Monday, October 27, 2014

This I believe, Family Medicine-style!

I was honored to be recognized for the following piece at the FMEC annual meeting this past weekend. The FMEC encourages members to submit pieces similar to the NPR "This I Believe" campaign but focused on elucidating the core beliefs within Family Medicine.

I thought I would share it here as my first step back into regular blogging (now that I've finished moving and getting settled in my new position), hopefully to further stoke the fires of the #FMRevolution...

* * * *

I believe that Family Medicine is the solution to American health care, but only if we stand united against the threats to our specialty and our patients.

I believe that family doctors give high quality, cost efficient care. US Counties with the right proportion of primary care to specialty care have populations who live longer and health care that costs less. (In 2014, with fewer and fewer general internists and pediatricians, primary care in the US is Family Medicine.) Too many specialists and not enough family physicians lead to unnecessarily expensive care and shorter life expectancy.

I believe that family doctors provide something intangible to our patients and our communities. We value relationships. We tailor the care we give to our patients’ values and preferences as much as possible. We care for every age at every stage, and we provide continuity of care to individuals and generations.

I believe, though, that Family Medicine has an image problem that is largely our own fault. The average American does not know what a “family doctor” is. Many family physicians are fatigued from wading through our fragmented health care system, and too few of us feel we have the time and/or the skills to share who we are and what we do with the public. 

I believe that we let the insurance companies dictate too much of what we do.  We let fear of inadequate reimbursements change the tenor and flow of our office visits. We order tests to fulfill insurance company mandates.

I believe that we allow trial lawyers and the fear of litigation to interfere with how we practice.  Gone are the days when someone might present with abdominal pain and walk out without a CT scan.  We order expensive lab tests “just to cover the bases” and prescribe unnecessary antibiotics to keep our patient satisfaction scores up.

I believe that Family Medicine is under attack. The Relative Value Scale Update Committee, or “RUC,” devalues what we do. Out of 31 physicians on the RUC, only 1 is a family physician. My office is paid more for snipping off a skin tag than for a thirty-minute patient visit treating multiple chronic diseases. 

Perhaps worst of all, I believe that we resist self-scrutiny.  “I’m not the problem – that’s not me,” I can hear you all thinking.

It is you, and it is me.

We must advocate for our specialty if we are to advocate for our patients. We must resist fear and fatigue. We must stop practicing medicine as if our nation’s health care dollars are infinite.

If we don’t, then the insurance companies and the trial lawyers and the RUC will win – and our patients will lose.

I believe that Family Medicine will overcome these challenges. The 21st century demands a strong Family Medicine infrastructure based on equity and compassion. Even now, thousands of us fight tirelessly for our patients. We volunteer for leadership roles and organized medicine societies. We innovate new models of patient care without waiting around for insurers and the government to do it.

I believe that I have seen the future of our specialty in the applicants to our residency programs and the students who attend our meetings. They are intelligent, dedicated, and optimistic. They believe in Family Medicine and are not shy about sharing it. Their courage and energy will fuel our future, and that future is bright.

Family Medicine is the solution to American health care, but only if we stand united against the threats to our specialty and our patients. This I believe.

Wednesday, July 23, 2014

MS4s: what to look for in FM residency programs

This time of year I get a lot of questions from fourth-year medical students about applying to residency. So, here's my answer to "What should I look for in a good Family Medicine (FM) residency program*?"

It's FM, so everyone (for the most part) is going to be super-nice, friendly, and welcoming when you go to visit. They will show you a curriculum that's in line with the ACGME (Accreditation Council on Graduate Medical Education) regulations. They will take you out for a nice meal and show you the town.

So, what separates the wheat from the chaff? The men/women from the boys/girls? The *insert your favorite cliche here*? Here's what you want to ask about above and beyond your questions about the call schedule and available electives:

1. "How do you teach evidence-based medicine (EBM)?"
A top-notch residency program will have a formal EBM curriculum with sessions on a regular basis. This curriculum should teach you how to independently read and interpret the medical literature. There is no more important skill than this to be successful after graduation; if you can't keep up with the changes in best practice after graduating from residency, you will be practicing out-of-date medicine within five years (heck, probably within five months).

2. "Is the office I'll be working in an NCQA-certified Patient Centered Medical Home?"
Forward-thinking Family Medicine residency offices subscribe to the PCMH model and have gone through (or are, at least, in the process of going through) the rigorous process to prove that they are coordinating care effectively for patients by tracking referrals and tests, offering after-hours care, and connecting with patients asynchronously (usually via patient portals). You want to learn how to work in a PCMH because, chances are, you will be working in one - and leading one - after graduation.

3. "How do you teach patient safety and quality improvement?"
Understanding that medical errors are the result, ultimately, of system problems, and not just individual mistakes, is a critical concept for 21st century docs. Good systems buffer individual mistakes. How is the residency program training future family docs to lead in building these buffers?  What kinds of QI projects are residents involved with? Residents should be leading QI teams to improve office efficiency, reduce error, and improve the patient experience in the residency office - and your residency should train you how to do it.

Medical knowledge is not enough for 21st century family docs. Without the above skills, your practice will be out of date, doctor-centered (instead of patient-centered), and error prone. A good residency program should have formal curricula in place to ensure that you graduate with these skill sets. A program not committed to those ideals, that is superficially addressing these concepts but not orienting their care model around them, will leave you woefully unprepared to provide optimal care to your future patients.

Do you agree? Did I leave anything off the list?

* Frankly, I think these general attributes apply to all residency specialties, though some specialties participate in the Patient-Centered Specialty Practice accreditation instead of "Patient Centered Medical Home" for question #2.

Tuesday, June 24, 2014

To blog or not to blog?

I confess that it's been awhile since I posted here.
I confess that this has happened before.
Should I throw in the towel? End the blog? Force myself to crank out posts?

I feel like I still have a lot to say, and I'm trying to figure out why I haven't been here much lately. True, my work with American Family Physician is taking up the time I used to spend on this blog. True, I am in the middle of yet another job transition. True, most days I'm just running on autopilot, ticking the boxes of responsibilities, waiting for my life to fall back into some semblance of normalcy.

I should know better by now! As much as I long for stability, I am coming to grips with the fact that these are not givens in academic medicine. Virtually all of the classmates I trained with have gone through at least one (if not two or three) job transitions in the last five years. Medicine is trying to reinvent itself, and we are all trying to figure out what role we want to play.

And yet, again, I am not comfortable divulging all of the gory details regarding my latest career upheaval. I wish, sometimes, that I was as brave as those medical bloggers who share so much of their personal life. Alas, I am not and will not be them. I don't want this blog to die, yet I don't know how to keep it alive when I am unwilling to share the stories that are consuming me right now.

I know that there are many medical bloggers who are busier than I am and make time for their blogs. It is true that I am not prioritizing this blog as I once did. I'd like to believe that I will again in the future, but will anyone still be around to read it when I do?

Do I put the blog on life support or hospice?