Friday, December 14, 2012

Reflections on trends FM Obstetrics

As an aspiring Family Medicine doc who also has her eye on Ob/Gyn, I wanted to take a look at the intersection of these two fields in order to understand the practical side of aspiring to “provide medical care throughout the life cycle.” I am drawn to the romantic idea of delivering a child to a mother who you had taken care of since she was a little girl, and then seeing them both back in the office for the first new baby check up a few weeks later.  As my “time to decision” (aka those lovely ERAS applications) creeps closer, I find myself wondering, are family docs really doing this anymore? Why or why not? This is a complex issue, but with a little research the answers I’ve come up are with so far look like this: “yes, somewhere in the ballpark of 10-20% of family docs still deliver babies” and  “we need ‘em, they love it, but it’s challenging for many reasons.”

On the decline, but still there.  Pulling some stats from an article in the JABFB, we learn that the decline in family docs practicing obstetrics has been quite dramatic, “in 1978, 46% of family physicians reported having privileges for routine deliveries; that rate 22.4% in May 2000.” The latest numbers from the AAFP’s yearly member surveys (which, granted, probably don’t include all practicing family physicians), just 10.1% of respondents delivered one or more babies in the previous year.  Broken down by geography, 8.2% of urban-practicing, and 17.0% of rural family docs report to be engaged in deliveries.  Before getting into the reasons for this decline, I want to quickly highlight a new program, which may impact this trend in coming years. The American Board of Physician Specialties recently established the Board of Certification in Family Medicine Obstetrics (BCFMO), with the first batch providers becoming board certified in 2009. This new board certification programs was added to “address the shortage of obstetric providers in rural and underserved areas and a desire by graduating family medicine residents to obtain additional training in obstetrics.”  There also has been an increase in family medicine obstetrics fellowship programs, further demonstrating in increase in interest and need for this training and services.
So why do it? The reasons family docs cite for wanting to provide obstetrical care to their patient’s are not surprising. In one study the most commonly cited reasons were enjoyment, desire to care for younger patients, having adequate training in residency, the ability to obtain privileges, a supportive practice and community obstetricians, adequate reimbursement and, (perhaps surprisingly) affordable malpractice insurance. And why not? The most commonly cited reasons for the exit of family practitioners from obstetrics are perceptions about malpractice risk, attitudes of obstetricians, difficulty obtaining hospital privileges / appropriate Ob, anesthesia and neonatal back-up, and the impact of obstetrics on physicians’ lifestyle and income. To address the malpractice piece for a minute, malpractice insurance carriers categorize the majority of family physicians who do not practice obstetrics as Class 1 liability risk. Those who do offer perinatal and obstetrical care are often classified up to a Class 4 (obstetricians are usually a Class 8). Premiums increase with each class, so there is a definite increase with the addition of obstetrical care, however it typically remains about half of that of a practicing Ob/Gyn. 
Is it necessary? I would argue that yes, there is a specific niche for family docs in the world of obstetrics that is distinct from other practitioners (namely obstetricians, and nurse-midwives). First, patients will tell you that family docs are different. It’s not just the continuity of care from mother to newborn, although this is a big part of it; a family doc intrinsically has a different perspective on the process of birth; viewing it first as the process of integrating in a new family member, not an isolated event for mother and child. Family doctors are in a unique position to provide pre-conception counseling to their patients and can build on existing rapport with their patient to address difficult behavior change issues for a safe and healthy pregnancy (smoking cessation, alcohol, diet, chronic disease management, etc.) Additionally, we simply need more providers of perinatal care.  Within obstetrics, there has been increasing specialization, more Ob’s dropping obstetrics from their practice, practicing in well-served areas and/or retiring early from the field. There are significant, unsafe gaps in the provision of effective perinatal care, especially to women who are under or un-insured, and/or live in rural or otherwise medically underserved areas.  Family Medicine is perfectly situated to step in and fill those gaps, accompanying our patients who already know and trust us through this exciting phase of their life. 
           In an effort to keep this short and sweet, I'll stop here, knowing I was only able to scratch the surface of a very complex topic. I do hope this will serve as the beginning of a conversation and I also encourage you to look for future posts & to contact me with any questions or comments you may have. 

Friday, November 9, 2012

Expectations: Where and How to Set the Bar for Family Medicine?

The first thing you should note is that I titled this post with a purposeful question mark.  My fourth grade teacher labeled me "most inquisitive", and I'd like to believe that superlative still rings true.  But I challenge you to stop and think about it for a second - how do you set the "bar" of expectations in your own life? With your patients? With your family? With your commitments?

Are you the kind of person to place the bar nice and low and manageable, allowing you to gracefully step over?  Perhaps you have your own sort of personal limbo bar, and are flexible enough to test it out at various heights :)  But my guess is that you, like most high achieving and hard working doctors and students I know, have a bar that is set so high that you couldn't even jump to reach for a pull-up.  That's just the problem with expectations - we often experience disappointment when we fail to meet them.

So what happens to our patients, then, who have been raised with an admiration for the miracle of medicine; who are ever more present members of a society that glorifies instant gratification; and who are now emboldened by the political momentum guaranteeing health care as a natural right? Expectations are high, indeed.  And we stand with a perfect opportunity to disappoint our patients if we fail to set the bar to that perfect height.

So taking a step back......Have you ever had the kind of day in which you expected you'd be working until 8pm, but when you got off at 6pm it felt like you won the lottery?  Conversely, we have all experienced the opposite - planning and looking forward to getting off by 4pm, only to be waylaid and stuck until 6pm.  In reality both sorts of days end at the same time, but it is our expectations at the outset that ultimately dictate our emotional response. 

Translating this, how do we create that "I expected to get off at 8, but was home by 6" feeling within our patients?  I believe that we can set realistic expectations at the forefront of our practice of medicine, rather than offer graceful apologies as we wave goodbye. 

I have a few thoughts on how we can set these realistic bars in family medicine:

1) Be willing and forthcoming in surrendering the role of omniscient provider
   Let's get real for a second.  Each and every one of our patients now carries a device that contains more information with the stroke of a few keys, than all the textbooks we read in training.  We are no longer purveyors of information, but rather intuitive and experienced interpreters for our patients.  I think that we already do a pretty good job of acknowledging this in family medicine, where we are often willing to defer and consult to our specialist colleagues.  I suggest we be transparent and upfront about our role, from the point of our first patient encounter. We need to be clear that we are supportive guides for our patients in their health as they move through the stages of life and the intricacies of health systems.

2) Create an office environment that thrives in its consistency 
   Provide an experience such that, when patients walk in the door, they know what to expect from front to back.  By this I am referring not to the exam room door, but the front door.  The second they walk in, they should feel at home and have a good sense of what will be happening.  This is the reason that so many people choose to shop at Target or buy Apple products - the reliability, consistency, and comfort.  This is the best way to prevent that "I thought I'd be home by 4pm, but got stuck working till 6pm" feeling as they leave a clinic appointment.

3)  Be willing to respond to change - Be willing to move the bar
   When was the last time that you "moved your bar"? In concert with what has been written about all good being the enemy of great, many bars are set in concrete.  Conversely, as previously mentioned, some bars are set far too high with no hope of finding accomplishment.  As family physicians, we need to be adaptable in our goals and transparent in our abilities.  When we reach that figurative double aim, then our patients can realistically expect accountable and consistent action.

Doing this, we will never let them down. 

Monday, October 8, 2012

Future of Family Medicine Blog Celebrates National Primary Care Week 2012

After much anticipation, National Primary Care Week 2012 is finally here!

We have a surprise cross-post that will be published on a prominent national blog and set to go up on Wednesday, so stay tuned!

In the meantime, we would like to take this opportunity to look back to our many blog posts. We have put together a list of 10 posts with some relevant links of interest to help students (and residents) accumulate a source of information to reference when speaking with your institutions about the importance of Primary Care.  We encourage you to utilize these links for your reference as well as to share with your classmates, colleagues, and mentors across the country.  We enjoy your comments as they indicate that we are stimulating conversation, which is what this blog is all about!

1. Family Medicine is a Waste of Your Talent
We would like to start out by saying: Family Medicine (and Primary Care) is NOT a waste of your talent.  You are not too smart for Primary Care, and, in fact, it is impossible to be too smart for Primary Care.

2. The Dean's Lie about Medical School Primary Care Workforce Production
Did you know that medical schools inflate their numbers by skewing statistics in their favor when reporting how they contribute towards primary care workforce production?  Liken the lies about these statistics to falsifying a company's quarterly/annual report to its members - immoral and illegal!  Hold them accountable!

3. Is There an Underlying Specialty Bias at your Medical School?
A hidden curriculum?  A hidden agenda?  Be cautious about comments/suggestions/mentorship by those involved with your medical education.

4. Has the RUC Destroyed Medical Student Interest in Primary Care?
A small group of physicians formed by the American Medical Association provides payment formulas to the Center for Medicare and Medicaid Services which sets payment for services provided by physicians.  Private insurance companies use these formulas and rates as well.  Less than 1/3 of members on this committee are primary care physicians.  Since starting in 1991, the salary gap between primary care and subspecialist physicians has widened to a point of crisis.  Learn more about it here.

5. Incorporated Patient-centered Medical Home training throughout all 4 years of medical school
PCMH is the model of primary care moving forward.  It is the responsibility of medical schools to ensure that students are learning in this environment starting on the first day of medical school.  Early exposure to primary care and its innovative model is crucial to increase our workforce.  Encourage your medical school to ensure that PCMH is the foundation of your education.

6. The 20th Report by the Council on Graduate Medical Education: Advancing Primary Care
This report is the bible of Primary Care delivery moving forward and provides recommendations to accomplish the strengthening of Primary Care in the United States.  This is a must read.

7. Does Building a Primary Care Workforce Start With Medical School Admissions Committees?
Admissions committees will deny this, but they have the ability to select from its applicants a strong set of potential medical students who are more likely to choose a career in Primary Care.  Studies upon studies confirm these characteristics.

8. The Hazing of Family Medicine
Building off of the Waste of Talent post, this post goes into depth about the struggles medical students face when proclaiming their desire and passion for Family Medicine and Primary Care to faculty throughout the clinical years of medical school.  Say no to hazing and bullying by faculty!

9. Medicine is a Team Game - And every team needs a good Family Physician!
Primary Care physicians are the quarterbacks, the point guards, and the one in charge of coordinating the care provided by a multi-disciplinary team of other specialty physicians and providers.  Fragmented care is unacceptable.

10. Living out our Personal Statements
A medical school dean once said that upon evaluation of personal statements for medical school admissions, more than 90% would choose primary care careers.  If you are currently writing a personal statement for residency, compare it to your personal statement for medical school.  If you are currently in medical school and trying to figure out what specialty to pursue, open up your personal statement and reflect on what you were feeling when you wrote it and how your medical education has influenced your career path.

Thank you for reading and we hope you have an enjoyable Primary Care Week!

Thursday, September 20, 2012

Patients are the 'real' leaders in the Patient-centered Medical Home

This week, the American Academy of Family Physicians (AAFP) took a bold stance in a report regarding the future of primary care in the US by reinforcing its endorsement of the Patient-Centered Medical Home (PCMH), specifically led by physicians.  The report was supported by other large national physician organizations including the American Academy of Pediatrics, the American Medical Association, and the American Osteopathic Association.  The report took a close look at independent nurse practitioners as they have had political swing in a number of arenas to lead primary care teams and practice independently of a physician.  Without surprise, the American Academy of Nurse Practitioners (AANP) "ripped" and responded (because if they did not "rip", then a number of members probably would have wondered why).  Turf battle?  Probably.  In the best interests of the patients?  Hopefully.  Does this solve any current problems?  Doubtfully.

I am currently in a Family Medicine Residency which is a National Committee for Quality Assurance (NCQA) Level 3 Patient-Centered Medical Home - the highest level attainable for Medical Home recognition.  Our "reimbursement" for services provided is not fee-for-service, but based on capitation (per member per month).  Our Medical Home is made up of several physicians, residents, interns, nurse practitioners, physician assistants, registered nurses, and medical assistants.  We also have  booking/check-in clerks, two case managers, a social worker, a diabetic nurse educator, a pharmacist, a psychologist, coding managers, and a medical home business manager.  This is the interdisciplinary team that I work with everyday.

My experience is n = 1.

The physicians and nurse practitioners all have a specific panel of patients assigned to each of them.  Each provider is known as their patients' primary care manager (PCM). If the PCM is unavailable and the patient wants to be seen, they will only see providers from our Medical Home team.  PCM continuity is maintained as a metric for providers to reach certain goals and rewarded throughout our command if a certain percentage of continuity is achieved over a set number of days.  The ability for a patient to be seen within 24 hours as well as the 3rd next available for acute and established appointments is also tracked.  A number of many other performance-tracking measures are in place to monitor our ability to care for our patients - the most important being patient satisfaction.

Since starting our Medical Home model, ER utilization has decreased and more importantly, patient satisfaction has increased.  Because our primary care payment is based on capitation, we are also not incentivized to see 30-40 patients in a day, allowing us more time to see our patients.  We also have mid-level providers and ancillary staff to take care of the many things that should never enter the examination room.  We use a secure electronic messaging system which allows our patients the ability to send messages 365/7/24 to our support staff regarding refills, triage, and arranging appointments.

Our Medical Home team has a team leader.  At any time, it can be a nurse, a physician, or whoever is available to take charge and make sure our patients are cared for.

This is the point.

Whether or not it needs to be a physician or a nurse practitioner - the evidence is definitely lacking.  However, when looking at the IOM report for nursing and the AAFP report for the future of primary care, the only thing that really sticks out to me is the idea that we should be working together in collaboration.

The national organizations can spin their reports and backlashes however they would like.  Unfortunately, this is what media will do for a news story.

All I know is, from my n=1 experience, physicians and nurse practitioners, as well as the many other people involved with our patients listed above, all need to work in collaboration to provide better, more advanced and evidence-based primary care.  Independent practice by nurse practitioners does not achieve this.  Independent practice by physicians with limited staff does not support this.

You can go to battle to defend your turf, your ego, or whatever else may get in the way of your patients.

My medical home team is going to go to battle for our patients.  With my n=1 experience, I am proud to say that this is worth fighting for.

So, who is the leader in the Patient-Centered Medical Home?  The answer is easy - our patients.  And they deserve the right for increased access to a team of providers - physicians, nurse practitioners, not practicing independently - who all need to be leaders in advocating for the patient's ability to achieve a healthier life.

Monday, September 10, 2012

Through a Patient's Eyes

I recently came across a Harvard Business Review article detailing an approach to attribution of health care costs around unit of time measurements.  That is, if a physician makes so many dollars per hour, then time spent on a minute by minute basis can be calculated.  Taking into consideration extender and staff involvement on a unit basis, as well as disbursed cost of overhead, equipment, and other expenses - the cost of a single patient visit could be directly and specifically quantified. 

I'm not so sure costs and time spent can be broken down quite so easily.  However, this motivated me to consider how patients view time spent by family physicians "with" and "on" them.  In an indirect way, I started to question the value and commitment that our patients see within us.  Though it is clear that we are not transparent with costs in medicine, I have a suspicion that we are even worse in regards to the transparency of how we utilize our time.

So think for a moment, and put yourself in a patient's shoes.  We have all been there, at one stage or another.  How much time is really perceived as being dedicated specifically to them?  Through the course of an office visit in which a patient is first greeted by a receptionist, nurse, or even a computer terminal.  Next up is the inevitable waiting game. The physician visit can be the big finale.  But while patients may see the lightshow - I'm not convinced they totally appreciate the prep time and cleanup for the event. 

Obviously, tremendous practice-to-practice variation exists.  I would never attempt to lay down a blanket statement in regards to work flow and visit dynamics.  Rather, I have three specific inquiries:

1) How do patients personally perceive the doctor-patient interaction?
2) To that end - how much of patient perspective is ignored in systems development?
3) Should work transparency be valued as much as cost transparency?

I gather that most do not realize the amount of time spent on paperwork outside of the exam room - billing, coding, pre-visit prep, as well as note completion.  This says nothing for time spent on CME, private reading, and newer interfaces with email and phone interactions. I think as physicians, we have done a poor job of demonstrating our actual time spent "per patient"; when the modern visit may mask much of what is done behind the curtain.

How will this interaction and perception change as we drop live EMR into the middle of the patient-physician dynamic?  The immediate goal is to increase accuracy and efficiency in note-taking, and provide an at the point of care tool for documentation.  Intriguingly, the time spent to make this process more evident has often had the opposite effect - instead of patients feeling more "thankful" for the perception of increased time, they may feel cheated that time isn't spent on face-to-face interaction and counseling. 

Certainly, generational and cultural differences are at work here - as are physician preferences in interaction style.  However, I think it is worthwhile to take my three aforementioned questions into consideration as we move toward more full adoption of HIT.  In recent decades, patients have voiced an increasing discontent with the amount of time spent with their doctors.  I think we stand to continue to agitate this discontent if we neglect to acknowledge the patient perspective as a priority in episodic visits. 

The next step, then, is to transform this perception from episodes of interaction into a spectrum of continuous oversight and care.  I suggest that we should be clear in our efforts, and drive transparency of work to be equivocal with transparency of cost.  I believe this to be a huge step in the direction of generating global and perceptively steadfast models of care.

Monday, August 6, 2012

Taking the Plunge or Taking Off? Advice for Starting as a Family Medicine Resident

Have you ever seen a B-52 Bomber flying in mid-air?  If you haven't - just humor me and imagine a big 'ol plane soaring at about 10,000 feet :)

How do you think it gets up there?  Well, we know it certainly doesn't just pop up in mid-flight, ready to rock and roll.

There is a lot of work that goes into getting one of these 500,000 pound planes off the ground.  First - original design plans are drafted, followed, tested, and reviewed.  Sounds a bit like college, huh?  I'd like to think of it that way - a college student is a blank slate, looking at all the different models they can choose to build of themselves.  Whether one strives to be a lawyer, a doctor, or even an elementary school teacher - the first step is to start by sitting down and drafting plans.

From here, I like to think that medical school is the period of assembling the plane.  Parts and pieces are gathered from all over and combined to build this perfect machine with a directed purpose.  While the pilot is reading the instruction manual, the fuel tanks are being filled (with knowledge! Sorry, I couldn't help but throw in a little cheese).  Medical school is all about making sure the plane is ready for that first flight.

Residency is like take off.

As a new intern in family medicine this year, I have spent the greater part of the last year trying to gather advice from my predecessors.  Over and over I have heard comparisons of residency to "taking a big plunge" or "stepping into fire" or worst of all - "being pushed off a cliff".  Wow. 

This is why I like to think of my first two months of residency as the start of my "Take Off".  My plane is built, I have all the equipment ready to fly, and I've got the manual down (mostly).  I just need a short period of going down the runway, building up speed, and checking all the instrument panels, before I'm ready to take flight.

So my plan in writing this post isn't to rehash any of the same recommendations that you've likely read before, i.e. - "be nice to the nurses", "be on time" etc.  I'm writing this to invite you to consider residency from a different perspective, one opposed to the pessimistic downtrodden black hole that many of us have been trained to believe it will be.  Rather, think about it this way - if you were fully prepared to be a practicing physician on the day of medical school graduation, then why would we need a residency period?  These three years are a time to grow, a time to test your limits, and most importantly - a time for you to build up speed for your big take-off.

Certainly, the hours and days will be long.  But you can do much to prepare yourself for that.  Dedication to sleep, nutrition, and exercise will go far in combating the evils of prolonged and straining work requirements and environments.  My previous post on advice for first year medical student, still holds very true.  After all, this is a building process, and we cannot neglect our foundations.

At the risk of reaching hyperbole, I'll stop just there.  But allow me one more indulgence on the analogy.  While I like to think of myself as a B-52 bomber -sturdy, reliable, and loaded with firepower :) Maybe you are a different sort of plane - an F-15, or stealth bomber, or even a Zeppelin! Ha.  The great news is that in the world of family medicine, there is a residency (or runway) perfectly built for each of us.

Wednesday, July 11, 2012

Primary Care, Subspecialist Physician Payment Gap Narrowing - Are you listening?

The Family Medicine Revolution is happening before our eyes.  The payment gap between primary care and specialties is shrinking - is anybody listening?

According to a recent Medscape article titled "CMS Proposes Primary Care Raises Funded with Specialist Cuts," Family Medicine is set to get the highest raise of all specialties with a 7% jump.  This is great news when considering Medical Group Management Association (MGMA) recently reported that, when considering 2011 statistics, primary care docs saw a 5% increase in pay compared to the previous year.

CMS administrator Marilyn B. Tavenner states that "helping primary care doctors will help improve patient care and lower health care costs long term."  The Vermont Medical Society produced an article that explains the proposed rule by CMS in a bit more depth.  In an AAFP News Now article published today, 11JULY2012, states that the proposed rule would pay for non face-to-face care as well as care-coordination.

An article by MedPage Today discusses the potential investment in primary care-coordination during the 30 days after a patient is discharged from a hospital stay as an investment worth making - getting patients appropriate follow-up to prevent bounce-backs, readmission rates, and other costly inefficiencies that go along with inadequate primary care follow-up, specifically with a family doctor.  I say specifically a family doctor because this is also a statistically significant data point in recent studies by the Graham Center, not just because it is a biased opinion.

One of the main driving forces for medical student interest for primary care and Family Medicine as a specialty is the gap between reimbursement for services provided and salary achieved for specialists compared to primary care.  This of course was carefully outlined in the Council on Graduate Medical Education's 20th Report, "Advancing Primary Care."   Of course, it does not take a formal report to understand that a difference in pay that averages about $3.5 million over a lifetime can be quite influential to a medical student set to graduate with greater than $200,000 in student loans.  This is not anecdotal, it has been extensively researched by COGME, the Graham Center, and a number of other studies.

Look no further than the military in regards to how payment disparities, or lack thereof, can lead to the production of more primary care doctors.  Take into consideration the annual incentive pay between the different specialties within medicine.  The largest payment disparity between a military family doctor with the same number years of service, rank and the same number of dependents as a military doctor who hit the ROAD (Radiology, Ophtho, Anesthesia, Dermatology) will usually be about $20,000 per year.  Compare that with the civilian world where the disparity is, on average, about ten times that amount.  It is no wonder why the Uniformed Services University of the Health Sciences continues to rank in the top 10 in matching its students to Family Medicine Residencies.  Is this the way that civilian medicine should go in regards to paying physicians?  Probably not.  However, it is interesting how the military world values a foundation in primary care and how it values all of its doctors appropriately within its single-payer system.  

So, where are we heading?  Are new CMS proposals going to make a difference?  Are medical students listening?  Are current family doctors who persuade medical students away from the specialty changing their message?  Will the American Academy of Family Physicians Task Force on Primary Care Valuation truly influence CMS?  Are the new increases a way in which CMS did actually in fact take the AAFP's recommendations rather than the American Medical Association's Relative Value Update Committee's consistently secretive, non-transparent valuation of specialists services?  Only time will tell.

Something that should be listened to and resonated around the country originates from a recent tweet by the American Academy of Family Physicians Family Medicine Interest Group account states: "A new study shows compensation of primary care docs (>$200,000) grew at a faster rate than specialists in the last 5 years."  Now that is something worth talking about.  

Friday, June 8, 2012

Instant Review - Get Family Medicine Out of the Shadows

I must say, it has been a while since I was geared up enough to write a post so quickly after an article has been published.  This immediately changed about 10 minutes ago when I read the following article on Huffington Post by Ranit Mishori, MD, MHS in collaboration with a good friend of Family Medicine, Larry Bauer of the Family Medicine Education Consortium.

"Time for Total Family Medicine -- Get Family Medicine Out of the Shadows"

Contained in this piece is a wonderful assortment of problems Family Medicine continues to face as our country's failed system has evolved over time, specifically within the past 20 years.  In fact, this is probably one of the best overall summaries I have seen in quite some time, really taking everything and putting it into one article.  Many of these ideas have been highlighted by a number of our authors and we really do appreciate the time Dr. Mishori and Larry Bauer put into creating this masterpiece.

Similar to a post I wrote back in December 2010 titled "What is Family Medicine," Dr. Mishori describes the frustration Family Docs face when explaining the specialty.  Many people still do not understand why we run from the pediatric floor, to deliver a baby, and then back to the clinic to see our panel of patients ranging from newborns to the elderly.
Me: "I'm a family physician."
Woman: "Oh, you're an internist." 
Me: "No, not really. I am a family doc. I also see children." 
Another woman: "So, you are a pediatrician"? 
Me: "No, I am a family physician. I also deliver babies." 
First Woman: "Ah, so you are an Ob-Gyn!"
Other major points landed in this article deal with NIH funding - 10 cents per $10 of NIH funding goes to family doctor research, much of what is being done in the communities, where >90% of the USA is actually receiving their care and expecting good outcomes.

The author talks about having a seat at the table for valuation of physician services.  As many already know, we have mentioned the RUC (I will say AMA's RUC no matter how much they deny to have an official hand in it - how much do they make on those coding books again?).  As the RUC is currently sub-specialist dominated, I am still convinced that no major changes will be made to go along with COGME's 20th Report - Advancing Primary Care to get the gap in pay for primary care decreased to 70% of sub-specialists.  To be fair, I will say that family doctors do have A seat at the table.  It is interesting how primary care makes up about half the pie of Medicare services but barely has representation at the table valuating said services.

Dr. Mishori also incorporates the "Too Smart for Family Medicine" routine that we so frequently hear about.  Over here, we say that Family Medicine is a waste of your talent.

Much like the initial calling for the Family Medicine Revolution by Jay Lee, MD, Dr. Mishori ends the piece, calling on all of us to rise up to the occasion and change the current culture:
Some of this needed change requires those of us in the field to step up. Maybe we've bought into our own misconstrued image, as the crunchy granola docs, and don't like to rock the boat. Enough. Total docs, let's rock. Let's demand a place at the table of decision makers. It is fine to be the "sensitive" M.D.s -- we believe in that value -- but we need to wise up when it comes to getting our message out.
Let's wise up and get that message out!  Hoping that this can bring some energy to the upcoming AAFP National Conference of Family Medicine Residents and Medical Students in July as well as the AAFP Congress of Delegates this upcoming fall in Philadelphia. 

Wednesday, May 2, 2012

Living out our personal statements

"Money, Family Medicine and You." That was the name of a talk for medical students I attended last month at the Massachusetts Academy of Family Physicians Annual Meeting. During the talk, the speaker challenged us to examine whether the vision for medicine that we had written in our personal statements for ourselves and for medical school admission panels still rang true now.

For someone like me who is a 4th year medical student at the twilight of my lengthy medical school education, my personal statement for medical school admission was something I hadn't thought about for a long time. I went home that night and spent some time searching for my personal statement and re-reading it. In it, I had written passionately about my dad's fight with cancer while I was in high school and my subsequent desire to accompany patients and families during their struggles.

I challenge all health professionals out reading this blog whether a current student, resident or physician:
  • What did you write about in your personal statement?
  • Are you still living true to the vision and the passion you wrote about then?
  • Why or why not?
Studies have shown that medical student empathy drops throughout medical school with a huge plummet in 3rd year. This sounds counter-intuitive when one first hears this - how does it make sense that when students actually start seeing patients every day they become less compassionate? However, given today's stressful medical education environment, it comes as no surprise. Students live from one exam to the next, are scutted out and pimped by residents and attendings, and work long hours in the hospital and clinics. In the midst of this chaos of 3rd year, students are expected to make decisions about specialty choice.

I watch the 3rd year medical students, one class below me, struggle with these decisions now. Some students have known from day 1 of medical school that they want to do pediatrics or neurosurgery, while others are still juggling a number of different specialty choices. When that decision is made, the next and equally (if not more) challenging decision looms: where to apply and what one is looking for in a residency program? My advice would be to take a step back, take a deep breath and look at the reasons why one entered medicine in the first place. Look at your personal statement. Who did you want to be then?

True, you may be making less as a family physician then you would as a cardiothoracic surgeon or an ophthalmologist, but your income will still be among the top 10th percentile of the general population. Even as a resident, you will be making more than the average American household individually! Are our motivations driven by financial incentives, peer pressure or prestige/pride? Or are our motives driven by true concern for those we serve and work with each and every day?

Our society needs compassionate and caring physicians who stay true to their own personal visions and dreams. Are you still living out the vision in your own personal statement?

Tuesday, March 20, 2012

The 2012 Family Medicine Match Results - Future of Family Medicine Match Day Coverage

Match Day is once again upon the world of medicine, and we are eager to outline and track updates to 2012 match results for Family Medicine. While the Family Medicine Match continues to increase for the 3rd year in a row, gains in the number of positions filled and the percentage fill rate are marginal this year.

NRMP Match Results: 2,611 of 2,764 Family Medicine PGY-1 positions were filled in the match, making for a 94.5% fill rate, which is 0.1% higher than last year's 94.4% match rate when 2,576 of the 2,730 available positions were filled. 48.3% of PGY-1 spots were filled by US medical graduates, marking a 0.1% increase from 2011.
2000-2012 NRMP Family Medicine Match Results (Source: AAFP)

Regarding the NRMP match, AAFP President Glen Stream commented in the AAFP News Now:
"Family medicine's 2012 Match numbers barely increased from 2011 numbers and certainly did not indicate enough growth in the specialty to keep up with America's increasing demand for family physicians. Family medicine is the foundation of improved health care in this country. We must continue to promote programs that generate and sustain student interest in the specialty."

The AAFP president identifies several priorities that need to be addressed to increase the family medicine match and ultimately sustain (and hopefully increase) access to health care services  across the nation: "Several things need to happen, including narrowing the income gap between primary care and other physician specialists, reforming the medical education infrastructure, changing the system that funds graduate medical education, and increasing support for programs such as the National Health Service Corps and health professions training programs."

Also read AAFP News Now coverage of Match Day at: Family Medicine Match Rate Increases Slightly.

The Osteopathic Match: Family medicine continues to be the largest matched specialty among osteopathic medical students which announced the results of the 2012 osteopathic match in mid-February. Family medicine saw a 16% increase from last year, and was the largest matched specialty with 433 positions filled. Last year family medicine also was the largest matched specialty with 373 positions filled. This represents an increase of 60 spots for 2012.

Last years family medicine match results: 2,576 family medicine positions were filled out of 2,730: a fill rate of 94.4% - impressive when taking into account that 100 more positions were available for family medicine vs. 2010. Of the 2,576 candidates who selected family medicine, 1,317 of them were U.S. medical school graduates - this as a result of 133 more US Grads choosing family medicine, or an increase of 8.4% in 2011.

See for more detailed match analysis. Follow AAFP detailed analyses at: also!