. Eighteen states mandate private payer coverage for telemedicine, and 14 other states have legislation pending.

But telemedicine is complicated in many other ways. According to the American Telemedicine Association, more than half the state legislatures are considering bills related to telemedicine. One of the most prevalent issues is licensure.

In Florida, for example, the state medical association has said that it supports the expansion of telemedicine, but the association is lobbying against a bill that seeks to create statewide standards and establish reimbursement requirements for telemedicine. The association is fighting the bill, which also would create a system for registering out-of-state physicians, because it opposes the idea of physicians licensed in other states treating Florida patients via telemedicine.

That's a significant issue in Florida because of the annual migration of people who spend the winter months in the Sunshine State.

What's at stake? A nonpartisan, nonprofit public policy research institute released a report this month that said reducing costly interventions, such as ER visits, by as little as 1 percent could reduce the state's health care costs by $1 billion a year.

Among my interview subjects, there was broad recognition that telemedicine is an important issued related to access to care. But another barrier we must overcome is that many rural and underserved parts of country still don’t have access to broadband internet. That's important because although the "tele" in telemedicine might prompt people to imagine a physician on a telephone, there's much more to it. Telemedicine can involve video conferencing with a patient from his or her home, electronic monitoring of chronic conditions and so much more. The fact that telemedicine means different things to different people could be a barrier as well. There's no consensus on what the term actually means.

That's unfortunate because more than 50 percent of U.S. hospitals already are using telemedicine in some manner. Incorporating the use of this technology in care delivery is happening, and it will continue to expand, so we have to figure out how it fits in primary care.

A good step forward would be finding a way to expose medical students and family medicine residents to telemedicine. I'm a fourth-year medical student and have yet to experience it. Medical school and residency is where we get our feet wet, and the models we train in influence how we will practice later.

We have the technology and the ability to extend ourselves, improve access to care and save our patients time and money, but there are many questions left to answer. I hope that when the Graham Center's survey lands in your in-box later this year, you will take a few minutes to give us your thoughts on telemedicine. The more people who participate in this important survey, the more valuable our data will be.

Tate Hinkle is the student member of the AAFP Board of Directors.

Wednesday Feb 26, 2014

Stories of Successful Underdogs Resonate With FPs

I read my first Malcolm Gladwell book more than 10 years ago when a fellow family physician gave me a copy of Tipping Point: How Little Things Can Make a Big Difference, at an AAFP commission meeting. Since then, I've read Gladwell's Outliers, Blink and What the Dog Saw.

I recently read the author's newest book, David and Goliath: Underdogs, Misfits and the Art of Battling Giants. In this book, Gladwell tests the reader's perception of what obstacles and disadvantages create apparent setbacks in life. His examples include the titular bible story, the dynamics of successful and unsuccessful classrooms and the thought processes of cancer researchers.

As I was reading, I kept thinking about family medicine, the apparent underdog in the playing field of medicine. David, who was skilled with a slingshot, faced Goliath, a man who clearly suffered from an endocrinopathy but who was big in stature and strong.

Family medicine has the right stuff. We are bright and strategic. But unlike the original story, there are many Goliaths on our battlefield, and this is distracting and time consuming, especially when we would rather focus on the things most important to us such as our patients, families and communities. How do we fight the many giant challenges -- dealing with payers, adapting to regulations, etc. -- that stand in our way?

In an interview with INC. magazine, Gladwell said, "Effort is the route available to the underdog. I may not be able to outspend you, but I can outwork you."

Gladwell's David and Goliath has a chapter about people who have been successful despite having dyslexia. Gladwell's theory is that if a task is made slightly harder, a person may learn better because he or she will be forced to concentrate more and is likely to read something multiple times instead of just once.

Family physicians certainly know about hard work. The amount of work required to become a family physician is significant -- 21,000 hours of standardized education and training, including exams overseen by a single certification body.

No one can truly replace us, although others are desperately trying to claim that they can. Gladwell makes a case for the proper number of students in a classroom to make learning optimal. Similarly, we are making a case for the number of hours of training required to provide primary care. Nurse practitioner (NP) training, in particular, ranges from 3,500 to 6,600 hours, and the clinical aspects of their education and training vary tremendously. Each of their three accrediting organizations has their own criteria for certification.

And yet, there are those who claim NPs and physicians are interchangeable. How can this be? Family physicians are the best medicine that the system has to offer.

But where is the best place to be standing in today's times? Should we position ourselves in the midst of the Goliaths who would prefer us to quietly do our work and not cause a fuss? Or do we steer clear of these challenges and let others decide our fate?

Gladwell observes that in many instances, underdogs can prevail with hard work and strong will. As modern day Davids, we, as family physicians, must strategically place ourselves where we can do the most good for the most people. Gladwell writes that while you are working on changing the game, you also have to make sure that you get the most out of the rules that already exist. That is exactly what the AAFP is trying to do. For example, the Academy continues to stay involved with the flawed AMA/Specialty Society Relative Value Scale Update Committee (RUC) rather than being absent from the table and having no voice at all. However, we also are advocating directly to CMS about payment issues.

And although it can be extremely frustrating, we continue to have regular meetings with the nation's largest private payers because it gives us an opportunity to work on common issues while promoting the value and importance of primary care.

We, the family physicians who are strong medicine for America, must emphasize our unique ability to listen, understand and help our patients, offering our valuable time and resources. We must be the brave David and use all our resources to stay in the game and win the fight.

You can learn about being an advocate for our specialty -- including a day of training and a day of lobbying on Capitol Hill -- at the Family Medicine Congressional Conference April 7-8 in Washington. I hope to see you there.

Rebecca Jaffe, M.D., M.P.H., is a member of the AAFP Board of Directors.

Thursday Feb 06, 2014

Dedication to Lifelong Learning Reflects Specialty's Heritage

I recently attended a meeting of the Family Medicine Working Party, which is a convocation of the seven organizations that represent our specialty.

These groups are led by outstanding family physician volunteer leaders, and these biannual meetings allow these leaders to ensure each organization is aware of what the others are doing. Often, a focus area for one group affects the other groups as well. Even if our initiatives don't directly overlap, it is important to hear updates about what is happening.

It also is a great opportunity to talk about some of the remarkable things that we see in family medicine. I was particularly inspired by a story from James Puffer, M.D., the president and CEO of the American Board of Family Medicine (ABFM). One topic that we routinely review with the ABFM is the process of maintenance of certification, and the exam all diplomates are required to take. This conversation allowed us to review the commitment to lifelong learning that has exemplified family medicine.

It is important to recognize that when family medicine began as a specialty, we were the first and only specialty that challenged our members to continue to recertify. Other medical specialty organizations had lifelong certifications in place that allowed a physician to take one exam, one time. Our specialty's founding fathers knew that lifelong learning was a critical aspect, and that certifying only one time would not guarantee that a physician was at the top of his or her game throughout his or her career. We now have data showing that recertification maintains a knowledge base over time, whereas taking a single exam one time allows a person's knowledge base to decline.

However, the inspirational part of this story has to do with a group of family physicians who continue to recertify well into their 80s and even 90s. In fact, the oldest family physician who recently sat for the recertification exam was 93. Puffer personally calls all of these physicians to let them know their scores and to ask an important question. He was especially pleased to call the 93-year-old physician to inform him that he had indeed passed. Puffer asked the man if he was still practicing. The family physician replied that he had not practiced for many years. So, Puffer asked why he was recertifying. This member said that he could not imagine letting his certification lapse. He has always been board-certified, he said, and he always would be.

I think this comment is a testament to something unique about family physicians. This is a dedication to true lifelong learning. This member is going to continue to challenge himself to learn more about his craft even though he is no longer practicing. It also speaks to the pride and work ethic of this member that I think exemplifies family physicians. We recognize that board certification means something. We recognize that in family medicine, we have made a commitment to continue to challenge ourselves to be the best that we can be in order to give the best possible care to our patients.

This kind of story challenges me to continue to do everything I can to help our organization be the best that it can be so it can serve members like this extraordinary family physician in the way they deserve. I hope that I, too, am continuing to recertify until it is time for me to go to my next great adventure.

Reid Blackwelder, M.D., is president of the AAFP.

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