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.
New Year Brings New Life, New Hope
As the year winds down, the holidays give us an opportunity to share time with our family and friends. It is a time when the young create new memories and the old share theirs.
One of my most memorable holidays as a family physician happened just a few years ago. Brenda and I were preparing for New Year's Eve -- packing things to take to a friend’s house to celebrate the new year with friends and family -- when I got a call from the hospital. One of my maternity patients had arrived and was contracting. I admitted her and told the nurse I would stop by and check on her shortly. On my way to the party, I stopped at the hospital and confirmed my patient was in labor.
© 2014 Sheri Porter/AAFPHere I am checking on a new patient in the hospital. Maternity care can make things challenging during the holiday season.
I spent the early part of the evening with good friends and family and limited my celebration to sodas and coffee. I received hourly updates about my patient, and by 10:30 p.m., her labor had progressed enough that I excused myself from the gathering and made arrangements for my brother to take Brenda home.
I went to the hospital and sat with my patient and her husband, monitoring her labor’s progress. At 11:30, it was time to start pushing. She did well, and around 12:30 a.m. -- at the start of a new year -- we celebrated the birth of their new son.
Both parents were elated, although the father did ask if we could have "rushed this along a little" so the tax deduction that comes with a new child could have been applied to the year that had just ended. I told him I didn’t have much to do with the timing, and he agreed. The next day, however, the local newspaper took a photograph of the county's first baby of the year, and the family received many gift certificates and congratulations from businesses in the community.
I headed home around 1:30 a.m. Brenda got up, and we opened a bottle of champagne and celebrated the new year, a healthy new baby boy, and a new patient in my practice.
That is family medicine. Sometimes our families have to make sacrifices, but it is part of who we are. And our communities are stronger for it. This was a memorable New Year's for me and this family. I'd like to hear the story of your most memorable holiday spent with patients in the comments field below.
Happy New Year from the AAFP. Take a look at this video to see some of what we accomplished in 2014. And here's to a prosperous 2015.
Robert Wergin, M.D., is president of the AAFP.
The Center for the History of Family Medicine: At First, I Didn't Care Either. But Now I Get It
Probably like many of you, I don't think about history much. Between the responsibilities of my practice, my family and my service to the Academy and its members, I just don't have a lot of time to study the past.
So when I was appointed recently as the Academy's representative to the Board of Curators of the Center for the History of Family Medicine, I did not know what to expect. As the principal resource center for the collection of the specialty's history, the center struck me as a dull abstraction at best and at worst, a waste of time, space and money. With all of the many issues and challenges facing our specialty, it just didn't seem important to me.
Photo courtesy the Center for the History of Family MedicineArthur "Lud" Ludwick Jr., M.D., won the Silver Star while serving as a physician on the frontline during World War II. Ludwick is one of the many physicians whose stories are told through the Center for the History of Family Medicine.
But then I came to the center and saw it for myself. And now I get it.
The center is much more than just a place where old papers are stored. It is the collective memory of family medicine.
Told through its many documents, photographs, videos and artifacts, the story of our specialty is one of hardship, struggle and, ultimately, triumph. It begins in 1947, when a group of general practitioners -- facing the almost certain extinction of general practice -- formed the organization that we know today as the AAFP. It's a story worth remembering as we venture into the future and turn our sights to addressing the challenges and opportunities ahead through the Family Medicine for America's Health project.
But fundamentally, the story of family medicine is a story about people. It's a patchwork of the intensely personal stories of the many GPs and family docs who, throughout the history of our country, have served on the frontline of American medicine, caring for patients in wartime and in peacetime, and from birth to death.
Take for example, the story of Arthur "Lud" Ludwick Jr., M.D., who won the Silver Star for "gallantry in action" while serving as a GP on the Italian frontline during World War II and then went on to have a long and distinguished career practicing in Wenatchee, Wash.
Or the story of Olin Elliott, M.D., of Des Moines, Iowa. Described by one colleague as "a delightful, well-rounded doctor, loved and respected by patients, colleagues, family and acquaintances alike," Elliott was renowned for his compassion and dedication to his craft. In 1957, when his wife was diagnosed with amyotrophic lateral sclerosis, he became her primary caretaker while still continuing his medical practice, providing her with medical treatment until her death. In later years, Elliott volunteered at a clinic for the homeless in Des Moines, and even after being diagnosed with pancreatic cancer in 1981, he continued to care for his patients up until the day of his death the following year.
Or, more recently, the story of Regina Benjamin, M.D., M.B.A., a family physician from the small fishing village of Bayou La Batre, Ala., who went on to become the 18th surgeon general of the United States.
All of their stories -- and the stories of many others -- are told through the center's collections.
And there are practical applications for the center's holdings, too. An important educational resource for the specialty, each year, the center sponsors both a research fellowship and an internship program. The information contained in the center's collections helps us understand -- and hopefully avoid -- the mistakes of the past, thus saving us time and money that might otherwise have been spent trying to reinvent the wheel. It also plays an important role in advancing our specialty by supporting and enhancing public relations and marketing efforts through interesting and informative exhibits.
In short, the center allows us to make a direct and vital connection between family medicine's distinguished past and its exciting future.
So now I get it. And I hope that you will have the opportunity one day to visit the center -- either in person at the Academy's Leawood, Kan., headquarters or through its website -- and discover this for yourself.
After all, in the words of author and historian Theodore Draper, "If history can teach us nothing, we have nothing that can teach us."
Robert Lee, M.D., is a member of the AAFP Board of Directors.
My Year as President: The Honor Has Been Mine
It is hard to believe that a year has passed so quickly. In fact, I was blessed to have a 13-month term as AAFP president, and I did my best to make the most of it. In so many ways, this time on the AAFP Board of Directors has reminded me of my professional path, having worked as a small-town family physician before becoming residency faculty.
I always tell new faculty at East Tennessee State University that you have to work at least five years to see the patterns in medical training and avoid the panic that often comes when challenges arise. Similarly, I am finishing my fifth year on the Board, and I have learned a lot in that time. It has been an exciting period, and I want to summarize some of my experiences.
© 2014 Marketing Images/AAFPSpeaking with students, like I am here at the National Conference of Family Medicine Residents and Medical Students, is one important aspect of being the Academy's president.
When I was running for president-elect, I promised I was going to do my best to say yes -- and I have. This has been an amazing year. I topped 1 million miles on Delta and visited 17 AAFP chapters. One of the most profound experiences was the chance to meet not only the state leaders that we install in those chapters, but to meet our members who have chosen to put their energy into patient care and help our communities. Thank you for your dedication, your inspiration and for working through the many challenges. The time I have spent with you has helped me do a better job of understanding those challenges and representing family medicine in Washington, D.C.
I have spent a significant amount of time trying to reframe discussions about health care, including about scope of practice. Although this remains a significant issue from state to state, it's important to remember that we have a number of states that have allowed nurse practitioners to practice independently for years, and the results demonstrate this isn't the right solution to our nation's primary care shortage. Every state in our country is experiencing poor patient outcomes, decreased provider and patient satisfaction, and high costs.
The solution to these problems is to truly focus on increasing the number of primary care physicians in practice, creating more effective patient-centered medical homes, and providing care in a team-based fashion. The Comprehensive Primary Care Initiative for example, is demonstrating that the kinds of changes the AAFP has been advocating for more than 10 years are the changes that lead directly to improved outcomes and decreased costs.
And there are more data to come, so stay tuned.
One facet of the president's job is to represent the Academy at meetings with other health care organizations, which creates opportunities to network and make important connections. After all, it's critical that team-based care also include organizational teams. I was honored to be invited to meet with a number of organizations -- some for the first time -- and help create new relationships for the AAFP or strengthen existing ones. Among the opportunities I have taken advantage of have been invitations to the Academy of Breastfeeding Medicine, the AMA, the American Academy of Physician Assistants, the American Association of Nurse Practitioners, the American Board of Family Medicine, the American College of Osteopathic Family Physicians, the American Osteopathic Association (AOA), the American Pharmacists Association, the Association of Family Practice Physician Assistants, the National Hispanic Medical Association, the National Medical Association, the Society of General Internal Medicine, the College of Family Physicians of Canada and the Society of Teachers of Family Medicine.
Another important role of the president is to represent the Academy in Washington, and I was fortunate to be able to make numerous visits to the nation's capital. The sustainable growth rate remains one of our biggest challenges, but I truly have hope that we are moving in the right direction. Proposed bipartisan and bicameral legislation already in play could provide a unique opportunity during Congress' lame duck session. Our comprehensive advocacy approach with organizations such as the AMA, the American College of Surgeons, the American College of Physicians and the AOA have created a unified voice for medicine that is getting the attention of those on the Hill.
We have other serious issues ahead, such as avoiding Medicaid cuts and addressing the regulated sunsetting of the primary care bonus, but we are opening more doors and sitting down at more tables to discuss these matters.
Years of effort recently culminated in some major steps forward in graduate medical (GME) reform. The Institute of Medicine released its long-awaited report, with which the Academy substantially agreed. We followed that up with our own recommendations and a GME summit on Capitol Hill that was quite positively received. We are challenging long-held processes in significant ways. Much discussion and negotiation awaits, but once again, we are at another table addressing one of our primary goals.
Just before coming to this week's Congress of Delegates and AAFP Assembly, I attended a premedical health fair at the University of California in Davis, a gathering of thousands of students who are considering careers in the health professions. In addition, I have been blessed to speak with students everywhere I have gone this year. Students are our life blood and our pipeline. These connections are critical, and I look forward to maintaining them.
One key way to stay connected is social media. Three years ago, the Academy made a commitment to giving members real-time updates about how the president is representing family physicians. The AAFP President's Facebook page now has more than 1,400 "likes," and the AAFP President's Twitter account -- @aafpprez -- has 2,400 followers. The Board also is providing regular and more in-depth updates through this blog. The better we stay informed and connected, the better we can advocate for each other.
It has been an honor to represent you, and I will continue to work for you during my year as Board chair. Thank you for the opportunity to take your stories forward. I am excited this week to be handing off the president's role to Bob Wergin, M.D. A small-town doctor who practices full-scope family medicine, he is the right person at the right place at the right time to lead us forward.
Reid Blackwelder, M.D., is president of the AAFP.
The Flight of My Life: Reflecting on Six Years of Service
In its more than 40 years, my little Hatz biplane has had quite a life. In the two decades we have shared the sky, we have introduced more than 400 kids to the thrill of flying and traveled all the way across the country. It has brought me immeasurable joy.
But like all things physical, wear and age were beginning to show. So six years ago, we started the long process of restoration from the ground up. We replaced fabric covering, installed new instruments and a wood propeller, and finished with an updated paint job.
Today, she looks like a beautiful new airplane that's ready for new adventures. When you fly as a pilot and when you restore a plane, you keep a record -- a logbook -- that lists every flight and every improvement you make.
Coincidentally, it was six years ago that I joined the AAFP's Board of Directors. In many ways, looking back over those six years is like opening my Academy logbook.
Just like for my plane, there was a lot of work to be done in family medicine. The specialty was in crisis. Payment was woefully inadequate. AAFP membership was down. Student interest was low. Forty-seven million Americans were uninsured. As a candidate running for the AAFP Board, I asked the Congress of Delegates, rhetorically, if we were actually witnessing the collapse of primary care.
Fast forward to today, and the outlook for family medicine has changed. Day to day, our work in the trenches continues to be challenging, but the forecast for the future from the 10,000-foot level of the Board chair is now encouraging.
Six years ago, we knew family medicine was valued by our patients -- we could see it every day in our offices. Barbara Starfield, M.D., M.P.H., had showcased the value of primary care in her research. Still, recognition of those truths -- and support for primary care – from payers, employers and government was lacking.
Today, the patient-centered medical home model has shown that improving primary care is the key to meeting the triple aim for health care: higher quality, lower costs and improved care for patients. The Comprehensive Primary Care Initiative launched by CMS' Center for Medicare and Medicaid Innovation is changing the way our government pays for primary care -- paying for value over volume -- and it is expanding. A growing number of employers, health plans and government agencies are beginning to demonstrate that they really value what we do. When it comes to payment reform, we haven't arrived at our destination, but we are on the way.
On Capitol Hill, we no longer have to explain to legislators and congressional staff what we family physicians do and why we matter. Federal agencies seek the Academy's input on important health care issues, and legislators are actively looking for ways to train more family physicians to address our country's primary care shortage.
But what about access to care? Today, there are 10 million newly insured Americans thanks to the Patient Protection and Affordable Care Act (ACA). Our uninsured rate now stands at 13 percent -- 5 percent lower than it was six years ago and the lowest it has been since 2000. Americans may be split on the ACA, but there is overwhelming support for some of the basic tenets of the law: getting more people covered by insurance and reforming unfair insurance rules, including no longer allowing denial of coverage based on pre-existing conditions, caps on coverage, or retroactive canceling of coverage after someone becomes sick.
However, there is still much work to be done. We need restraints on rising health care costs, malpractice reform and a path to creating the primary care workforce our country deserves. And we still have millions of uninsured. We haven't arrived at our Academy's ultimate goal of health care for all, but we are on the way.
Interest in family medicine is up nationally. AAFP membership reached a record high this year at 115,900. And for the fifth consecutive year, the number of medical students choosing family medicine climbed higher than the previous year. Twenty-five percent of all U.S. medical students are now Academy members.
To meet the needs of our nation's health care system, those numbers must continue to grow; this year, the AAFP took steps to proactively ensure that they can. Last month, the Academy unveiled a proposal that would significantly change the way graduate medical education is financed. Our proposal would bring transparency and accountability to a system that invests $15 billion a year on physician training but is unable to produce a workforce that aligns with the needs of the nation.
I'm also proud of the work the Academy is doing in public health. Last year, we included the social determinants of health in our strategic plan. And this year, we began the process of reimagining Tar Wars -- a program I helped develop more than 25 years ago -- as part of a comprehensive tobacco and nicotine prevention and control program that will include new tools for family physicians, community programs and advocacy.
We've talked about where the Academy has been, but where are we going? During the AAFP Assembly in Washington next week, the AAFP -- along with seven other national family medicine organizations -- will launch a national campaign that is the culmination of the Family Medicine for America's Health initiative and the biggest thing to happen in family medicine since the Future of Family Medicine project in 2004. This campaign will speak not only to family physicians but also to patients, payers and others, defining what we do as family physicians and why primary care is the vital foundation of our health care system.
Now when I climb in my biplane, I can tell she is still the same plane I have known and loved all these years, yet with new energy and new life -- the way she climbs, handles and how her paint flashes in the sun. She has come a long way.
Today, we are all part of a rebirth of family medicine. Our voice is being heard, our contributions are being valued, and we, too, have come a long way. Our country is counting on us to continue to be "bold champions" for America's health, transforming health care for optimal health for everyone.
As for me, my Academy logbook is now full. It's time to open up a new logbook and start my next adventure. Thank you for granting me the privilege of serving you. It has been the flight of a lifetime.
Jeff Cain, M.D., is Board chair of the AAFP.
The Countdown Begins: One Year to ICD-10
One year. That's how long we have to get ready for the official implementation of ICD-10. Oct. 1, 2015, is the day we have been nervously awaiting since July, when CMS confirmed that as the revised compliance date for the new coding system.
Later this month, the Academy will offer CME courses related to ICD-10 to help us prepare during the AAFP Assembly in Washington. Will your practice be ready?
Every time I read an article about ICD-10, I wonder how small practices like mine will survive this new hurdle. A study conducted by Nachimson Advisors and published by the AMA estimated that small practices could suffer costs between $56,000 and more than $226,000. A large practice's financial impact is estimated to range from $2 million to $8 million. These figures are three times what was estimated by the same research group just five years ago.
ICD-10 has more than 68,000 diagnostic codes compared with ICD-9, which has a little more than 14,000 diagnostic codes. This is a significant shift for family medicine. The differentiation of right, left and bilateral accounts for about 40 percent of the increase in codes for ICD-10. Initial versus subsequent diagnosis codes might create an obstacle for the busy physician but will ultimately be helpful for tracking purposes.
According to the American Health Information Management Association, the new coding system will result in higher-quality data that can improve measures of quality and performance, provide "increased sensitivity" to reimbursement methodologies, and help strengthen public health surveillance.
But how do we get there? Updates to my practice's electronic health record (EHR) system have allowed us to "bridge" to ICD-10 for the past eight months. Testing and payment disruptions are variables that are impossible for me to anticipate, and every consultant we talk to offers a different opinion as we try to assess how to proceed.
In my search for assistance on the web, I found "The Road to 10: The Small Physician Practice's Route to ICD-10," an online resource an online resource to help small physician practices transition to ICD-10. This tool was developed by CMS in collaboration with industry partners. It allows a small clinical practice to create a customized action plan for ICD-10 readiness and preparation. It provides a five-step action plan that covers planning, training staff, updating systems and processes, engaging partners, and testing.
Although that resource is geared to small practices, the AAFP and its journal Family Practice Management have resources that can help practices regardless of size.
In addition, CMS recently announced the dates that it will do readiness testing using ICD-10 codes. What are you doing to prepare?
Rebecca Jaffe, M.D., M.P.H., is a member of the AAFP Board of Directors.
The Doctor is Out: Retention Poses Major Challenge for CHCs
HHS announced Sept. 12 that it is making nearly $300 million available to nearly 1,200 community health centers (CHCs) across the country. The funding is intended to help CHCs hire more than 4,700 new health care professionals and offer longer hours and expanded services, including oral health, behavioral health, pharmacy and vision.
The funding is expected to help CHCs reach about 1.5 million new patients.
Although the funding for additional staff is needed -- and welcome -- the change doesn't address one of the biggest problems CHCs face -- retention. Not only do these clinics need more physicians, they need the physicians already working in these settings to feel motivated to stay in communities where they are desperately needed.
© 2014 Casey Health InstituteMy first job after residency was at a community health center, but I now work at an integrative primary care practice. Research has shown that family physicians at community health centers have lower rates of job satisfaction.
Federally qualified health centers (FQHCs) are a source of primary care for millions of uninsured and underinsured patients. They're also the place where many family physicians -- like me -- get their first "real" job outside of residency.
I spent my first four years out of residency at a CHC, and I loved it despite the challenges. I served a culturally and socioeconomically diverse population that was in need of good health care. I truly felt like I was living up to being the doctor I wrote about in my medical school personal statement.
In addition to the reward of serving a community desperate for medical care, many physicians are drawn to CHCs by offers of loan repayment -- either as part of a National Health Service Corps commitment or through state and local programs. Although many physicians enter these doors excited and eager to help the people they went to medical school to serve, too often, physicians are just as eager to leave after their loans are repaid.
Research tell us that family physicians at CHCs are less satisfied with their work situation than other physicians. The reasons are multifactorial, including low compensation and excessive workload. Isolation from cultural activities and limited career opportunities for physicians' spouses in rural areas also contribute to dissatisfaction.
I saw several colleagues come through, do their time, repay their loans, and move on. This is a common theme, because family physicians often feel burned out after just a few years at a CHC. Many went to an FQHC not just to get their loans paid off, but rather to make a difference and fulfill a personal mission to serve the underserved. One friend and colleague told me she planned to come back to an FQHC at some point in her career. But after five years of having worked in that setting, she felt that if she hadn't left when she did, she would never have wanted to go back.
More than half the states and the District of Columbia are expanding their Medicaid programs under provisions of the Patient Protection and Affordable Care Act. Many of these new Medicaid enrollees will be seen at CHCs because many private practices don't accept Medicaid. This could lead to an increase in patient visits -- and potential headaches -- at the centers, which often struggle to fill vacant positions for physicians and other clinicians. To make matters worse, the low retention often creates a burden for those who do stay.
My interest in CHCs started in high school because I had a mentor who worked in that setting. Later, I volunteered at CHCs during medical school, and I had no doubt where I wanted to go after residency.
When I left my first job at a CHC, it wasn't because I was burned out. I had an amazing opportunity to work as a White House Fellow and spent a year advising the U.S. Department of Agriculture on a range of issues related to nutrition. When my time there was up, I didn't go back to an FQHC. Although I don't miss the headaches, I do miss serving that population.
Today, I'm the medical director of an integrative primary care practice where we incorporate some of the features of an FQHC to ensure access to care, including a sliding payment scale for uninsured patients and a sliding scale for insured patients who seek services that may not be covered, such as chiropractic, acupuncture and massage therapies. At the same time we're trying to ensure access in the way FQHCs do, we're trying to avoid some of the pitfalls these centers face. We try to give our clinicians the time, space and support they need in order to be there for patients and to make them feel valued and respected.
So how do we get more CHCs to operate the same way and improve their recruitment and retention rates?
- The Bureau of Primary Health Care (BPHC), a segment of HHS that funds health centers, should track physician retention at FQHCs and publish these data along with other quality measures. Ultimately, the goal would be to create a recommended standard for clinician retention that centers can be compared against.
- Once a physician commits to a community for the long term, that community has a powerful advocate. The BPHC should encourage FQHCs to create strategies for physician recruitment and retention. The National Association of Community Health Centers has already done a lot of work in this area.
- The AAFP recently established member interest groups to provide a forum for AAFP members with shared professional interests. A CHC member interest group would provide physicians who work in these settings to communicate with each other and develop relevant AAFP policy. If you are interested in starting a member interest group for family physicians in CHCs, you can find more details -- including information regarding the criteria and application process -- online.
Kisha Davis, M.D., M.P.H., is the new physician member of the AAFP Board of Directors.
FSMB Offers Licensing Solution for Docs Looking to Practice in Multiple States
My home state -- Iowa -- shares its borders with six other states. With my state-issued driver's license, I can drive not only in all six of those states but in any other state in the nation. As part of this system, a longstanding interstate compact allows the vast majority of states to share information regarding license suspensions and traffic violations of nonresidents. The states where infractions occur may forward information to a driver's home state, which then applies its own laws to the out-of-state offense.
That system makes sense. Unfortunately, the same can't be said of the way states view medical licenses. I've been in practice for more than 20 years, but the second I drive across one of those state lines, my Iowa medical license is invalid.
On Sept. 5, the Federation of State Medical Boards (FSMB) took a major step toward solving this problem when it finalized model legislation to create an Interstate Medical Licensure Compact that would expedite the process of issuing licenses for physicians who wish to practice in multiple states.
The key word here is "expedite." Under the current system, physicians who wish to practice in more than one state have to navigate a fairly burdensome process that involves paperwork, fees and three to six months of waiting.
Expediting the process would benefit physicians who live near a state line, are licensed to practice on one side of that state line and seek privileges at a hospital or other facility on the other side of that line. The change also could help alleviate physician shortages in rural and underserved areas and pave the way for greater use of telemedicine. (It's worth noting that earlier this year, FSMB adopted new guidelines for telemedicine.)
Under the terms of the model legislation, a physician would apply for a multi-state license through his or her home state. That state would determine whether the physician meets the following eligibility requirements for the compact:
- Possession of a full and unrestricted license in a compact state;
- Successful completion of a graduate medical education program approved by the Accreditation Council for Graduate Medical Education or the American Osteopathic Association;
- Specialty certification or possession of a time-unlimited certification recognized by the American Board of Medical Specialties or the American Osteopathic Association Bureau of Osteopathic Specialists;
- A clean disciplinary record;
- No discipline from any agency related to controlled substances;
- No pending investigations by any agency or law enforcement entity.
The proposed legislation would make it easier for states to share information and improve tracking and investigation of physicians who have been disciplined or are under investigation. Physicians who do not meet these criteria may still be able to receive a license in multiple states but not through the expedited process.
The model legislation has the potential to help put more physicians in the areas where we are needed most, but, ironically creating an expedited process could take time. Now that the model legislation has been finalized, state legislatures and medical boards can begin to consider its adoption. Each state must pass the compact to participate. That means family physicians who want this proposal to succeed should talk to your state chapters, who could help move this issue forward, or your state medical boards. Better yet, share your opinion directly with your state legislators.
Robert Lee, M.D., is a member of the AAFP Board of Directors.
When It Comes to Mentoring, Both Giving and Receiving Are Important
Many mentors helped guide and direct me to medicine, in general, and to family medicine, specifically. There are too many to name here, but there was always someone to help me when I reached the next transition point. From high school to college and through medical school and residency, I could list a steady stream of physicians who were there to offer support, guidance and teaching along the way.
I truly valued these relationships and took to heart the importance of mentoring. Along my path, I have made a point of reaching back to offer the same guidance to others that was given to me. I treasure being a mentor, continue to learn from the students I teach, and I can't wait to see what they will do in their own careers.
| Here I am with AAFP President Reid Blackwelder, M.D. It's important to have a more experienced physician we can turn to for guidance even after we've transitioned from resident to new physician.
I was satisfied with my own transition from mentee to mentor -- or at least I thought I was -- until I had a recent conversation with my husband.
My husband, an administrator in education, had been contemplating a position change. During the application process, he mentioned several mentors that he was turning to for strategic advice. After he accepted the position, he was promptly paired with a new mentor to help guide his professional development.
When I contemplated my own position change, I looked around and, for the first time in my career, saw no one there to help me. My first few years out of residency had been spent at a community health center with several seasoned doctors, one of whom was a mentor and had been faculty at my residency program. Those more senior physicians provided a great bridge to the real world.
However, at my current job, I'm the doctor who has been in primary care practice the longest, despite the fact that I'm only in my seventh year out of residency. I'm also the only family physician.
Although I know the mentors I have called on in the past would still answer my call, it is easy to get caught up in the daily grind and not have time to reach out. Unlike residency, where there is always an attending around the corner, there are fewer people above us to help guide us after we move into our own leadership roles.
New physicians are pulled in many different directions, and those who have families and/or are relocating may find it especially difficult to take time to reach out to other doctors and potential mentors. Doctors in small and single physician practices, as well as those in rural areas, are also at risk of feeling like they have to go it alone.
My recent state chapter meeting, however, reminded me that we are not alone. While there, I had the opportunity to discuss my career goals and aspirations with AAFP President Reid Blackwelder, M.D., of Kingsport, Tenn., whom I also now call a mentor. In addition, the meeting provided a chance to reconnect with friends and colleagues and swap stories and experiences. State chapters have a wonderful opportunity to bring family physicians of all different career experiences together, and that can facilitate these types of exchanges between new physicians and our more seasoned colleagues.
The chapter meeting's educational program was appreciated, but what really will stick with me is having that opportunity to reconnect with peers and learn from those more experienced than I am. I can't wait to do it on a grander scale at the AAFP Assembly in October. I hope to see you there.
Kisha Davis, M.D., M.P.H., is the new physician member of the AAFP Board of Directors.
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.
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.
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.
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.
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.
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.
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.
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