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Friday Apr 19, 2013

They're Your Comments; Make Them Count

Since AAFP News Now opened its stories to member comments in 2010, we've heard from you more than 3,000 times. Through the comments field, Academy leaders and staff have been able to answer numerous member questions, clarify issues and provide additional information from our in-house experts.

We've also been able to correct broken links and other errors that members have brought to our attention.

Since we launched the AAFP Leader Voices Blog in 2011, family physicians have been able to communicate directly with Academy Board members, who have answered questions related to advocacy, education and clinical issues.

Academy staff and leaders also have responded to member questions and comments on Facebook.

Overall, it's a system that has worked pretty well, and the discourse, although sometimes spirited, has been overwhelmingly professional in nature.

But, on occasion, comments can get out of hand. Although we have had many interesting, helpful dialogues between members, members and leaders, and members and staff through comment fields, we also have had a few members resort to personal attacks.


And, there have been a few instances of inappropriate language.

Disagreement is fine. We created the comment fields to encourage and improve communication, but let's remember that we all share a common goal of delivering the best care for patients that we possibly can and steer away from anything that gets in the way of that goal.

It's also worth keeping in mind that our news stories, blogs and social media content are open to the public and anyone -- patients, other health care professionals and members of the media -- can and do read that content.

The issues we discuss in these venues are important to the health of our nation and deserve level-headed discourse. Negative, hostile comments have a polarizing effect. Researchers published findings earlier this year that showed that readers who were exposed to antagonizing comments were more likely to dig in their heels on an issue than commenters who read the same story or blog without the accompanying name-calling.

In other words, readers faced with an online fight aren't open to new ideas or the other side of a discussion. Ugly arguments actually reinforce readers' preconceived ideas -- right or wrong -- on a given topic.

Name-calling can disrupt constructive dialogues, and that's not what we want. We family physicians need to be able to discuss important topics, including payment issues, health care reform and gun laws, with the understanding -- indeed, the expectation -- that our diverse, 100,000-plus members won't all agree. Some topics are divisive, but we can't afford to allow them to divide us.

We're here. We're listening. We want to hear from you. And we hope you'll continue the conversation with your colleagues. How will you make your comments count?

Glen Stream, M.D., M.B.I.is the Board Chair of the AAFP.


Family physicians are indeed passionate about their patients, their practices, and their potential. All three are being squandered. The Families of Family Medicine must return to the reality facing us and our patients across most of the nation. We will only reach our full potential when we are truly family - those who serve by leading and those who lead by service. FM docs remain committed despite 30 years of aberrant cost cutting policy that keeps fees lower to lowest, that drives away medical students, and that moves other workforce (NP, PA, IM, PD, and MPD) away from primary care. They deliver less with each passing year and claim more - but we know better and the nation should too. The move to departments in every school and residencies in every state was a great academic choice, but not the right choice for our future. We should have listened to University Without Walls, Invisible Faculty (Joe Hobbs), and the 10,000 Square Mile Classroom (Jack Verby). Integration of training with practice is the solution and the academic route has led to disintegration and compromise. Another academic move to 4 years of GME shrinks who we are and what we can do. Leaders that understood the specific learning from tens of thousands of visits after graduation would be shortening preparation and medical school and possibly residency (2.5 years). The Future of Family Medicine ended up with the Primary Care Medical Home. PCMH might make sense for those focused on grants, consultants, and marketing where competition for primary care services is high. PCMH is a substantial expense. The consultations have had mixed reviews. PCMH is little or no gain for most family physicians who have no competition. They practice where the issue is not competition. The issue for them is 30% revenue over costs - same as every primary care practice. Team care, training, and consultation is important, but this expensive work is negated when teams cannot be retained as teams. Until primary care has achieved 30% revenue over cost, primary care will not be able to pick the best, train the best, and retain the best. Note to the designers: If you want to increase this cost of primary care delivery with more bells and whistles, you cover this added of delivery by 30% greater revenue. No other situation will attract the investors and the personnel and support to grow complex health access - by design. Growth in our residency programs has required new mechanisms with better reimbursement. The same is true regarding restoring primary care. We can no longer allow rapidly rising cost of delivery with little or no response in revenue – for us, for primary care, or for most of the nation left behind. We cannot allow the designers to further compromise health access by their aberrant designs that proceed without the field knowledge that we have developed decade after decade in research, teaching, and practice. It is common sense that tells us that we are unlikely to improve the quality measures in the patients in most need of primary care. Far more than simple practice changes are needed to change the challenging social situations and social determinants. This is also the lesson family medicine much teach the nation because of our awareness of most Americans left behind. When we financially fix the hemorrhage, we can fill the personnel/team member tank and the primary care workforce tank. After 20 years to recover the workforce so that nearly all Americans have access to us, we can look at innovation. Until then the greatest gain for the financial investment is the move of millions of Americans from no access to some and from some access to sufficient. More of us and 30% more revenue over cost is required. Help the nation understand that only primary care clinicians most experienced in primary care are a top priority in primary care. Other sources of primary care workforce multiple times fewer visits should be lower priority. Enhance the studies demonstrating how much more experience we have and what that means. When we are challenged (as happens often to those best at what they do), there is no need to take the bait. We can stand on who we are. We are more than enough. When we do this we will also make it easy for those desiring to become us. For a true local health access result, we need to move our recruitment to the local level. We still do the "national" plan but are still not local. We invest millions in national student and resident meetings in a great centralized location - as far away from our future as possible. Rotating sites would help but we still invite the wrong people to the party. The national meeting fills up with those already committed to become family physicians. Such an investment should be spent substantially on attracting our future. An even better model of preparation and recruitment is possible. We should begin with Distributive Education during high school and feeding right into our practices, schools, and residencies. Local health access should begin and end local and we are the vehicle once again. We clearly need different medical education for family medicine. How will students get the 6 months of exposure needed to overcome being overwhelmed with the complex jobs that we do? Three months is all any student gets for career exposure and three months is exactly the level to overwhelm. The only real choice for something so complex and so subtle in its rewards is to change the design. The commitment to family medicine must be determined across preparation and throughout training. Basic health access demands such focus. Bench research, hospital volunteer hours, and shadowing subspecialists is the wrong pathway for us. Two years of isolated basic sciences is also a poor fit. Hands on clinician guided training is needed at each level. The academic setting has taught us compromise. We can no longer afford to compromise what we can be and what this nation should receive. A family medicine specific training should never waste admission time and effort speculating whether a student will become one of us or not. The investment of time and effort should result 100% in family medicine. The design for us must be changed by us. We are important enough that we need designs that 100% result in us. Incremental improvements of a few percentage points are not worth the time and effort. Medical education design is actually a barrier to becoming one of us and it is a barrier to health access as well. We should build on the solid 3 years of FM GME by adding medical school and preparation on to the front end - preparation and training specific to us and our patients. This is the solution for us and for health access. Screening for admission should include those who will become family physicians. Exclusive admissions is not a tolerable design. Those who desire to become us deserve the chance to demonstrate what they are and what they can do. A single day, a single test, and a few dozen sheets of paper cannot come close to sufficient admissions evaluation for such a complex career. We have had 40 years to develop our concept of what a family physician should be. In every aspect of preparation and admission we can do much better. Top priority for Health Access Recovery is about us. We are the source of by far the most primary care delivery (visits, years, lives) per graduate. We are the source with multiple times greater primary care delivery where needed per graduate for all of the populations and locations behind by design. We are the vehicle to more health spending in 40,000 zip codes with multiple times less health spending per person despite 200 million people. This is a true route to recovery of health access and to economic recovery where needed. We are the efficient and effective primary care training source. Our training cost of about 1.2 million for all post high school costs is high, but the 80,000 visits per FM doc in a career results is only 15 dollars per visit for training cost. Other sources are $50 - 200 per visit due to fewer primary care visits - the result of fewest years in a career, lowest volume, lowest activity, and lowest primary care retention. We can reach less than 1 million training cost in training costs and over 100,000 visits for even greater efficiency, increased recovery of health access, and lowest cost for the yield of primary care. the most efficient source of all. Our Future Family Physicians can be even better because they were trained before, during, and after training to be clinicians connected to their communities. When people understand us, they will understand why only permanent broadest generalists as MD, DO, NP, PA, and RN can work for health access recovery. And we are the only example of permanent broadest generalist at the current time - and we have been as long as we have existed – and we can be even more specific, more efficient, more effective, and better. But it will need to be a design for us and by us and for most Americans – those that we most serve.

Posted by Robert C. Bowman, M.D. on April 26, 2013 at 11:05 AM CDT #

Dr. Stream: your request is quite reasonable. It is also reasonable to request that the AAFP leadership stop denigrating, both explicitly and implicitly, those of us who have chosen not to adopt the PCMH style of practice management. The AAFP's unprofessional and divisive approach to this issue is far more damaging to our specialty than a few four letter words. Thank you.

Posted by Drown on April 28, 2013 at 11:41 AM CDT #

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