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 21^st 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.

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.

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?

After the conference

I attended the Society of Teachers of Family Medicine (STFM) annual meeting last week, and, as usual, I left with a lot of great ideas and inspirations for things to try in our residency program and in my practice. Unfortunately, I have yet to review those ideas and inspirations and do anything with them, which is also as usual. I hate to think that everything from that conference will quickly be lost if I don't apply it, but I know from past experience that it will.

Attending conferences is a great way to learn from others, gain new skills, and expand your horizons. I love the networking and inspiration I also often come away with after attending a Family Medicine conference. I just wish I could figure out a way to not lose all of that great energy and motivation once I get back to the daily routine at home.

I think I'm making some strides. For the last couple of years, I've live-tweeted every session I attend at a conference. Not only does that help disseminate ideas outside of the physical conference, but it also leaves me with virtual notes of everything that I thought was interesting that I can review afterwards. The piece that is missing is making the time to do after I leave.

So, this year, I'm blocking out time in my schedule next week to review all of those tweets and compile a "to do" list from what I learned. In the future, I should probably block that time out before I even leave. I'm working hard to be a lot more deliberate about how I spend my time anyway (fodder, perhaps, for a future post!), and this approach seems to fit into that general idea pretty well. But I'd definitely welcome any and all suggestions!

After all, I invested too much time and energy into attending to lose all of those good ideas.

An alternative to "Do you have kids?"

*National Infertility Awareness Week 2014*
(For our story with infertility, read here.)

The question "do you have kids?" might seem innocent, but it can be a heart-wrenching one for couples struggling with infertility. Well-meaning people have asked this question of my husband and me many times, but our "no" answer seems to effectively end the conversation. "No" is not the answer most question-askers expect of a couple in their late 30s, and I suspect that it leaves them feeling as awkward as we do.

The main problem with "do you have kids?" is that assumes a "yes" or "no" response. A "yes" answer leads to all kinds of follow-up questions; it continues the conversation. A "no" answer, in my experience, usually leads to silence. And, frankly, the people asking this question are typically acquaintances, and thus not necessarily people that we want to open up to about our experience with infertility (at least not yet).

I'd like to propose an alternative that doesn't limit itself to a "yes" or "no" answer but still allows for relationship-building:

"Tell me about your family."

This statement is open-ended; couples with children will certainly share details about their progeny. But by not limiting the question specifically to kids, those without children (this might include single adults, couples who don't want kids, and/or LGBT couples, too) have the opportunity to provide a positive response. Some might talk about their parents, their pets, those friends who really are family, etc. Some might even say something along the lines of "oh, I'd rather not. They're quite crazy!"

No matter what the response, conversation can continue to flow.  Infertile couples don't have to provide a negative response, and the positive response can even remind us that our lives are defined by more than just our infertility.

So, next time you're tempted to ask someone if they have kids, try asking them to tell you about their family instead.

This I believe

I believe that Family Medicine is the solution to American health care.

I believe that family doctors give high quality, cost efficient care. Counties with the right proportion of primary care* to specialty care have populations who live longer and health care that costs less. Too many specialists and not enough family physicians = unnecessarily expensive care and shorter life expectancy.

I believe that family doctors provide something intangible to our patients and our communities as well. We value relationships with our patients and our communities. 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 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 Family Medicine is under attack. The RUC devalues what we do, largely because Family Medicine is underrepresented on the RUC (only 1 family physician out of 31 physicians on the committee). My office receives more payment for snipping off a skin tag than for a thirty-minute patient visit working with a patient on his/her diabetes, hypertension, and heart failure, along with the the social challenges that often co-exist with the medical issues. 

I believe that Family Medicine will overcome these challenges. I have seen the future of our specialty in the applicants to our residency program and the students who attend our specialty meetings. They are intelligent, dedicated, and optimistic. They believe in what Family Medicine can do and are not shy about sharing it. They are taking over social media with their stories. They are our future, and the future is bright.

Family Medicine is the solution to American health care.  This I believe.

*In 2014, with fewer and fewer general internists and pediatricians, primary care in the US = Family Medicine.

Thank you

I had a pretty grueling office session yesterday - one of those days where you're sending someone to the hospital and calling another consultant on the phone and bouncing among three rooms at once and, well, you know...a typical family medicine day.

I was 45 minutes late seeing my last patient.  I was a little surprised that she was still on the schedule; we had actually resolved her issue over the phone the week prior, and I told her then to feel free to cancel this appointment.  As I knocked on the door, I wondered if something new had happened and why she was willing to wait so long to see me.

She started the visit by reviewing what we had talked about last week, and we both made sure that we were still on the same page.  After that, there was an awkward pause.

Me: What else can I do for you today?
Patient: Nothing.
Me (confused look on face): So....you came in today to make sure there was nothing else to do?  Do you have any questions?
Patient: No.  I just wanted to say thank you.

A seemingly mundane task from our end can have a big impact on a patient's life. We don't expect our patients to routinely give anything back to us, maybe because we worry that our gift of service could then make our patients feel obligated to give back.

But, needless to say, I was overcome with appreciation at this selfless act.  It was an incredible gesture that said more about this patient's character than my own, yet still reminded me why I'm a family doctor.

I don't expect it all the time, but, every now and then, a "thank you" is awfully nice to hear.

Easy on the eyes

I'm reading less of JAMA these days.  They recently changed the font they use in some sections of the journal, and it's not easy on my eyes.

There are two basic types of font: serif and sans serif.  "Serif" is Latin for "tail," and "sans" is Latin for "without."

Sans serif ("without tails") fonts include Arial, Helvetica, and Verdana.
Note: no little tails hanging off the edges of these letters.

Serif (with "tails") fonts include Times New Roman, Georgia, and Courier.
Note: the little dashes or squiggles on the tops of the w, along with the extra lines on the N and the T.
(Here's Arial's w, N, and T for comparison.)

Sans serif fonts are easier to read far away; your brain doesn't have to work as hard to make out the letters without those tails.  When I teach presentation skills workshops, one of the points I focus on is that projected material should always be in sans serif font.  (Try observing what happens to your interest and fatigue level during the next PowerPoint presentation you see with serif font.)

Interestingly, computer screens seem to be just far enough away that most people prefer a sans serif font. Look at the fonts on your favorite web sites, and, chances are, they will be sans serif.

Those tails, though, theoretically make reading close-up easier and less fatiguing on the eyes.  (Try observing what happens to your interest and fatigue level while reading the next printed material you come across in a sans serif font.)  I must admit that most of the studies done regarding readability disagree with me regarding serif fonts for reading, but my personal experience has shown a definite preference for serif fonts on printed materials.  JAMA is the only journal of the Top 10 impact factor medical journals, by my cursory review, to use sans serif font for some of its articles, so perhaps others share my bias toward serif fonts for close-up readability.

Not only did JAMA change several of its printed sections to a sans serif font last year, but they also dramatically reduced their font size throughout the whole journal.  I know that journals are trying to cut costs and stay relevant in an increasingly online world, but I am much less likely to read print material with eye-taxing font styles and sizes.  I actually prefer reading paper to the glare of a computer or tablet LCD screen, and I hope that print journals will find a way to continue delivering at least some content in a reader-friendly manner.

Take some time to observe fonts, both on big screens and close-up.  Which seem most comfortable to you?