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Lively Debate, Election of New Leaders Await at Congress of Delegates
The deadline for AAFP chapters to submit resolutions to the Congress of Delegates passed this weekend, and more than four dozen items will be up for debate when the Congress meets Oct. 20-22 in Washington.
© 2014 Marketing Images/AAFPThe AAFP's Congress of Delegates will meet Oct. 20-22 in Washington. Here I am addressing the 2013 Congress in San Diego.
The resolutions reflect the breadth of family medicine and the passion of our members, covering a variety of issues -- from clinical topics (contraception, end-of-life care, sterilization, tobacco and vaccinations, to name a few) to physician payment, scope of practice and more.
With more than 115,900 members, the AAFP represents a diverse group of physicians from many different backgrounds, practice types and political affiliations. Our members are passionate about numerous issues, and sometimes those passions collide.
For example, the Minnesota AFP has submitted a resolution urging the Academy to "participate in national deliberations and discussions pertaining to single-payer financing systems for health care reform."
The prospect of supporting a single-payer system likely would thrill some delegates and leave others itching for a fight. But spirited debate is what makes the Congress interesting, and we will no doubt hear from members with widely divergent views
Each chapter can send two delegates and two alternate delegates to the Congress. Delegates typically are individuals who have played leadership roles in their chapters. It's worth noting, however, that although only delegates may vote during the Congress business sessions, any Academy member present may speak and give testimony during the reference committee hearings.
A resolution from the Texas chapter seeks to examine the Congress' senatorial makeup and consider making the Academy's ultimate policymaking body one "based on limited proportional representation." Such a move would allow more opportunities for member participation in big states such as Texas, where physicians now often have to wait years for leadership opportunities. However, one might expect that delegates from smaller states will offer some impassioned testimony on this resolution.
Delegates also will choose a president-elect, other officers and a new class of Board directors. Unlike most years, when three new directors are chosen to serve three-year terms, delegates to the 2014 Congress will select four directors from a field of six candidates. The candidate receiving the fourth-most votes will serve a one-year term to fill the spot vacated by Clif Knight M.D., who resigned his position on the board earlier this year to become the AAFP's vice president for education.
For those who can't join us in Washington, you can follow the business sessions of the Congress via streaming video on aafp.org. More details about that will be published in AAFP News before the Congress convenes.
John Meigs, M.D., is speaker of the Congress of Delegates, the policymaking body of the AAFP.
Posted at 11:10AM Sep 24, 2014 by John Meigs, M.D. | Comments[0]
'What? Me Worry?' Family Medicine Residency Trained Me Well
From the first day of medical school we start a countdown to graduation and cannot wait until we are finished. Then we do the same thing in residency with even more vigor. The most frequently asked question we hear is, "When will you be finished?" We all answer -- with longing in our eyes -- that we are eager to be free, out on our own and liberated from residency requirements. No more checking out to attendings, holding interns' hands, or eating five consecutive meals in the hospital cafeteria.
It wasn't that long ago that I was worried about seeing patients outside the comfort zone of my residency program. Now I am mentoring David Paxton, left, a fourth-year medical student at West Virginia University.
But there is a point -- near the end of June -- when the end is in sight, and it is terrifying. The elation I thought I would experience (in my head, it always involved singing and skipping through the office past the exam rooms) was replaced by a GERD-inducing, mind-numbing fear that bordered on panic. I kept thinking, "Next week, I will see a patient and have NO ONE to ask to look at that rash or listen to this murmur. I will be alone."
Then, after a couple of weeks of being consumed by the fear of leaving my residency faculty, it was suddenly time to go to work. I had never even met my nurse. I was going to see patients -- MY patients -- who I will follow for the rest of their lives. And although I had my own panel of continuity patients during residency, there seemed to be so much more at stake with these new patients. What if they don't like me? What if I can't figure out what to do with the very first one? It felt like a major case of stage fright.
Much like during my medical school rotations, when the day arrived, I got up, made coffee, and left early ... but not too early because I've sat many a time in a parking lot of an office that wasn't even unlocked yet. My drive to work is 25 miles on a two-lane state road along a river where there is zero cell phone service and little traffic. About halfway to the office I saw something huge and black leap out of the river and attempt to sprint across the road. I slammed on the brakes and then watched a black bear climb up the side of the mountain that borders the road. All the while I was thinking that no one would believe this. But when I got to work and told my new co-workers about my bear sighting, they were unimpressed. They have all hit bears with their cars or seen them in their yards.
A couple of hours later, it was time to see a patient. My first patient. The front desk gave me an easy case, a walk-in who already had been diagnosed. I finished that patient, struggled through using a new electronic health records system and even submitted billing. I survived (so did the patient) and the world had not ended. I knew what to do and how to do it.
I looked a few days ahead in my schedule and found some seriously complicated stuff: refractory cases, uncommon or rare diseases, undiagnosed problems and genetic disorders -- lots of all of them. After about a week of seeing patients, I emailed my residency program director at Marshall University to say thanks. I had the training and background to take care of every patient who had walked through the door.
I love my job, and now I feel silly that I was ever nervous. Family medicine residencies are rigorous, and for good reason. We are the primary care workforce, and we have to be well trained and confident to manage complex patients and serve our communities well.
I had multiple patients who reported their reason for visiting was that they had been "waiting for the new doctor to come." These patients had high hopes, and I had to meet those expectations. Although I am not doing obstetrics (there isn't one hospital in the entire county) I have had multiple pregnant patients, so I have to know how to safely treat -- and just as importantly, counsel -- them, so my obstetrics training is well utilized. There are days when I see more pediatric patients than adults, and there are other days that the average age is 70.
Throughout medical school and residency, I heard every argument that exists against choosing family medicine. The one I can 100 percent discount after just two short months of practice is the concept of getting bored doing primary care. Really? Bored? I could be a lot of things in my office (annoying, loud, messy) but bored is not one of them. Every day is full of amazing variations that I think highlight family medicine as a specialty. I learn new things, read new articles and teach every day.
My patients are my favorite part of my job, but my second-favorite part is that I have medical students. I'll never forget my first patient as a student, my first continuity patient as a resident, or my first patient in my new office. And I'll definitely always remember the first medical student who trusted me to teach him family medicine. Of all the awards and achievements I have hanging on the walls, nothing beats having a medical school place a student in my office.
I remember asking my rural preceptor when I was a third-year medical student why she took students into her office. Did she get paid or have access to university resources? Now I know why she just smiled at me and explained that she thought they gave her an email address.
Obviously, no one asks me when I'm going to be finished with school/residency anymore. But now I have new daily questions that follow a similar theme: Where are you from (and they want a town name because they can already tell that, like them, I'm from West Virginia)? Are you going to stay here? How long do you think you'll stay?
It feels good to be wanted, and it feels good to be a family physician. And yes, it feels amazing to be done with residency!
Kimberly Becher, M.D., is the resident member of the AAFP Board of Directors.
Posted at 04:37PM Sep 19, 2014 by Kimberly Becher, M.D. | Comments[1]
GME Reform: An AAFP Call to Action
Primary care is the foundation of high-performing health care systems throughout the world, but in the United States, we primary care physicians make up less than one-third of the physician workforce, and our numbers are dropping.
| I talked about the need to reform the graduate medical education system during a presentation Sept. 15 in Washington. Other speakers, from left, were pediatrician Fitzhugh Mullan, M.D.; Kisha Davis, M.D., M.P.H., the new physician member of the AAFP Board of Directors; AAFP President Reid Blackwelder, M.D.; and AAFP EVP and CEO Douglas Henley, M.D.
A growing number of organizations -- including the Association of American Medical Colleges, the Council on Graduate Medical Education (COGME), the Pew Health Professions Commission and the Robert Wood Johnson Foundation -- have stated that at least 40 percent of U.S. medical graduates need to enter primary care fields if we are to meet the needs of our nation's health care system. But our current GME system is failing to hit that mark because nearly 80 percent of new physicians are choosing subspecialty careers. We are rapidly falling behind.
A primary care physician shortage already exists, and it will only be exacerbated by our changing health care needs: a growing population, the increase in chronic disease seen in our aging population and expansion of health insurance coverage.
The calls for change are mounting. Last year, COGME -- which was created by Congress to provide assessments of physician workforce issues -- released a report that called for drastic changes in the GME system, including increased funding to support 3,000 more graduates per year and prioritized funding for high-priority specialties, including family medicine.
Just this July, the Institute of Medicine released its analysis of GME in the United States and found that the current system lacks transparency and accountability and is producing a physician workforce that doesn't meet the country's needs -- despite an annual $15 billion investment from U.S. taxpayers.
On analysis, it's not surprising that our current GME system produces the outcomes that it does, because funneling funds through hospitals leads to residency workforce decisions based on the financial needs of those local institutions and not on the overall needs of our health care system.
This week, I was pleased to join other AAFP leaders on Capitol Hill as we took things a step further, unveiling a new budget-neutral proposal that would address those issues of transparency and accountability while aligning funding resources with actual workforce needs. The Academy's proposal recommends that policymakers and legislators take the following steps:
- Establish primary care thresholds and maintenance-of-effort requirements for all sponsoring institutions and teaching hospitals that currently receive Medicare and Medicaid GME financing.
- Require all sponsoring institutions and teaching hospitals seeking new Medicare- and Medicaid-financed GME positions to allocate one-half of their new positions to primary care.
- Limit direct GME and indirect medical education (IME) payments to training for "first-certificate" residency programs. Repurposing funding currently spent on fellowship training would be used to create more than 7,500 new first-certificate residency training positions.
- Align financial resources with population health care needs through a 0.25 percent reduction in IME payments and reallocation of those resources to support community-based primary care training.
- Fund the National Health Care Workforce Commission. The Patient Protection and Affordable Care Act created this panel to review health care workforce supply and demand, but Congress has failed to allocate funding for it.
Yet it is important to note that the current and future physician workforce cannot be corrected through GME reform alone.
Earlier this year, a task force created by the Council of Academic Family Medicine -- which comprises the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors, the Society of Teachers of Family Medicine and the North American Primary Care Research Group -- with support from the AAFP, the AAFP Foundation and the American Board of Family Medicine, created the "Four Pillars for Primary Care Workforce Reform" concept, a comprehensive approach that includes:
- the medical school pipeline,
- the process of medical education,
- improving the practice environment for a more rewarding professional setting and
- primary care payment reform.
Even as we work on all of these comprehensive reforms, changing the GME system is one of the most important policy levers we can pull now because of the vast government investment in the program and the multiple recent national reports calling for reform. Our GME system is stale. It was created in 1965 -- a different time -- and for a different purpose. Now, it is one of the few areas of the health care system that has not experienced major disruption in composition, function or financing.
Please join me in engaging our nation's leaders in a conversation about why our GME system should be reformed. It is time for the investment our nation makes in GME to be transparent and accountable and to produce the physician workforce our country needs and deserves.
Jeff Cain, M.D., is board chair of the AAFP.
Posted at 09:36PM Sep 17, 2014 by Jeffrey Cain, M.D. | Comments[1]
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.
Posted at 02:31PM Sep 11, 2014 by Robert Lee, M.D. | Comments[2]
Called to Serve: Being Patient-Centered Puts Joy Back Into Practice
One of the exciting things about being president of the AAFP is the many opportunities to interact with medical students from all over the country. I have frequently said that students are not so much our future as they are our present. They have the ability to affect us in a positive way with their curiosity, fresh perspective and drive. And we, in turn, have the ability to make an impact on them and to influence their education and training.
Along those lines, I wanted to share two recent experiences and challenge each one of us to step up and build these critical relationships.
| Our recent National Conference of Family Medicine Residents and Medical Students drew more than 1,200 students and nearly 1,100 residents to Kansas City, Mo.
I was honored to be asked to welcome all attendees to the National Conference of Family Medicine Residents and Medical Students a few weeks ago in Kansas City, Mo. This is the largest meeting of medical students and residents in the country, and this year we had record attendance, with 1,211 medical students and 1,092 residents.
For students in particular, National Conference is a critical leadership development opportunity. Obviously, we want to expose them to family medicine, and the experience of attending the conference often solidifies students' decision to pursue family medicine as their specialty of choice. But the conference has another important function: educating and challenging students to advocate and be part of our policymaking process.
One of my main messages at National Conference also was the focus of my closing main stage presentation. During that session, I challenged students to be patient-centered in all they do. I let them know that they have this opportunity, from the ground up, to be patient-centered even before they enter the workforce.
National Conference is a great experience for attendees, but our engagement needs to extend beyond those three days each year. We can all look for other ways to reach out to medical students where they are. For example, we recently had our second Family Medicine on Air session using Google Hangout. This is an innovative approach to connecting people, and it is a technique the Academy likely will be using in other ways to connect with members.
The structure of the Google Hangout -- which you can view on Google Plus or YouTube -- allowed people to actually see me, moderator Alice Esame (a fourth-year student from Howard University School of Medicine who also is the AAFP's student liaison to the Student National Medical Association), and AAFP student interest staff as we talked about the patient-centered medical home (PCMH). I gave a brief introduction in which I emphasized that the PCMH is truly about a philosophy and an attitude as well as about being patient-centered. Students need to understand the PCMH, yes, but most importantly, they need to be empowered to become patient-centered even if they don't yet understand all the aspects of practice transformation.
The opportunity to be patient-centered truly is a way to put joy back into a practice. It is a way for all of us to remember that we are called to serve, and that we can truly help our patients often just through the compassion we display in recognizing that they are dealing with difficult issues. This is especially important for students to understand as they consider choosing a career in family medicine that will be satisfying to them, as well as to their patients.
I was impressed with the quality of the questions that came from the students. For example, they were concerned about the administrative hurdles that come with practice transformation. This allowed me to emphasize our advocacy efforts to help streamline the process involved with PCMH recognition.
Another question acknowledged the important role of other members of the health care team, such as care managers, nurses and others. Specifically, the student's question addressed how to assemble a team in rural settings where there are fewer resources. This gave me a chance to talk about how at my first practice in Trenton, Ga., the small town's health care professionals (chiropractors, pharmacists, public health officials, etc.) worked together even though we weren't in the same building -- or the same business -- to make sure that we provided the care our community needed. The key was good communication as well as the recognition that we all were working together for our patients' well-being.
The students were on top of recent evidence, too, quoting an article in JAMA that found PCMH pilots from 2008-11 were not associated with health outcome improvements. I pointed out that this article described older PCMH models, and so was essentially similar to being concerned about a review of the iPhone 2 when we're actually using the iPhone 5. PCMH models now are significantly different. Those pilots did not have many of the patient-centered changes in place such as extended hours, and did not really study decreased ED visits, and hospitalizations which are clear improvements in current PCMH pilots.
Students keep us on our toes. They challenge us, in a good way, with their fresh viewpoints, inquisitive minds, and drive to do things the best way possible. And the questions these students asked amply illustrated that reality.
The challenge for us as educators is to recognize that our students need a different approach for many of these issues. If you are an educator, or involved with a family medicine interest group, consider watching the Hangout and sharing the link. You can also refer to or use supporting materials that are available to help our family medicine interest groups, faculty and others who influence medical students frame these critical issues for them.
For members who work with students -- even if you're not faculty, I challenge you to engage them in discussion about patient-centeredness. Talk about how you have been changing your practice to become more patient-centered. Take advantage of this chance for us to walk our talk and demonstrate to our students how much we love what we do.
Although I still say students are our present, they are definitely also our future. We have a chance to give them a solid grounding in patient-centered education, and they can help to move us forward in our own processes.
Our next edition of Family Medicine on Air will address what medical students need to know about direct primary care. Stay tuned for more details about that event, which is planned for November.
Reid Blackwelder, M.D., is president of the AAFP.
Posted at 11:59AM Sep 05, 2014 by Reid Blackwelder, M.D. | Comments[0]
Family Medicine for America's Health to Launch at Assembly
I am extremely excited that the launch of Family Medicine for America's Health is less than two months away; the official rollout will occur in October in Washington, D.C., at the 2014 AAFP Assembly. As president-elect of the AAFP, I want to personally invite you to be there for this big event. This is truly history in the making, placing family medicine at the center of health care delivery in our nation.
For those of you who are unable to attend the Assembly in person, stay tuned, because we are working on a plan to deliver this event to you through digital channels.
Here is our latest update on this important project.
Organizational Update No. 8
September 2014
The goal of the Family Medicine for America's Health initiative is to meet the needs of the American public by achieving the triple aim of better care, better outcomes and lower costs. This initiative includes two integrated elements: a communications program aimed at consumers, policymakers, payers and the medical community and a strategic plan that will focus on addressing key issues facing the specialty of family medicine. I will unveil the communications program at the first Assembly general session on Oct. 22.
Family medicine's strategic direction is composed of seven statements. Working together with its health care colleagues and other engaged stakeholders, family medicine aims to achieve the following:
- Show the value and benefits of primary care.
- Ensure every person has a personal relationship with a trusted family physician or other primary care health professional in the context of a medical home.
- Increase the value of primary care.
- Reduce health care disparities.Lead the continued evolution of the patient-centered medical home.
- Lead the continued evolution of the patient-centered medical home.
- Ensure a well-trained primary care workforce.
- Improve payment for primary care by moving away from fee-for-service and toward comprehensive primary care payment.
The strategic plan is focused on six key implementation areas: practice, payment, workforce education and development, technology, research, and engagement. We are in the process of developing teams that will focus on tactics in each of these six areas. These teams will rely on support and input from a broad network of expertise in family medicine and beyond. Please be on the lookout for ways you can get involved.
We strongly welcome and encourage your input on this process. We are developing a calendar of events where you can hear directly from, and share your views with, Family Medicine for America's Health leadership about this initiative. We will work to ensure you have a wide variety of in-person and virtual opportunities for engagement. Look for a calendar of events in the next update. We are also in the process of building a website -- FMAHealth.org -- to keep you fully informed on the progress of this effort.
As a reminder, the list below shows the members of the Family Medicine for America's Health Board of Directors and the organization or other affiliation each represents. We are still working to identify a patient advocate to join the team and expect to have that vacancy filled in time for the launch.
Representative and Organization/Affiliation
- Glen Stream, M.D., M.B.I., Chair, AAFP
- Michael Tuggy, M.D., Vice Chair, Association of Family Medicine Residency Directors
- Paul Martin, D.O., Secretary and Treasurer, American College of Osteopathic Family Physicians
- Jen Brull, M.D., represents full-scope, full-time practicing family physicians
- Thomas Campbell, M.D., Association of Departments of Family Medicine
- Jennifer DeVoe, M.D., D.Phil., North American Primary Care Research Group
- Lauren Hughes, M.D., M.P.H., represents family physicians early in their careers
- Vincent Keenan, C.A.E., represents AAFP chapter executives
- Jerry Kruse, M.D., M.S.P.H., Society of Teachers of Family Medicine
- Robert Phillips Jr., M.D., M.S.P.H., American Board of Family Medicine
- Jane Weida, M.D., AAFP Foundation
- TBD - patient advocate
Additional background and earlier updates on this project are available online.
Robert Wergin, M.D., is president-elect of the AAFP.
Posted at 04:50PM Sep 02, 2014 by Robert Wergin, M.D. | Comments[0]
More Than Meets the Eye: Value of Small Practices Shouldn't Be Ignored
For years, we've been hearing about the decline -- even death -- of the small primary care practice, but I'm here to say that obituary is premature, if not flat-out wrong. When a recent study published in Health Affairs touted the value of small practices, I didn't need convincing. I'm a small practice owner and have been for nearly 30 years.
The study found that primary care practices with one or two physicians had one-third as many preventable hospital admissions compared with practices with 10 to 19 physicians. The study also reported that smaller practices achieved their impressive results despite caring for a higher percentage of patients with chronic conditions than larger practices.
© 2014 Texas AFPMy rural, two-physician practice recently achieved Level 3 patient-centered medical home recognition from the National Committee for Quality Assurance.
So how did the small practices in the study manage to have better results regarding preventable admissions (and likely lower costs) than their larger counterparts? The authors point out patients in smaller practices may have closer relationships with their physicians, which might offer greater insight into patients' comprehensive health needs while facilitating ready access to care.
Patient-centered care, which includes enhanced access to care along with other elements, has become a focal point of the movement to improve our health care system in the past decade and, increasingly, is being embraced by small and large practices alike. Large practices, in particular, are likely to benefit from economies of scale that enable them to readily invest in health information technology and other organized care processes recognized as components of the patient-centered medical home (PCMH) model. And indeed, in this study, some of the larger practices appeared to use more such processes than the smaller practices, yet didn't fare as well in keeping patients out of the hospital.
Clearly, there's more to the story.
An abundance of evidence tells us that the PCMH can lower costs and improve outcomes. Just think: How much more could we bolster those outcomes if we combined the efficiencies of a Level 3 PCMH with the strengths and accessibility of a small practice?
Welcome to my small rural practice, which recently achieved Level 3 recognition from the National Committee for Quality Assurance (NCQA).
Regardless of a practice's size, there are hurdles to jump through on the way to PCMH recognition. The process can be overwhelming at the outset, and the AAFP has discussed the need to simplify the process with the NCQA and other such groups.
Although the process can be especially difficult for small practices, which lack the time, capital and resources of larger practices, it can be done. My two-physician practice achieved Level 3 recognition, from start to finish, in two years. We did it by working together with other small practices in our area, combining our efforts and resources.
The key, for me, was taking the process one step at a time, which made it seem more attainable. To that end, the AAFP has created a PCMH Planner to help practices of all sizes transform to the new model; that resource offers a step-by-step guide to follow.
I'm sure many small-practice physicians look at the PCMH checklist and think, "I'm already doing this. I'm already patient-centered."
I was one of those docs. And I was wrong. That's a difficult thing to realize, but my practice is better now than it was two years ago. We've improved vaccination rates, lowered the number of missed screenings and made care more accessible.
I realize now that it's important to be open to change and to always be looking for opportunities to improve. For example, I initially thought a patient portal -- a requirement to achieve the recognition level we did -- would be money wasted, but it's actually changed the way I practice. Giving patients access to their individual records improved the overall quality of our data. I've had patients point out mistakes in their records that were quickly corrected, and I even had one patient point out something we hadn't billed for that we should have. One benefit I had not expected is that my patients who are hearing-impaired now communicate with my office more often and with greater ease through the portal.
For our patients, the quality of care we provide has improved; so what's the payoff for the practice? BlueCross and BlueShield has agreed to a 5 percent payment differential for small practices in the group we are working with if they achieve Level 3 recognition. Four of the practices already are there, and six have Level 2 or Level 3 paperwork pending.
Moreover, my accountable care organization, which also is made up largely of small primary care practices, is in negotiations with two other payers to increase payment for those who have achieved PCMH recognition.
For years, payers marginalized small practices, which lacked the bargaining power of our larger counterparts, leading to more and more employed physicians and fewer and fewer small practices. But if those of us in small practices continue to prove our value, our future may be a lot brighter than anyone anticipated.
As the authors of that recent Health Affairs article noted, "Small practices have many obvious disadvantages. It would be a mistake to romanticize them. But it might be an even greater mistake to ignore them, and the lessons that might be learned from them."
Lloyd Van Winkle, M.D., is a member of the AAFP Board of Directors.
Posted at 03:53PM Aug 27, 2014 by Lloyd Van Winkle, M.D. | Comments[1]
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.
Posted at 02:43PM Aug 20, 2014 by Kisha Davis, M.D. | Comments[0]
On Air: AAFP President Engages With Students in Online Forum
I recently returned from the AAFP's National Conference of Family Medicine Residents and Medical Students -- which set attendance records, by the way, with more than 1,200 students and nearly 1,100 residents -- and I am tremendously fired up! The energy of that group, and the challenges they put before us, motivate me and all of our Board members to do an even better job representing these critical members of our Academy.
With that in mind, I want to share some innovative new things we have been working on to connect with students and residents.
| My Google Hangout with Family Medicine Interest Group leaders in July allowed students to ask questions on a variety of topics, including direct primary care, leadership development and patient satisfaction.
Almost a year ago, I was invited to be a featured speaker for the American Medical Student Association's National Primary Care Week webinar series, part of the AAFP's collaborative efforts with AMSA on this annual event. I participated in a webinar with a number of student leaders. This exciting experience allowed me to get the message of family medicine out to students nationally. That led me to think about ways we could start a similar process within the AAFP. I have been trying hard to increase our use of technology and to find new ways for the Academy to connect with medical students where they are and how they want to be reached. Many medical students and residents are extremely adept at using Facebook, Twitter, YouTube and Skype and actually prefer to access information digitally.
I often have ideas and send out frequent emails to Academy staff asking questions and seeking suggestions for growth. On this topic, our Medical Education Division responded quickly with a suggestion that we try Google Hangouts to connect with students. I had never heard of this tool before, but the Academy staff members responsible for increasing student interest in family medicine were exceedingly excited about the opportunity. We explored the resources, did test runs, and mobilized our dynamic Family Medicine Interest Group Network leaders to work through it. This process is similar to platforms like Skype; however, in addition to connecting people by video, it also allows users to share screens, use PowerPoint, correspond with other participants in the session and perform other tasks. The utilities seemed ideal for some of the things that we wanted to do.
We had our first Hangout on July 8, and you can watch it on the FMIG Network's Google Plus page or on YouTube. We recognized that this resource would allow us to reach out to medical students and residents all over the country. We also realized that we needed to focus the content so that these video installments, which are 15 minutes in length or less, are long enough to be informative but short enough for busy med students to work into their schedules.
The results of the first Hangout were outstanding. We received a great deal of positive feedback, and, most importantly, the FMIG Network leaders were excited about having a new tool to help them coordinate FMIG groups all over the country. Google Hangouts allow us to create an immediate connection between AAFP leadership and our students and residents. This is one of the things that we love most -- being able to talk with these enthusiastic members personally, answering their questions and sharing our passion for family medicine. This platform could help connect students who don't have much exposure to family physicians at their medical school with FP leaders who can provide them with insights on important issues in health care.
In addition to using Google Hangouts, I'd like to find other ways of tapping into this technology to help all of our members. For example, one of the biggest challenges we all face in these busy times is traveling to and from meetings. Although face-to-face meetings are critical for some functions and discussions, a great deal of what occurs at many meetings could easily be handled in a different fashion. Email is not always ideal, because visual cues and clues are still important and connect people in significant ways. Perhaps, however, Google Hangouts could allow us to have some meetings in a more dynamic fashion and respect people's need for work/life balance. Any time we can minimize travel and still get the work of the Academy done -- that is a good thing!
Moreover, especially with students and residents, utilizing this technology may allow a quicker connection between these member groups and our leadership for such things as noon conferences, forums and talking groups. In fact, some of you may have ideas about how to use this and similar technology. I would love to hear your thoughts, and I hope we can continue to move our Academy into a more efficient future. In so many ways, this is actually an aspect of the patient-centered medical home (PCMH) because what we can do for ourselves to become more effective and efficient is something we can then also do for our patients.
These days of telemedicine and telehealth are challenging us to expand our boundaries. I look forward to continuing that expansion with all of you. Our next Google Hangout will be about the PCMH and is scheduled for 12:30 p.m. EDT on Aug. 26. You can join us on Google Plus or YouTube.
Reid Blackwelder, M.D., is president of the AAFP.
Posted at 02:51PM Aug 14, 2014 by Reid Blackwelder, M.D. | Comments[0]
Walk the Talk: Students, Residents Step Up to Support AAFP Advocacy Efforts
If you want students and residents to get involved in an issue, sometimes all you have to do is ask.
At an AAFP Board of Directors meeting earlier this year, we heard a report on FamMedPAC, the Academy's political action committee, which helps elect candidates to the U.S. Congress who support the AAFP's legislative goals and objectives.
During the National Conference of Family Medicine Residents and Medical Students, we challenged our respective member segments to see who could raise the most money for FamMedPAC, the Academy's political action committee. Residents and students donated more than $1,000 during the three-day event.
The report included data on the relatively small category of student and resident support. As the resident and student members of the Board, we thought that category could -- and should -- be much larger. The perception has been that students and residents don't have a lot of money to contribute and, therefore, typically aren't a focal point for fundraising efforts.
However, we thought our colleagues would step up to the plate if given the opportunity, so we came up with the idea of the FamMedPAC Challenge. During the National Conference of Family Medicine Residents and Medical Students in Kansas City, Mo., last week, we rallied our respective groups of students and residents to support the PAC. We knew that the residents and students would answer the call and donate, but the results exceeded our expectations.
Advocacy consistently ranks among the top Academy priorities for students and residents, and both groups consistently bring issues to the AAFP's attention because they feel so passionate about the advances that can be made for our specialty and, more importantly, our patients. There were nearly two dozen resolutions in the resident and student congresses at National Conference that related specifically to advocacy.
During the conference, AAFP President Reid Blackwelder, M.D., of Kingsport, Tenn., gave a presentation on advocacy, and the room was packed. As part of that session, students and residents worked up an advocacy issue, which they then transformed into short "elevator speeches" in small groups. Each group practiced pitching their talking points to the entire room, and we were blown away by how well they articulated their messages.
Throughout National Conference, we spoke about the FamMedPAC Challenge and the PAC from the stage, but we also got the word out through social media and, of course, lots of old-school, face-to-face chatting. Both of us handed out donation forms with $1 (an actual dollar bill from our personal accounts) and a PAC donor ribbon attached. Many students and residents had already donated during the past year, but some gave again by adding $9 to our $1 for a $10 contribution, the minimum amount to get their respective group a point toward winning the challenge. Most donors, however, were new.
The FamMedPAC Challenge was a huge success. We had 51 donations: 31 residents contributed a total of $629, and 20 students gave a total of $431 for a three-day total of $1,060, which is by far the most money ever donated to the PAC during National Conference.
Now we'd like to challenge the rest of the AAFP membership. If medical students and residents -- with their ever-growing student loan burdens -- can reach into their pockets and make a donation to help advance our specialty, won't you?
Kimberly Becher, M.D., and Tate Hinkle, M.D., are the resident and student members, respectively, of the AAFP Board of Directors.
Posted at 09:38AM Aug 13, 2014 by Kimberly Becher, M.D., and Tate Hinkle, M.D. | Comments[2]
Reality Check: Residents Aren't Prepared to Deal With Patients' Financial, Coverage Limits
In medical school, our patient encounters typically consisted of completing a history -- including talking with patients about any concerns or issues that led them to seek care -- doing a physical exam, and developing a diagnosis and treatment plan with the resident and attending.
In the real world, it turns out, it's not that simple. I recently began the first year of family medicine residency, and I quickly realized that some important steps were left out of the learning process. As students, we were not often exposed to what happened next for patients. We missed the part where the physician talked with the patient about his or her insurance, what it covered and what it did not.
| This week I'm attending the AAFP's National Conference in Kansas City, Mo., which offers students and residents opportunities to learn about clinical skills, leadership and more. One thing students don't learn in medical school is how to manage patients who lack the means to pay for needed treatment.
I recently saw a patient, a woman in her mid-30s, who came in for a checkup. In addition to her chronic conditions, including hypertension and diabetes, she complained of joint pain in her knees and hips. After taking her history and talking with her about her discomfort, I wanted to have her tested for rheumatoid arthritis.
Her first question was, "How much will that cost?" The patient had private insurance, but her plan left a lot to be desired. It covered office visits and some medications, but it did not cover labs.
The patient, a single mom who also was supporting her mother, informed me that she already was paying off a large lab bill from a previous visit. She needed to repeat labs related to the medications for her chronic conditions, but she couldn't pay for those, let alone for a blood test for rheumatoid arthritis.
I could have ordered the labs, but there wasn't any point in doing so because she told me it would have to wait. It's not that she would have been noncompliant, she simply couldn't afford to do what needed to be done. From her perspective, doing the labs would have meant asking the people she supports to sacrifice something else.
I asked her to come back in two months so that we could reassess her situation -- both physically and financially. For now, she plans to continue treating her joint pain with OTC medications.
This situation is hard for me to get used to. I can't do what I want to do -- what I've been trained to do -- to help some of my patients. Instead, I have to consider a patient's medical, social and financial situation and work within those limitations.
Medical students should have more exposure to this part of the process so they are more aware of the reality that awaits them. What do you do -- or what can you do -- when your patients' financial or coverage limitations are barriers to needed care?
Tate Hinkle, M.D., is the student member of the AAFP Board of Directors.
Posted at 03:41PM Aug 07, 2014 by Tate Hinkle, M.D. | Comments[1]
Heads Up: School Sports Season Is Upon Us
My practice of family medicine includes sports medicine, and I care for a number of athletes in my community. However, it was an athlete I never cared for -- someone from the other side of the country, in fact -- who changed my practice and the care of young athletes across the United States.
Zackery Lystedt was playing football for his junior high school when he was injured in a game in 2006. He did not lose consciousness, and he returned to the field in the second half. He collapsed and had to be air-lifted out of the area for life-saving surgery. After several strokes and three months in a coma, Zack woke up. But it took nine months before Zack could begin to speak again and nearly three years before he could stand on his own.
I learned about Zack during a presentation by Stanley Herring, M.D. -- a team physician for the Seattle Mariners and Seahawks and a member of the Head, Neck and Spine Committee of the National Football League (NFL) -- at an American College of Sports Medicine (ACSM) meeting in 2009. He described how Zack and his family had taken up the cause of trying to prevent other young athletes from suffering similar experiences. That same year, the Washington state legislature passed the Lystedt Law, which requires concussed athletes to be cleared by a physician knowledgeable in traumatic brain injury before being allowed to play again.
I had met Herring 10 years earlier when I served as the AAFP liaison at the ACSM's Team Physician Consensus Conference. He played a major role in advocating for the Lystedt Law in Washington, and he asked me to spearhead advocacy efforts for similar legislation in Delaware. It was a great learning experience in policy making as I worked with a state legislator, the NFL and others, and the law was signed by our governor in 2011. By 2013, all 50 states had passed legislation that prevents a concussed athlete from returning to practice or competition for at least 24 hours, and their return to play depends on clearance by a clinician.
There is still much to learn about concussions, as highlighted by a recent White House summit that brought together a diverse group of stakeholders, including the AAFP. Protecting young athletes is an important part of our job as family physicians, and there are resources worth highlighting.
- With support from the NFL and the CDC Foundation, the CDC has created tools for health care professionals as part of its Heads Up campaign.
- The agency's resources include a free online CME course that applies not only to young athletes, but also to other concussed patients.
- The AAFP's sports safety Web page links to journal articles on the topic, including the American Academy of Neurology's guidelines for managing concussions in athletes, as well as to other resources.
- With schools around the country starting soon, now is a good time to think about preparticipation exams to ensure that our young athletes are in the best possible condition for competition before their season starts.
May all of our patients be safer because we learn to protect them from injuries like the one Zack Lystedt and his family live with every day.
Rebecca Jaffe, M.D., M.P.H., is a member of the AAFP Board of Directors.
Posted at 04:31PM Aug 05, 2014 by Rebecca Jaffe, M.D. | Comments[0]
Rural Practice May Pose Challenges, But It's Where I Was Meant to Be
Two years ago, at the beginning of my second year of residency, I signed a contract to work in a rural county in West Virginia. Although I've known where I was going for quite a while, I don't think I really understood what living here would mean until now.
I grew up in what most people would consider a rural area of West Virginia, but my new home is in an even less developed region of the state. You know the kind of area I mean, where you are driving down the interstate and there is nothing to see but trees. There are no gas stations and few restaurants -- it's really mostly just trees. Not only does the town nearest me not have a stoplight, there's no stoplight to be found in the entire county -- nor in an adjacent county, for that matter.
But this is exactly where I want to be. I love growing a lot of my own food and cooking or canning it. I wanted a home where my husband could hunt and my son could fish, and we were fortunate to find just that. The sense of community in these rural areas is genuine and is part of what drew me to work and live here. I did multiple rotations away from my medical school and residency, and those that really stood out for me were the rural ones. It was obvious to me that rural West Virginia was where I was meant to practice. Often, people will live in a larger city and commute to work because that is what resonates with their family or their lifestyle. Not us. We wanted to hear nothing but bugs when we open our windows at night.
There are things that I hadn't considered about living here, however, that quickly revealed themselves. The first neighbor I met warned me that the power goes out often, and that if it stays off long enough, there is no water either (not that I'm all that excited about tainted West Virginia water), because an electric pump brings it up the mountain.
I've also been warned that the road floods, and that I might get stuck at home or be unable to get home if there is too much rain, too much snow, or -- the more common scenario in a West Virginia flood -- too much of both together.
And then there is the Internet, which is only available through a satellite provider. It is expensive, takes eons to download documents and, generally speaking, makes it a struggle to even check my email. Gone are the days of streaming World Cup games or watching programs on Netflix.
Also gone is the option of running down to the local Mexican restaurant to watch a game while someone else cooks dinner; that's because the only restaurants in town are a Dairy Queen that closes during the winter and a carry-out pizza place. Oh wait, there's also a Tudor's Biscuit World, a standard found in nearly every small West Virginia town that I can't even begin to explain.
Don't get me wrong, I am happier than I've been in years. We eat food we cook ourselves for every meal and spend far more time outside. We could spend hours identifying birds and picking blackberries. My son is learning to ride his bike on our road, which might see three cars on a busy day. The moon rises behind two distant mountain ridges that we can see from our deck.
I realize this lifestyle is not for everyone. Although many of my patients and I choose to live in a rural part of our state, many are here by default. West Virginia has the highest homeownership rate in the country at 76 percent. That's right -- we are first in something positive.
It is a multifactorial situation driven, in large part, by a tendency to stay close to home, inherit land and homes, but also because there are not adequate employment and education opportunities for many of the state's residents.
One thing I have already learned is that most of the public health and wellness strategies used in larger cities will not work here. There is no venue for truly large-scale advertising because much of the population -- regardless of financial status -- relies on the newspaper and does not have access to the Web due to limited Internet availability. You can't direct patients to healthcare.gov or familydoctor.org. These patients need doctors, often doctors who will go to their homes, and patient information developed with appropriate health literacy in mind. Even a simple obesity intervention such as calorie-counting is often doomed to failure because many people cook from scratch and there are no food labels.
But these are challenges I embrace. I value the trust my patients place in me, and reaching out to connect with them to find solutions to their health care challenges -- especially those complicated by social, financial or logistical hurdles -- strengthens that relationship far more than any simple treatment regimen. I live here; I understand.
In addition to appreciating rural living challenges, I have been experiencing life without health insurance. I didn't go straight through college and medical school so -- like some of my patients -- I've had periods of time without health insurance coverage in the past. I have always found my advocacy voice for the uninsured to be louder than some, partly because of my first-hand experience with the medical system from an uninsured perspective.
The first time I found myself uninsured, I was 22 years old, had just graduated from college (this was before you could stay on your parents' plan until age 26), and was living in remote West Virginia in the Monongahela National Forest working on a research project as a contract employee. I would run on the rail trails nearby, and one evening, I rolled and broke something in my ankle. I don't know exactly what I broke because I didn't have enough money to seek medical attention. I bought a plastic air cast that I duct-taped into a hiking boot and went back to work because there were zero sick days. So, not only did I experience an injury without access to health care, I still live with the implications of an untreated fracture that didn't heal properly.
At least then it was just me. Now I have a family for whom I had provided health insurance for years, but that coverage ended June 30 when I graduated from residency. Why not just start my new job July 1? Insurance companies take up to 90 days to credential health care professionals, and until that process is complete, I can't see patients. So, just as many other graduating residents who have a gap between graduation and starting work, I again do not have health insurance. Granted, there are safety nets in place; I could extend my prior plan under COBRA (the Consolidated Omnibus Budget Reconciliation Act), if needed, and in West Virginia, we have an extensive network of federally qualified health centers where I can pay according to a sliding scale based on my income. However, a gap in coverage is a gap in access to my primary care health professional and to preventive services for my family, as well as being a huge gap in my peace of mind.
I think I am a pretty responsible person, and I value continuity of care. Yet here I sit with no ready access to health care despite knowing the risks and insurance industry protocols. This situation further fuels my desire to promote the AAFP's vision of transforming health care to achieve optimal health for everyone. We have made some progress but we still have a lot of work left to do, and each community provides its own set of lessons to be learned.
Kimberly Becher, M.D., is the resident member of the AAFP Board of Directors.
Posted at 03:17PM Aug 01, 2014 by Kimberly Becher, M.D. | Comments[0]
Keeping It Real: Preceptorship Exposes Students to Importance of Rural Family Medicine
Roughly 20 percent of Americans live in rural areas, but only 11 percent of U.S. physicians live in those same communities. In fact, the Health Services and Resources Administration (HRSA) has designated more than 6,000 Health Professional Shortage Areas for primary care, and 67 percent of those are in nonurban areas. According to HRSA, it would take 17,000 additional primary care health professionals to achieve a ratio of one clinician per 2,000 patients in these locations.
So, how do we convince more medical students to first choose family medicine and then practice it in the places that need them the most?
I recently had the opportunity to talk to students during the Appalachian Preceptorship, which exposes students from around the nation to rural family medicine in Tennessee. Ten students from seven medical schools participated in the four-week program.
Let them experience it first-hand.
Nearly 30 years ago, Forrest Lang, M.D., retired vice chair of the Department of Family Medicine at East Tennessee State University (ETSU's) Quillen College of Medicine in Johnson City, created the Appalachian Preceptorship to introduce students to rural family medicine in a highly relevant and culturally sensitive way. Since then, hundreds of medical students from all over the country have come to Tennessee to experience first-hand the delivery of primary care in Appalachia.
It is critical that we find ways to connect with medical students early in their first and second years, and this year all of the students participating in the program were sophomores. We know that in the first 18 years of the program, more than 80 percent of the students who participated matched to residencies in primary care, including 60 percent who matched to family medicine programs.
Students are called to medicine to help people, and there is no better way to do so than practicing family medicine in rural, underserved America. In the Appalachian Preceptorship, students participate in one week of didactic sessions at ETSU before spending three weeks with a physician practicing in a rural Appalachian community.
These dedicated family physicians allow students to become part of their practices, and the students see patients, participate in the diagnosis and management of acute and chronic diseases, practice preventive medicine, and enjoy a wealth of other experiences.
The experience is invaluable for both the students and the preceptors. In fact, we dedicate significant resources at ETSU to connecting with our preceptors throughout the year, and we devote a special weekend session to allowing them to offer feedback on our educational methods and identify and address the resources they need.
Another key aspect of this program is the opportunity it gives us to show students that it is possible to not only survive but to thrive in small-town practices. Some of the preceptors are from individual physician practices, and most of the rest belong to small groups. The students are able to experience how health care is provided in these communities and to really understand the nature of physician-patient relationships. In addition, each of these preceptors and the communities in which they work are great examples of different types of patient-centered medical homes. This reinforces to the students that team-based care is not about having everyone located under the same roof; but rather the resources that are available within the community to care for its residents.
Another advantage of this process has been the chance it offers to expose students from all over the country to our school's residency programs. Almost every year, students who have participated in the preceptorship interview with at least one of our three family medicine residency programs. These are outstanding students, and we are frequently blessed that at least one of them matches with us. This is important because data from the Robert Graham Center for Policy Studies in Family Medicine and Primary Care indicate that up to 75 percent of physicians will practice within 100 miles of their residency. In this way, the ETSU programs are consistently fulfilling their mission to provide rural family physicians for our patients.
On a personal note, I had the privilege of talking with students about a number of issues, including the importance of herbal medicine in Appalachian culture, bedside manner and patient-centered communication. I encourage each of you to consider how you can be a part of such a process in your community.
If you are academician, are there ways you could create student or even resident experiences that can mirror some of these goals of exposing students to underserved areas? If you are in private practice, is there a school or residency in your area that you could connect with to create a unique and transformative experience for learners?
Although we struggle nationally with physician pipeline issues, this is how we can walk our talk and directly influence students. This is a great opportunity to remember that the root word of doctor is docere -- to teach!
Reid Blackwelder, M.D., is president of the AAFP.
Posted at 05:13PM Jul 30, 2014 by Reid Blackwelder, M.D. | Comments[0]
Like Father, Like Son: How I Raised a (Future) Family Physician
Like many small-town family physicians, I've volunteered over the years as a team doctor for our local school's athletic teams. On Friday nights, I often found myself on the sidelines, watching football and cheering on the local team (which often included many of my patients). More often than not, my son Brett would tag along, soaking up anything there was to learn.
On one particular fall evening, one of our players was badly injured, and I hurried onto the field to evaluate his condition. In retrospect, I probably should have paused just long enough to tell my son, who was about 7, to stay put.
Last weekend I represented the AAFP at the Nebraska AFP's board meeting. My son Brett, left, is a student member of our state chapter's board of directors.
As I kneeled next to the injured young athlete, I heard a small voice from behind me say, "Dad, there's blood."
That's Brett. Always eager to experience and learn something new. It wasn't the last time he got an up-close view of his dad trying to help someone who needed it. We've lived in a few small Nebraska towns that lack urgent care facilities and hospitals. So when people needed help in a hurry, they often call me directly. If Brett was with me I got one of those calls, he often came along to the office.
I remember one day when Brett was about 10, a young girl fell and needed stitches in her chin. Brett and I were out running errands when I got the call, so we went straight to my office to meet the girl and her parents. With the permission of the patient and her parents, Brett watched me clean the wound and stitch it closed.
Through these types of encounters, Brett learned not only about medicine but about the importance of building relationships with patients, families and the community.
As a high-school student, he participated in a medical interest group and expressed interest in becoming a family physician. He followed up on that by shadowing other family physicians in our area.
When he enrolled in a college halfway across the country, I thought he might come back with plans to become a subspecialist because although Brett has seen all the positive things that family medicine has to offer, he is aware of the payment issues and other challenges we face, as well.
He also knows the time demands of being a family physician. One year, Brett and I signed up for a father-son basketball camp. The night they were taking photos of the sons with their fathers, I got tied up at work and was late. The other kids got a nice memento to remember the fun experience they shared with their dads, and Brett got a photo of himself. Alone.
But Brett has stayed the course. Now in his fourth year at the University of Nebraska Medical Center, he is a student member of the Nebraska AFP Board of Directors. This past weekend, I represented the AAFP at the Nebraska AFP's annual meeting, and my son was there as a member of our state chapter's board. It was a proud moment, and Brett has given me plenty of those.
He's served as president of the Student Alliance for Global Health and in the student senate at UNMC. But the point of this post isn't just for me to say how proud I am of my son. It's to point out the importance of mentoring. Brett obviously got an early start, but if we expose students -- in high school or college -- to the broad scope of family medicine and show them the relationships we develop with our patients, they will understand and value what we do.
And some, no doubt, will follow.
Robert Wergin, M.D., is president-elect of the AAFP.
Posted at 10:17AM Jul 22, 2014 by Robert Wergin, M.D. | Comments[2]
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Sorry I bought this appliance
By Joan
from Undisclosed
Comments about Electrolux Gas 30.0 Inch Range:
The fan for the convection oven takes up so much space, we are limited in the size of pans and trays that we can use in the oven. The oven racks are very difficult to adjust. The stove burners are so sensitive that any liquid that accidentally spills causes the ignition to fail. I feel as though I'm walking on egg shells when I try to cook with this unit.
Bottom Line No, I would not recommend this to a friend
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Hard to Clean
By pitchkri
Very difficult to clean the stove top. The diagrams on the knobs has already worn away. I don't like the way it pushes air out when the oven is on. It heats up the kitchen even more. Oven door just randomly locks and it is difficult to get it unlocked. We tried switching off the breakers several times. This happened to us twice.
By DD
For the price, I'm somewhat disappointed. During the set-up, I could not adjust all but one burner low flame adjustment. I tried using reasonable torque levels but could not get the screws to turn. Finally had to call a service rep to come and do the adjustment. Apparently the adjustment screws were just turned tightly into the stops. After about 2 months, the rubber feet that keeps the cast iron grates from resting directly on the stove surface are melting. Maybe Electrolux has not heard of silicone rubber.
Love it,
By Uk
Beautiful range - extremely functional & we'll-designed. Easy to operate. Love the roll-out shelving in oven.
Bottom Line Yes, I would recommend this to a friend
It batter than I would belive!
By V tate
what I have ask it to do it has done it well. I did not know much about Electrolux. but I look in to it and what I found out was It was a good appliances. all the thing I try, it has dome well. and I look to do more.
Love it
By Roelongo
Used it for the first time for Christmas dinner. Absolutely love it. I was able to make everything due to its large capacity and the warming drawer.
To keep or not to keep?!
By terryl
Love the design! Bought for good brand name reputation and good reviews. So far on third service call for dual burner issues. Only have had range 2 months. Requesting from Electrolux a replacement. We'll see what happens! expensive range!
Great Range
By bichonmom
The gas range is very nice. It is extremely easy to use. The perfect turkey setting did not disappoint us this Thanksgiving. We enjoyed the most perfect turkey we have ever had. So this is a correctly named feature. I really have only good things to say about this product. One design feature that I didn't like at first is where the top of the range meets the oven portion. There is some silicon that shows in that portion of the range top. I am use to it now so it doesn't bother me anymore.
best range for the money
By randy
this range does it all .It will make perfect cakes every time. It has every feature most cooks will ever want. The stove top is precise and super easy to clean, and being a man I really appreciate that ( so does my wife ). You cant go wrong on this range but if you have ANY problems Electrolux is there for you.
Too Deep cooktop ..Ugly design
By Tomtocook
I Live in New york where space is scarce ...The range is too deep to stick out of the counter which is 26 inches and not flush with the counter...who on earth designed this range ...not for the common household in new york ...sorry not a good buy.
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Fantasy Football And Sample Size: The Validity Of Advanced AnalysisTodd describes his internal conundrum, comparing and contrasting advanced baseball and football analysis.
- Posted On Thursday, 25 Sep
- Todd Zola
Fantasy Clones Is HERE!Todd officially announces the inaugural season of Fantasy Clones, a novel fantasy football league
- Posted On Wednesday, 13 Aug
- Todd Zola
The Real Fallacy Of Value Based DraftingWhat do Phoebe Cates and cheap beer have to do with proper drafting? Todd explains.
- Posted On Wednesday, 06 Aug
- Todd Zola
Fantasy Halvsies: Are Two Heads Better Than One?A silly idea or the next big thing? Todd introduces an intriguing variation on fantasy football.
- Posted On Thursday, 31 Jul
- Todd Zola
Enough About You, Let's Talk About MeTodd lets his guard down and talks about writing for a living
- Posted On Wednesday, 07 May
- Todd Zola
The Pontifications Of Lord Zola: Introducing The Fantasy Alarm Daily Projections Points ToolTodd Zola outlines the projection process that fuels the Fantasy Alarm points projection tool
- Posted On Thursday, 01 May
- Todd Zola
The Pontifications Of Lord Zola: Controlling An AuctionLord Zola concludes his trilogy with a rant on overspending and a means to avoid it.
- Posted On Thursday, 20 Mar
- Todd Zola
The Pontifications Of Lord Zola: Dissecting An AuctionIn the second installment of his series on auction dynamics, Lord Zola breaks down the prices from three recent NFBC auctions
- Posted On Friday, 14 Mar
- Todd Zola
The Pontifications Of Lord Zola: Going Once, Going Twice, Sold!Lord Zola begins a three-part series on auction dynamics
- Posted On Wednesday, 12 Mar
- Todd Zola
The Pontifications Of Lord Zola: Hey You Kids, Get Off My Lawn!Todd reminisces about the good old days.
- Posted On Thursday, 06 Feb
- Todd Zola
About Todd Zola
Affectionately known as Lord Zola, Todd was the 2013 Fantasy Sports Writers Association recipient of the Fantasy Baseball Article of the Year, Web. He's been with Mastersball since its inception in 1997 and presently Todd writes for the ESPN Insider and Baseball HQ. Todd is a frequent guest on SiriusXM and is a regular on HQ Radio. He's a veteran of Tout Wars and LABR as well as a multi-time NFBC champion. Follow Todd on Twitter @ToddZola
Fantasy Sports Headlines
FantasyAlarm on Twitter
Ivar G Anderson2:41 PM Jul 15th
Retweet & click the link to enter to win a beer trip for 2 to Sonoma, CA http://t.co/OCCCUzvd4n via @TheDrinkNation @RateBeer @WhereTraveler
Jonathan Impemba4:40 PM Nov 20th
@nickottaviano24 Game is going to be moved to Det or Washington.. Either way Jets blow. The dome will be even better for their pass rush.
Mastersball9:12 AM Nov 21st
The Duck has put together a Top 10 list, and the topic will not surprise you: http://t.co/BXc6KQy3VU
Steve Pimental12:38 AM Nov 21st
That cameraman is #ShaqtinAFool #NBAonTNT
Mastersball9:31 AM Nov 19th
.@ryanpcarey talks Jonas Gray, Coby Fleener and much more in this week's Waiver Wire Report: http://t.co/R28QNEDBGW


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Review Summary
Napier Silver-Tone Polished and Laser Cut Twist Hoop Earrings
$11.20 Original Price $16.00
Savings: $4.80 (30%)
- 0.9-in. L
- Polished and laser-cut finish
- Pierced earring
- Silver tone
- Imported
Shipping your purchase is easy on belk.com. Depending on the destination of your package, you can expect it to arrive within 4-7 business days. Shipping Information
Returns are easy on belk.com. Easy returns


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Highly underrated show that maintains through out all 6 seasons. Never saw it on the air, it was recommended enough time here on Amazon that I checked it out. Read morePublished 1 month ago by J. Jordan
One of my favorite shows. I am so glad to see the actors I loved watching on this show pop up in others since it has been cancelled. Read morePublished 1 month ago by Susan Harris
This is a collection of events staged in Canada of a team of truly dedicated, highly trained police who respond to extremely difficult, challenging situations which leave you... Read morePublished 2 months ago by Shar
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Hi Greg:
I apologize for the delay in responding. I purchased the photo at Cackleberry Farm Antique Mall in Lancaster, PA on 9/14/03. I spent over $150 that day on photos of people that I am not related to. It drives me nuts to see these identified photos lying there, so I buy them. I do not have any family history on the Githens name. I will be glad to send it to you, but would need a money order for $20. I would love to reunite this photo with its family, but need to recoup some of my expense of that day. I just buy them hoping to find their families, but am not wealthy enough to mail them to the families for free. Please let me know if you are interested. Please understand this is not a scam or business (I certainly have not made any money doing this). I am a genealogist. Thanks!
Lorrie Erdman
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- Coast Range Forest Watch is a project of the League of Wilderness Defenders (LOWD)
Upcoming Events
- CRFW Open Meeting December 3, 2014 at 6:00 pm – 8:00 pm North Bend Library Join us for our monthly open meeting. We will discuss carpoolin g to the December 9 State Land Board meeting and other upcoming CRFW projec ts and events.
- State Land Board Meeting and Rally December 9, 2014 at 9:00 am – 12:00 pm 775 Summer St NE, 775 Summer Street Northeast, Salem, OR 97301 , USA Meeting to discuss management of the Elliott. Public welcome to attend and sign up to give comment.


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I discovered this map by accident. Visually stunning and quite creepy in the depths. But zombines when weapon less! That is so cruel! Constantly spawning enemies is a bother but it does add a hint of pant-wetting pace to keep you moving.
Mars outside texture was really good and overall this is a little gem.
I got my *** to Mars and phoned home!


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Kate del Castillo
List of 50 most beautiful Latinos releasedSubmitted by Kiran Pahwa on Tue, 04/26/2011 - 04:47
New York, April 26 : Mexican actors Kate del Castillo and Rafael Amaya and Spanish actor Ivan Sanchez are among the celebrities on the 2011 list of the "50 Most Beautiful" Latinos, published in the People en Espanol magazine.
Singer Diana Reyes received the most votes at PeopleEnEspanol. com as the 2011 Readers' Choice winner.
Check out More news from Telecom Sector :: Pharmaceutical Sector :: Auto Sector :: Infrastructure :: Real Estate
Random Acidfree items
Lily Allen
Sports Update
- Pak claim series whitewash with 356-run win in second Test against Oz
- Federer moves to second spot in ATP world rankings post Shanghai Masters win
- Ronaldo scores hattrick as Real thrash Deportivo La Coruna 8-2 in La Liga clash
- Gerrard's late penalty helps Liverpool pip Ludogorets Razgrad in CL fixture
- Leander Paes drops out of top 10 in latest rankings


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Home Opinion Our View COOK DEVELOPMENT LOOKS GOOD FOR LA GRANDE
The La Grande City Council should commit to using Cook Development for rebuilding the Bohnenkamp property downtown. Why Cook? All you have to do is look at the $7 million project the company was responsible for in
The Dalles.
THE COMMODORE building, which sits in a highly visible part of downtown The Dalles, was completed recently. The building was an eyesore that had sat idle while community leaders looked at ways to improve the site that hadn't been used in almost a decade.
La Grande' s downtown has faced the onslaught of businesses moving out of the core area for higher traffic locations along Island Avenue, similar to what occurred in downtown The Dalles. La Grande was slower in creating an urban renewal district than the Columbia Gorge community, but both communities faced similar problems as their downtown cores deteriorated.
After wrangling over who would be best to redevelop the Commodore building, a four-story multi-use building, the City of The Dalles awarded the bid to Cook Development, which sold tax credits to generate the millions needed to complete the project. After two years, the Commodore was completed with retail, office and 24 fixed-income rental units available to the public.
At the open house for the remodeled building, more than 2,000 local residents showed up to look at the completed project. More than 100 applications were picked up by interested parties for the 24 rental units.
NOT ONLY WERE the city and urban renewal district involved, but the Oregon Department of Housing and Community Services helped facilitate the project. Cook was praised by Robert Repine, the housing agency's director and a retired home builder, for boosting the local economy by using dozens of local subcontractors on the project, turning $7 million into between $40 million and $49 million depending on the multiplying effect used.
Cook's commitment to creating a good working relationship with everyone involved and the quality of the end project are important considerations in redeveloping the burned-out Bohnenkamp site. Also the company's desire to create mixed uses should not be overlooked.
None of this is to say no one else could do a good job on the property, but considering the obstacles to be faced and the previous mistakes made that have cost the community at least a year or more in the Bohnenkamp property renewal, Cook Development appears to be standing ready to accomplish everything in an appropriate timeline to provide a quality, multi-use building in downtown La Grande.
Have an opinion that's different from ours, our columnists or our letter writers? Write it down and send it in. The Observer encourages reader input through letters and guest columns.


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Yeah, my bet is the nazi scum arrived shortly after. And Biden is the "dim" Agnew, as well...
Brave folks, must have caught the Nazis by surprise, otherwise a mass of thugs would have clubbed them down.
Biden is such a sleazebag,
Joe Biden retreats from angry crowd in Ukraine
Briefly about the Importance
Briefly on some important points.
1. This afternoon went panicky rumors that
A massive lake-effect snowstorm has left ten people dead, thousands without power, and many stranded in the Buffalo, New York region.
The UC board of Regents has approved steep tuition increases for the next five years.
The witch hunt against Valery Gergiev is part of the pro-war campaign of the German media and government.
An alliance between Russia and China is emerging in response to the US-led Pacific and Atlantic trading blocs and the Russia-NATO confrontation over Ukraine.
The ruling continues the monstrous frame-up and political persecution of the WikiLeaks editor.


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Established as a partnership in global health, the Global Fund works closely with a wide diversity of partners –implementing governments, donors, civil society, international development organizations, the private sector and communities living with and affected by the diseases. This partnership model actively supports country-owned approaches that develop and implement effective, evidence-based programs to respond to AIDS, tuberculosis and malaria.
Announcement - 26 November 2014
Global Fund Calls for End to Compulsory Treatment
Announcement - 25 November 2014
Global Fund Analysis of Audits and Investigations
News Release - 21 November 2014
Global Fund Board Considers Strategy, Governance, Ethics
News Release - 12 November 2014
Norway Signs Multi-Year Contribution to Global Fund
Announcement - 31 October 2014
Johannes Hunger Appointed as Head of Strategic Information
Turning the Tide Against HIV and Tuberculosis: Global Fund Investment Guidance for Eastern Europe and Central Asia
27 November 2014
No Cost, Huge Benefit: a Life Saved
20 November 2014
Good Nutrition to Support HIV Treatment Effectiveness
14 November 2014
Counseling and Testing for Tens of Thousands of People in Gambia
09 November 2012
GENEVA - The Global Fund to Fight AIDS, Tuberculosis and Malaria today named Christopher Game, an expert in procurement with broad experience in the auto and pharmaceutical industry, to be its new Chief Procurement Officer.
Mr. Game has more than 20 years of experience administering and leading and advising on procurement efforts, overseeing and securing the sourcing of billions of dollars of materials.
Raised in South Africa, Mr. Game worked most recently as Senior Vice President and Chief Procurement Officer at Capsugel Holdings in New Jersey, owned by KKR, a leading U.S. private equity firm.
"Christopher is exactly what we need – a highly skilled executive who can make sure our purchasing and delivery is top-notch," said Gabriel Jaramillo, General Manager of the Global Fund. "Procurement is a critical part of what we do, and Christopher helps us make a quantum leap forward in ensuring our operations are efficient and safe."
At the Global Fund, Mr. Game will report to Daniel Camus, Chief Financial Officer, who himself joined the organization recently from EDF, where he oversaw international operations including procurement at the largest electric utility company in the world.
"To operate with a superior level of efficiency, and to leverage our significant buying power, we need superior expertise in our core areas, like procurement," said Mr. Camus. "This appointment gets us there."
Mr. Game began his career at Nissan Motors in South Africa, where he was a foreman on a production team, leading 70 people. He later moved to Toyota Motors, where he learned about Lean, a production practice focused on efficient expenditure of resources, which has since become an internationally-recognized approach.
He gained valuable experience in procurement at BMW in South Africa, including negotiation practices, as well as learning about the advantages of high-standard and detail-oriented production.
He later worked at Abbott Laboratories in the United Kingdom, leading a team of buyers and procuring raw materials and packaging, and at a generic pharmaceutical company now called Actavis.
Mr. Game became the Global Head of Active Ingredients, Packaging and Excipients procurement at Sandoz, an arm of the Novartis group, and built a track record of innovation and expert management that led to enormous cost savings. He was promoted to become the Global Head of Sourcing at the pharmaceutical division of Novartis, managing the spending of $2.7 billion and leading a team of 120 professionals worldwide, and taking the division through an effective reform process, yielding tremendous cost savings.
Mr. Game's appointment is one of several major staff moves in recent months, as part of an organizational transformation undertaken by Mr. Jaramillo.
Mr. Game is married and has a son.
For more information please contact:
Director of Communications
Mobile: +41 79 788 1163
The Global Fund is committed to the highest standards of accountability and responsibility. If you have heard of any instance of inappropriate use of money related to the Global Fund, please report it immediately, here: Report Fraud and Abuse
© 2014 The Global Fund to Fight AIDS, Tuberculosis and Malaria


text: amazing, color, cool, photo, photography Added: Sept. 15, 2012 | Image size: 600 x 450 px | More from: www.pixfy.com | Source: linkRELATED IMAGES:This image is in 3 setsfavoritesby espwaDefaultby zs005photographyby funnyaticNo comments Please log in or sign up to post a comment. add to set Views: 801 Likes (**Who?): 3 Comments: 0 Tagged with :amazing 59412color 16506cool 85255photo 60337photography 195080Log in or Sign upLog In" or Sign Up


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Taking Aim: Unforgettable Rock 'n' Roll Photographs Selected by Graham Nash
If you happen to be in the Northwest—Seattle to be specific—make sure to stop by the Experience Music Project sometime in February to check out the photos featured in Taking Aim: Unforgettable Rock 'n' Roll Photographs Selected by Graham Nash.
This video trailer gives a taste of the book and the exhibition.
To celebrate the opening of the Taking Aim exhibition, Chronicle will give you a 30% discount, plus free ground shipping in the United States if you buy the book on our site before February 28th—just use promo code AD2010 at checkout.
The Experience Music Project is housed in an eye-catching 140,000-square-foot Frank O. Gehry-designed building—a spectacularly prominent feature of the Seattle city center.
Graham Nash curated the exhibition and the book, and brought his rich musical history, keen eye, and storytelling skills to showcase 98 rock 'n' roll images taken by 40 of the world's greatest music photographers, including Anton Corbijn, Lynn Goldsmith, Annie Leibovitz, Jim Marshall, Neal Preston, Mick Rock, Francesco Scavullo, and Nash himself. The Taking Aim exhibition opens February 6, 2010.
Share your photos and you could win a signed copy of the Taking Aim book! Have you taken a great rock 'n' roll photograph? Chronicle Books and EMP are sponsoring a contest and giveaway. Post a photograph you've taken to the EMP site by Friday, February 26th and you'll be entered to win a copy of the book signed by Graham Nash and Elvis Costello! There is already a great gallery of user-submitted rock 'n' roll photos. Submit your photograph here.
Patti Quill
Marketing & Publicity Manager
Design Desk: Designer Spotlight #3November 17th, 2014
Yes I Am The Art Book Editor and Yes I Want to Hear From YouNovember 10th, 2014
Design Desk: Inspiring Children's BooksNovember 10th, 2014
Design Desk: Stationery Good Enough to EatNovember 3rd, 2014
A Q&A with Cat Seto: Learning to Celebrate the EverydayOctober 28th, 2014


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Select () or exclude () categories to narrow your recipe search.
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Find exactly what you're looking for with the web's most powerful recipe filtering tool.
1/2 Photos of Crock Pot Black Eyed Peas
Prep Time:
Cook Time:
5 mins
10 hrs
Everyone knows you are supposed to eat black-eyed peas for luck on New Years Day. This is a great recipe to use your crock pot. You can use the stove to cook your collards (for money).
Units: US | Metric
Serving Size: 1 (257 g)
Servings Per Recipe: 6
The following items or measurements are not included:
ham hocks
Del Monte zesty jalapeno pepper diced tomato
Every recipe, menu, tip and how-to is right here, at your service.


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And then there was the ghost of Diana, wafting through the stage as delicately as like a drunk City worker on the train out to the suburbs. Intended as a surprise - maybe? - she was about as expected as regret after a one-night stand, and spoke in a faux-ghost voice that make several in the audience shift uneasily rather than lean forward with intrigue.
Having finished on the 29 September, Recon included a range of newly commissioned artworks that fostered collaboration between artists and musicians.
Pop-up has become something which is synonymous with urban cool, from restaurants to clothing boutiques, they are prime social media fodder and a notch on your "this great little place I know" list. But what if we could take the pop-up model and make it something so much more within the cultural sector?
It is a great day when a film such as this, a key and significant film, fruit of a wonderful golden passage in film-making history, is brought fully to light. It is a great day when credits expunged by the forces of darkness are restored to their proper place and talent be hailed as they should be
Of his new novel Arnold Drive, Hugh Cornwell says "it's like Being There meets Forrest Gump meets Father Ted. It's a Dickensian tale, a black comedy."
But Paris is not just about the Biennale - the whole city of art and design sparkles in the early autumn sun and shows proliferate. My friend Sylvain, who has an exquisite gallery on the Quai Voltaire, is putting his best foot forward with a gathering of Meissen porcelain.
I met with Chimamanda at her London Hotel where she stayed during her visit for the London Premier of the film Half Of a Yellow Sun. With the author's time divided between the US and Lagos, I was lucky to catch her during her short stay in London.
If humanised portrayals increase a child's empathy for animals - and such portrayals are ubiquitous across children's books, cartoons, films and toys - why do those with a positive attitude towards animals occupy such a marginalised position in society?
The web and sites like Change.org means that people can speak out and have more impact than ever before - proving wrong the assumption that the public don't care about politics. They care about the issues that matter to them and when institutions like the Barbican are challenged - we should celebrate that disruptive behaviour, whether you agree with Sara's campaign or not.
As well as the various ship-to-ship weapons, there were pikes, daggers and swords, longbows and handguns for long distance attacks, and rather nasty antipersonnel weapons such as the hailshot piece, a short barrelled gun that was used to blast iron dice at enemy boarders at close range.
The exhibition showcases an exciting group of 38 artists who are relatively unknown outside their homeland. Some of the artists featured in this exhibition have established reputations in Ukraine, while others are recent graduates.
For decades politicians have put education at the top of the agenda. But we seem to have ended up with a target and league-table based system, and a too-narrow focus. Head teachers are under tremendous pressure to ensure that targets around literacy and numeracy are met... From what I've seen, creativity in the curriculum is being squeezed hard.
By the end of the year, there will have been three major exhibitions in Great Britain devoted to the work of artists at the end of their careers - Matisse, Turner and Rembrandt. Yet it wasn't until the middle of the 20th Century, that late life creativity was considered a possibility.
Teh Internet is Serious Business (typo deliberate) at the Royal Court is a really exciting, dynamic production about collaborative hacktivism. Anonymous, LulzSec and 4Chan are all included in this show that blurs fact with fiction as it seeks to reflect the good and the sinister about lives lived online.
The Grisha Trilogy, consisting of three books Shadow&Bone, Siege&Storm and Ruin&Rising has also left a strong impression upon me, as an aspiring author, and made me eager to find out more about Leigh, and why she decided to write the trilogy in the first place.
Unlimited immigration from the EU is not a good thing. Immigration is, according to the polling, the second most important issue in British politics today - behind only the economy. In his Conference speech Labour's Ed Miliband, the man hoping to be our next Prime Minister, 'forgot' to mention both the economy and immigration. Understandable perhaps, given Labour's record on both issues when they were in government.