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Under Attack: We Can All Join the Fight for GME Funding
For thousands of U.S. medical school seniors, the end is drawing near. In less than five months, they will be completing their fourth year of undergraduate medical training and gaining those two highly prized letters at the end of their name: M.D. But their work is far from complete.
Throughout the fall, they traveled the country interviewing for residency spots at programs large and small. Now, with the National Resident Matching Program -- better known as the Match -- only six weeks away, their anxiety is starting to grow.
Getting into medical school was difficult. According to the Association of American Medical Colleges, more than 40 percent of those who apply are turned away. Getting through medical school was difficult, too. Hours of classes, tests, clinical clerkships and overnight call. Next stop, residency. Getting in the door there is no easy task, either, and now it looks like the process could get even harder.
At a time when a shortage of primary care physicians is getting worse, hundreds of family medicine residency positions are in jeopardy.
The Patient Protection and Affordable Care Act created the Teaching Health Center Graduate Medical Education (THCGME) program to increase the number of primary care physicians. Unfortunately, the federal government's $230 million investment in that innovative program -- and other critical primary care programs -- is set to expire this year. In a survey last year, two-thirds of THCGME program directors said they likely would be unable to continue supporting current residency positions without continued federal funding.
Some aren't waiting to see whether or not Congress will act, and it's hard to blame them for being cautious.
The Fresno Bee reported Jan. 31 that the Sierra Vista Family Medicine Residency program in Fresno, Calif., already has decided not to take on a third class of residents in anticipation of a funding shortfall.
That program had received nearly 800 applications for four residency slots, but the program needs $2.4 million over three years to train each class of four residents.
Nationally, there are 60 teaching health center programs with a total of more than 500 family medicine residency slots. If Congress fails to reauthorize and adequately fund the THCGME program, how long will it be until we hear of more residencies pulling the plug on residency positions?
You've invested considerable time and money and likely amassed a daunting level of debt to pursue your goal -- your dream -- of becoming a physician. But if you're medical student, you might be wondering how this funding crisis could affect your spot in the Match. And if you're a resident at a teaching health center, you might be worried -- justifiably so -- about whether or not you get to keep yours.
So what is the AAFP doing about it?
- Last fall, the Academy released a proposal that built on recommendations for GME made by the Institute of Medicine earlier in the year. The AAFP's plan would, among other things, significantly change the way GME is financed.
- Two months later, AAFP leaders were on Capitol Hill to discuss several key issues -- including funding for teaching health centers -- with legislators and congressional staff.
- GME likely will be one of the topics on the agenda when the AAFP Board of Directors spends another day lobbying on Capitol Hill later this month.
- The AAFP and the Council of Academic Family Medicine recently responded to the House Energy and Commerce Committee's request for comments on GME reform with a letter that reinforced the concepts in the proposal released last fall, including support for community-based training programs and the need for accountability for the roughly $9 billion in federal GME funds that are funneled through academic health centers.
- That letter is just one of many the Academy has sent to Congress regarding GME reform in recent months.
Health care faces a "primary care cliff" in 2015. In addition to GME, funding for the National Health Service Corps and community health centers also is set to expire this year. We students and residents can do our part by getting directly involved in the advocacy efforts of the Academy and our state chapters. For example, efforts by students and residents last year helped the Pennsylvania AFP secure state funds for nine new family medicine residency positions and a development program for residents interested in practicing in underserved areas.
Students and residents also should be aware of scholarship opportunities to attend the Academy's Family Medicine Congressional Conference (FMCC). The May 12-13 event in Washington trains family physicians (and students) to advocate for patients and family medicine and concludes with a day of lobbying on Capitol Hill. The deadline for scholarship applications is March 6.
Whether you attend FMCC or not, your legislators need to know how funding cuts to primary care programs affect medical training and health care in their states.
Andrew Lutzkanin, M.D., is the resident member of the AAFP Board of Directors.
Posted at 03:47PM Feb 11, 2015 by Andrew Lutzkanin, M.D. | Comments[1]
When Opportunities Arise, You Have to Jump
"OK, it's time to jump.
I have jumped into many challenges during my professional career -- from being an assistant residency director to practicing full-scope family medicine in the small town where I grew up to leadership positions in the AAFP -- but I had never done anything like this.
The U.S. Army recently invited Academy leaders to tour Fort Sam Houston and Brooke Army Medical Center in San Antonio, and I made the trip along with Andrew Lutzkanin, M.D., the resident member of the Board of Directors. The tour provided insights into the world of military medicine as we visited the facility's level-one trauma center, a burn treatment unit and the ICU.
We also toured the Center for the Intrepid, a world-class rehabilitation and prosthesis center. We heard inspiring stories from soldiers who had the will and personal stamina to rehabilitate themselves with the goal of returning to their units. The bond they feel with their comrades is truly hard to describe. In many ways, I thought of family physicians and the common bond we share to help our patients.
We also visited Camp Bullis, a military training site near San Antonio that includes a replica of a forward hospital medical treatment facility. The Army can construct one of these 84-bed facilities -- complete with operating rooms and ICUs -- in as little as three days. Medics and physicians train in this mock up "tent hospital" that could be run off of a generator.
But what about the jump? As part of our three-day visit to San Antonio, we also had the opportunity to make tandem parachute jumps with the elite Army Golden Knights Parachute Team. It was quite an adrenalin rush to leap out of an airplane at 14,000 feet and free fall for about a minute before feeling the chute open with a jolt and then simply floating. I had no experience with parachutes, but when given the chance, I jumped.
© 2014 Ashley Bentley/AAFP Here I am meeting with our student leaders via Google Hangout. Our family medicine interest group network leaders work to help promote family medicine at campuses across the country.
With our hectic schedules, it's sometimes difficult for family physicians to make the most of every opportunity that comes along. But I also had been asked to meet -- online -- with new family medicine interest group (FMIG) leaders. Their orientation meeting at AAFP headquarters in Leawood, Kan., was taking place at the same time Andrew and I were attending the Army's All-American Bowl, which features 90 of the nation's best high-school football players.
When it comes to speaking with medical students, you find a way to make it happen. Although an Alamo Dome filled with thousands of cheering fans and a marching band might not seem like the ideal place to hold a video chat, Andrew and I managed to find a quiet stairwell in the stadium and met the students via Google Hangout.
Each FMIG leader asked me a question related to the big issues -- such as scope of practice, student debt and new models of care -- that are affecting their peers' specialty choices. I addressed these questions, and I pledged to them that the AAFP will continue to work on issues that matter to students because they matter to the future of our specialty. I also reinforced the importance of the work these students will do this year to increase student interest in family medicine by working to strengthen FMIGs at medical schools across the country.
Before we returned to the game, Andrew -- who is a former FMIG network leader himself -- shared his experience with the students and also discussed how our young leaders will work together in the year ahead. Kristina Zimmerman, the student member of the AAFP Board; Richard Bruno, M.D., M.P.H., resident chair of the AAFP National Conference of Family Medicine Residents and Medical Students; and Brian Blank, student chair of the conference, also participated in the call.
During our visit in San Antonio, we met with several military officers. At one meeting, I pointed out to Andrew there were five generals in the room discussing the challenges they face in military medicine. Family medicine, no doubt, faces its own challenges. But meeting with our student and resident leaders, and spending a few days with Andrew, confirmed what I already knew. Our future is in good hands.
Robert Wergin, M.D., is president of the AAFP.
Posted at 03:10PM Jan 22, 2015 by Robert Wergin, M.D. | Comments[0]
Digital Media: It's Here to Stay, and That's a Good Thing
When I started medical school almost four years ago, I still used paper notes. I printed out lecture slides and scribbled my notes during live lectures. Oftentimes, I had to go back to the recorded, archived lecture to fill in any notes I missed. By the end of the year, my bookshelves were buckling under thick binders full of lecture notes -- notes that I could not readily refer back to because it was too time-consuming to flip through thousands of pages to locate one specific detail. It was faster and easier to search for the information electronically.
This, combined with my desire to be more environmentally conscientious, compelled me to go paperless during my second year in medical school. I downloaded lectures on my laptop and organized them for easy retrieval. I could type my notes more quickly than I could write them, and I could more easily link those notes to specific parts of the lecture. While studying, I used tools on my computer to find keywords and topics within seconds rather than wasting hours leafing through shelves of paper. After making the switch to electronic media, I never looked back.
Not only do electronic files take up less space, but electronic media can be read virtually anywhere and also can be listened to in the car or on the subway.
Now that my medical education has moved beyond the lecture hall into clinics and hospitals where hypothetical scenarios are replaced with real-time patient interactions, easily accessible information is even more important. I cannot bring bookshelves full of notes and clinical pearls from home. And only so much information can fit into a small, white coat-sized notebook. Plus, there's still the issue of quick retrieval. Fortunately, we live in an era when electronic media are readily available. Unlike generations of physicians before me, I only need one information retrieval tool in my white coat pocket -- my smartphone -- and I carry it now more than ever.
From my smartphone, I have quick, easy and unlimited access to the most relevant and up-to-date information I need to verify a diagnosis and/or treatment plan, as well as tools to help me educate patients. Among the electronic resources I use every day are the AAFP website; my medical school library's databases of DynaMed, PubMed and New England Journal of Medicine; and apps such as Epocrates, Micromedex, UpToDate, the American Heart Association's Cardiovascular Risk Calculator, Evernote, and the AAFP journals American Family Physician and Family Practice Management. I can use Dropbox to store my notes and important documents on the Web for retrieval on any of my electronic devices -- my tablet, smartphone or computer.
Some may argue that use of technology in the exam room diminishes meaningful patient interactions and harms the doctor-patient relationship. This has not been my experience. In fact, I would argue that proper use of electronics during a patient visit actually strengthens the interaction and engages patients more fully. For example:
- There are many instances where the computer screen can be shown to patients, such as when reviewing blood work results, growth or vitals. These numbers and trends can, and should, be shared and discussed with patients.
- Using electronic health records, various health trends can often be shown on graphs so patients can see how they are doing over time.
- When documenting/charting patient information, we can let patients see what we are typing and verify with them that the information is correct.
- Photos can be helpful when reviewing items such as rashes, anatomy or plants they are allergic to, etc. We also can clarify which medications a patient is taking by showing them pictures of the medication on the Epocrates app.
- And of course, we can use our electronic devices to quickly find an answer to a patient's question when we don't know the answer.
I have done all of these things, and patients have said that it has made many health topics easier for them to understand and has helped them feel more like a part of their health care team. Many patients appreciate the visuals, especially when they can access them again later at home.
During one patient interaction, I showed a patient two images of the English plantain, which was the source of his allergy symptoms. One image was a pencil drawing in a book from 1946. The second was a color photograph from Google Images. The patient found the photo more helpful and was happy he would be able to find it later if he forgot what it looked like.
Another reason it is important for physicians to become familiar and comfortable with electronic resources is that our patients are using them. Patients are trying to educate themselves by using the Internet and apps to look up health information and symptoms, track their health and fitness activities, etc. We need to keep up. We need to know what tools they are using and where they are getting their information so that we can guide them to valid, useful facts.
Are they using Wikipedia, WebMD, Google Scholar, MyFitnessPal, Apple Health, something else? Why are they using certain resources? These are conversations that are important to have. Many patients want to be more engaged in their health. They want to use electronic health tools to access their personal health information through an online portal, track health and fitness goals, and transmit their health data -- such as daily weights, blood pressures, glucose readings -- directly to their medical homes. As physicians, we have to be ready to navigate these new technologies and make them work to our patients' benefit.
Technology will keep moving forward. As it evolves, we need to be sure our ability to use it effectively with our patients does, too.
Kristina Zimmerman is the student member of the AAFP Board of Directors.
Posted at 01:57PM Dec 23, 2014 by Kristina Zimmerman | Comments[0]
Penny Wise, Pound Foolish: We Can't Afford to Cut Our Investment in Teaching Health Centers
Not that long ago, Pardee Hospital in Hendersonville, N.C., was considering dropping its family medicine residency. Although such a move would have saved the not-for-profit facility roughly $1 million a year, it would have been a severe blow to primary care and the primary care workforce in the area.
Instead, Blue Ridge Community Health Center, a federally qualified health center (FQHC), joined a collaboration last year that already included Pardee and the Mountain Area Health Education Center of Asheville. The move not only preserved a valuable training program, it also gave residents exposure to a second outpatient setting -- an integrated FQHC that offers dental, behavioral health, radiographic and laboratory services; an on-site pharmacy; and interpretive services for a patient panel that includes a large Spanish-speaking population.
Here I am touring the Hendersonville Family Medicine Residency with program director Geoffrey Jones, M.D., (left) and faculty member Magdalena Hayes, M.D. I visited the program Dec. 3 in Hendersonville, N.C. |
The changes didn't stop there. After Pardee ceded control of the residency to the FQHC, the program increased its number of residents from three per class to four with funding from the Teaching Health Center Graduate Medical Education (THCGME) program.
That five-year, $230 million initiative provides funds directly to community-based teaching sites with a goal of producing more primary care physicians. One hundred primary care residents have graduated from teaching health centers in the first three years of the program's existence. That's noteworthy because we know that residents who train in underserved areas are more likely to practice in those settings.
I toured the Hendersonville residency Dec. 3 and saw first-hand what a teaching health center is about. I came away impressed by the residents, the faculty and the facilities.
Unfortunately, the Hendersonville program -- and other teaching health centers in 24 states -- face uncertain futures because of funding. Barring a reauthorization by Congress, funding for the THCGME program will end in 2015. That means first-year residents took a giant leap of faith when they entered these programs this summer. Still, residents I talked with this week were focused on their training and optimistic that a solution will be found.
The AAFP is doing its part. The Academy and more than 100 other medical and social service organizations sent a letter to congressional leaders last month, urging that funding for teaching health centers and other important primary care programs be extended.
The second issue facing teaching health centers is that the Health Resources and Services Administration (HRSA) recently announced that it plans to reduce payments for each resident during the 2015-16 school year. The AAFP has responded with letters to HRSA and Congress urging that full funding be restored.
During a recent trip to Capitol Hill, Academy leaders discussed both the need to restore funding for the 2015-16 academic year and the need to extend funding for the program beyond 2015 with congressional leaders and staff. At a time when our nation already faces a dire shortage of primary care physicians, we cannot afford to abandon a program that shows great promise for producing more family physicians.
Robert Wergin, M.D., is president of the AAFP.
Posted at 04:51PM Dec 05, 2014 by Robert Wergin, M.D. | Comments[0]
Exposing Students to Rural Health Key to Producing Rural Docs
Less than half an hour from the U.S.-Mexico border, the tiny town of Patagonia, Ariz., lies nestled between a sprawling state park and a massive national forest. Although I was born and raised in Tucson and started my practice there, I came to Patagonia in the 1990s when I was offered the opportunity to work at the small town's federally qualified health center.
Why would a big-city physician leave home to come to a town that was literally 1,000 times smaller?
I liked the idea of practicing full-scope family medicine. I liked the challenge of doing more with fewer resources, putting pressure on myself to become a better clinician. And I wanted the chance to develop true, close relationships with my patients. I got all that in Patagonia because in a town of less than 1,000 people, it didn't take long to become a vital part of the community. I stayed for 13 years.
Photo courtesy Chandra Tontsch University of Arizona College of Medicine student Chandra Tontsch, right, completed a family medicine rotation in Lakeside, Ariz., with preceptor Elizabeth Bierer, M.D. The college places medical students in rural settings in hopes that they will later choose to practice in underserved areas. |
In 2006, the University of Arizona recruited me to teach rural health in Tucson. Earlier this year, I took on the role of director of the university's Rural Health Professions Program. Although I am no longer providing rural health care as an individual physician, my goal is to show medical students the rewards this area of medicine offers and hopefully draw more of them to this important practice setting.
More than 20 percent of the U.S. population lives in rural areas, but rural physicians account for only about 10 percent of the physician workforce. Compounding the problem is the fact that many of the physicians practicing in these areas are approaching retirement and not enough young physicians are stepping up to take their place. In fact, less than 5 percent of physicians who graduated from medical schools from 2006-08 went on to practice in rural areas.
At the state level, as much as one-third of Arizona's population lives in primary care health professional shortage areas. The state has more than 140 primary care shortage areas (including some inner-city areas), and it has been estimated that Arizona would need more than 300 additional primary care physicians to address the problem.
In our Rural Health Professions Program, 22 students are selected at the end of their first year and placed in rural settings, primarily working with family physicians. During their third year, students are required to complete a clinical rotation in a rural setting in family medicine, internal medicine, pediatrics, obstetrics, or surgery. (Many do more than one rotation in rural areas.) Finally, during their fourth year, students are encouraged to go back to rural settings for a four-week preceptorship, and roughly three-fourths of them do. It's worth noting that the university's Phoenix campus runs its own similar program.
One of the challenges in my new role will be tracking outcomes to see how many of our graduates are practicing in rural areas. In the past few years, we have added a number of new physician preceptors who participated in the Rural Health Professions Program as students. Having been through the program, they can provide good mentorship to new students and encourage them to stay on this path.
Students who have questions about rural health may be interested in an American Medical Student Association webinar that (then) AAFP President-elect Robert Wergin, M.D., of Milford, Neb., participated in last month during National Primary Care Week.
Finally, the AAFP created member interest groups earlier this year as a forum for family physicians to share their mutual interests and address common concerns. One of the six groups that has already been established focuses on rural health. You can learn more on the AAFP website.
Carlos Gonzales, M.D., is a member of the AAFP Board of Directors.
Posted at 02:39PM Nov 14, 2014 by Carlos Gonzales, M.D. | Comments[0]
Asking Right Questions Critical to Making Right Match
It may seem like the academic year just started, but for fourth-year medical students, the decision about where to spend the next three or more years is just around the corner. And the fall and winter, also known as "interview season," is when it gets really interesting.
Fall is the time for fourth-years to prepare for the National Resident Matching Program -- better known as the Match -- by visiting and interviewing with potential residency programs. The AAFP offers a tremendous free resource -- Strolling Through the Match -- that can be helpful to students regardless of year or specialty interest. The 80-page PDF covers a wide range of topics:
- residency application timeline and checklist;
- introduction to the Electronic Residency Application Service and the specialties that participate;
- a residency program evaluation guide;
- residency selection steps and interviewing tips;
- examples of how the Match works for applicants;
- new tips on post-interview etiquette; and
- tips on writing a curriculum vitae and a personal statement.
We used Strolling Through the Match widely at the University of Alabama when I was a student, and the information is practical and thorough. Still, some of the most valuable advice I received when preparing for interview season came from those who had been through the process and got their desired Match results, So, I thought it might be helpful to share the tips and takeaways from my experience just last year.
The most important thing to evaluate at each interview is how well you fit in with the faculty and, most importantly, the residents, because you will be working closely with them for the next three years (or more). If you can't get along with them, your life will be miserable.
After that, you have to prioritize the features you desire in a program, such as teaching exposure and the amount and extent of care you will provide to pediatric, obstetric and adult patients, as well as the amount of time you will spend working in inpatient versus outpatient settings. Your residency experiences form the bulk of your medical training, and if you aren't trained on something during residency, it's far more arduous to make that happen after residency.
If you have a spouse or significant other, involve that person in the decision-making process, especially if you are moving somewhere new. You will be extremely busy during residency, and he or she will have to spend a lot of time without you. Your loved one needs to be happy where you are going.
Realize that you aren't likely to find a perfect program, but you will have a gut feeling about where you belong, and that is more important than anything else.
You may already have interviews scheduled, but do you know what questions to ask? Here are some things to consider asking at each of your visits:
- What are the program's board passage rates? This will give you an idea of how good the clinical experience is.
- Where do the program's graduates get jobs? This will tell you whether the graduates are respected and perceived to be well-trained by the local community.
- What are the strengths and weaknesses of the program?
- What kind of interaction do residents and faculty have outside of work?
While you are evaluating the programs you visit, keep in mind that you also are being evaluated at every moment, not just during the formal interviews. Residents will scrutinize you for your "fit" at any moment they interact with you, including meals and tours, so treat every moment seriously and always be on your toes.
Residency representatives will want to know why you are interested in their program and what specific aspects drew you there, so show you have done your research and be prepared to name something about that program other than just its name or reputation.
While fourth-year medical students are planning for the long term, it's not too early for first- through third-year students to start building CVs, learning as much as they can about each specialty, and seeking experiences that can help prepare them to choose their future. Here are some possible scenarios to consider:
- First-year students, you can use your only summer off during medical school to experience family medicine. Find international service opportunities for students, or find a family physician to shadow. Your faculty or state chapter can help you with this.
- Second-year students, build your CV by pursuing leadership opportunities on your campus -- for example, with your school's family medicine interest group.
- Third-year students, get out of the academic health center during your elective rotations and experience primary care where it occurs most often -- in the community. Use the AAFP's clerkship directory to find an elective rotation.
Tate Hinkle, M.D., is the student member of the AAFP Board of Directors.
Posted at 09:42PM Oct 08, 2014 by Tate Hinkle, 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]
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]
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]
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]
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]
Turn the Page: Saying Goodbye Not Easy for Graduating Resident, Patients
My residency is almost over. By this point in our careers, all graduating family medicine residents have spent four years in college, four in medical school and at least three years (sometimes four) in residency. You might think there would only be elation, joy and relief on the cusp of completing this grueling, 11-year process.
It has been years of 80-hour (or more) workweeks, cafeteria food (if you even have time to go there), missing your kids' school events, missing your spouse's birthday, being that relative who misses weddings, funerals and Mother's Day -- all while struggling to pay the bills. By this time in some other industries, we might have made a fortune by working such long hours, but instead we are in serious debt. Most of us owe more in student loans than we do on our mortgages.
The bond a patient can develop with his or her family physician is amazing. Here I am with a patient who is interested in following me to my new practice -- more than two hours away. |
So why would anyone sign up for the not-so-enticing path I just described?
Three words: the patient relationship.
As a medical student, you get limited exposure to continuity of care because rotations are usually eight weeks long, at most, so the number of repeated contacts with a specific patient or family is limited. Family medicine residency, however, focuses on relationships and caring for a patient across all settings, whether that be at the physician's office, a nursing home, the patient's home, a hospital or a hospice facility.
I've delivered babies and handed them off in the delivery room to a grandmother who is also my patient. Moments like that give you more enthusiasm and energy than a venti coffee ever could.
What I'm realizing as I near the end of my training is that patients get more than quality medical care from our interactions. They develop a bond with us that has far-reaching implications. My patients feel like they know me as a person, not just as a diagnostician. We have conversations about their priorities and how their financial and logistical realities relate to treatment. We grow to understand each other.
I don't think most patients in a residency training program realize how much we appreciate them. They quite literally provide the foundation for our specialty training. Most of us can remember our first patient in the office, our first well-child visit and our first reading of a patient's obituary. We remember the cards and notes patients send us, but most importantly, we remember how they humbled us with their complex medical cases.
I recently added a little spiel to each patient encounter I have about how I will be leaving the program and transitioning them to another resident in July. This conversation fails to get any easier with repetition.
I have had multiple patients cry. Several have stood up and hugged me, and a lot have asked for directions to where I am going next.
Through this process, I have noticed a difference between two groups of patients. Those who I inherited from a former resident (or from generations of residents in my program) smile and say I better pick a good physician to take my place. In contrast, the patients I acquired from the emergency room or hospital and brought to this practice during my residency -- many of whom had never had a family doctor before -- tend to enter a brief panic. I explain that the same attending physicians who have been joining our visits occasionally are still going to be here to precept the residents, that the incoming class of residents is wonderful, and that the same nurses will answer their phone calls. Some of those patients say that they don't want a new doctor, and they will drive the 2 1/2 hours to my new office to see me.
I've heard over and over, 'I've never found a doctor like you,' 'You listen to me,' 'You know my whole family.' They say they like being able to come with their kids to one big, long appointment for everyone. They like to see a face they know if they get admitted to the hospital. And women have told me they want to have the same doctor take care of them during and after their pregnancy and see their new babies.
To all of these cares and concerns, there's really only one reply I can give, and it's a reassuring one: That's family medicine. I am a family doctor, and they will get the same care and have the same opportunities across generations with their next family doctor. I am nothing special within family medicine; it's family medicine that is special.
There are more than 3,000 family medicine residents who will be graduating soon. What tips do you have for other third-year residents who are preparing to say goodbye to their patients? If you've had a particularly gratifying goodbye, please share your story in the comments field below.
Kimberly Becher, M.D., is the resident member of the AAFP Board of Directors.
Posted at 10:03AM May 20, 2014 by Kimberly Becher, M.D. | Comments[0]
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I agree with What the...Submitted by Guest2012 (not verified) on Tue, 07/12/2011 - 3:18pm.
This story doesn't even tell the "victims" name. I agree with "what the", and wonder why the people are taking this all in stride, like this is a normal part of our daily lives in Wilmington. WELL, I guess it is NOW...if we let it be! I can see many reasons that these crimes are occurring, but like everyone, I turn apathetic and shrug my shoulders and say, "what can you do about it?" We need a NEW SHERIFF in Town, OBVIOUSLY! »
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subset: commoncrawl


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Wall Street Journal: LED Gaga, The Hottest New Lights
In this review of LED lamps, the Wall Street Journal identifies the unique Horizon as "a hovering wafer of illumination."
Ergo Info
Keep your mouse close to the keyboard to avoid excessive reaching. Any other tools that are used frequently should be stored within arm's reach.
Ergo Gear Guide


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G2D Games
Most Played Games
New Games
Dressup Games
Makeover Games
Girls Games
Celebrity Games
Cool Games
Cooking Games
Baby Games
Fun Games
Game Name
Fruit Fashion Dressup
Dressup Games
Game Tags
Click Here to Play
Game Details :
Dress this cute girl in fruity outfits and give her a complete makeover. There are a variety of dresses, shoes, hair Choose the best one.
New Games
Pou Ice Cream Decorati
Frankie Stein Injury
Pizza Mania
Dora Fly Hitter
Celebrities Pet Shop
Rock Star Kiss
Dora Messy Food
Beauty Cosmetics Shop
Celebrities Manicure S
Froggy Grabby-3
Dora Messy
Variety Food Shop


text: http://forums.opensuse.org – Quote: subprocess failed. Error: RPM failed: warning: /tmp/google-chrome-beta_current_i386.rpm: Header V3 DSA signature: NOKEY, key ID 7fac5991 error: Failed dependencies:lsb>=3.2 is needed by google-chrome-beta-184.108.40.206-34537.i386 That is the error message I get when I try to install Google Chrome's RPM for Fedora/openSUSE off the official website (Google Chrome - Get a fast new browser. For PC, Mac, and Linux) Any suggestions? I'm happy with Firefox for now, but the fact that it is not skinning near the address bar nor the actual menus themselves (when you click on them) makes it ugly. Plus, I'm up for a change - I've been with Firefox for quite a while now. Thanks, Matt. (Distributions)


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BEARdocs is currently undergoing a scheduled upgrade. We expect the upgrade to be completed no later than Monday, March 2nd, 2015. During this time you will be able to access existing documents, but will not be able to log in or submit new documents.
dc.contributor.advisor | Keele, N. Bradley. | |
dc.contributor.author | Blakeley, Hillary Joy. | |
dc.contributor.other | Baylor University. Dept. of Psychology and Neuroscience. | en |
dc.date.copyright | 2007 | |
dc.identifier.uri | http://hdl.handle.net/2104/5127 | |
dc.description.abstract | The amygdala is a critical part of the limbic system with important roles in social behavior. Abnormal activity in the lateral amygdala nucleus (LA) has been implicated in several disorders, including autism spectrum disorder (ASD) in which abnormal social functioning is a primary symptom. The peptide hormones arginine-vasopressin (AVP) and oxytocin (OT) are strongly implicated in social behavior, and may also be involved in the pathophysiology of ASD. AVP and OT increase excitatory responses in the brain, however their role in the LA is unknown. Here, the effects of AVP and OT on membrane properties of LA neurons were investigated using whole-cell recording of LA neurons in vitro. AVP decreased accommodation and hyperpolarization-activated current (Ih) in LA pyramidal cells, resulting in increased excitability. OT increased action potential accommodation and Ih resulting in decreased excitability. These results suggest AVP and OT may modulate social behavior by controlling excitability in the amygdala. | en |
dc.rights | Baylor University theses are protected by copyright. They may be viewed from this source for any purpose, but reproduction or distribution in any format is prohibited without written permission. Contact email@example.com for inquiries about permission. | en |
dc.subject | Amygdaloid body. | en |
dc.subject | Limbic system. | en |
dc.subject | Peptide hormones -- Physiological effect. | en |
dc.subject | Autism -- Pathophysiology. | en |
dc.title | Functional roles of arg-vasopressin and oxytocin on cellular excitability in neurons of the rat lateral amygdala. | en |
dc.type | Thesis | en |
dc.description.degree | M.A. | en |
dc.rights.accessrights | Worldwide access | en |
dc.contributor.department | Psychology and Neuroscience. | en |


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Trustmark gets earnings boost from BancTrust takeover
Published: July 24,2013
Tags: acquisition, BancTrust Financial Group, bank, banker, banking, earnings, finance, financial institution, Gerard Host, merger, profits, publicly traded company, Trustmark
JACKSON — Regional bank Trustmark Corp. says profit in 2013's second quarter rose 6 percent from the same three months of 2012, fueled by gains from its takeover of the former BancTrust Financial Group.
Trustmark posted quarterly profit of $31.1 million or 46 cents per share yesterday. That's up from $29.3 million or 45 cents per share in 2012's second quarter.
Analysts polled by FactSet had estimated 44 cents per share, on average.
Trustmark said money recovered from bad loans exceeded new money charged off by $771,000. The company not only didn't set aside any new money for anticipated loan losses, but released $4.8 million from reserves. Spokeswoman Melanie Morgan said that boosted after-tax profit by $3 million.
"Credit quality continued to experience significant improvements," CEO Gerard Host said in a statement.
BancTrust, of Mobile, Ala., merged into Trustmark Feb. 15. The new parent says those operations added $6.1 million in profit during the quarter.
The company said loans increased by $45 million, as increases in construction, real estate and government lending outweighed declines in mortgages held and general business loans.
Trustmark's return on assets was 1.06 percent. That key measure of profitability is down from 1.2 percent a year ago, but still exceeds other Mississippi-based banks. In 2013's first quarter, Trustmark had return on assets of 0.93 percent, compared to 0.84 percent for all banks based in Mississippi and 1.12 percent for all banks nationwide.
The amount that the company collected in interest from borrowers, net of what it paid out to savers, rose to $110 million. The net interest margin, a measure of that spread divided by all loans, was 4.02 percent, up from 3.98 percent in the first quarter, but down from 4.15 percent in 2012's second quarter. Low interest rates have generally caused that spread, which is a basic ingredient of bank profits, to narrow. Trustmark said that higher interest rates on acquired BancTrust loans boosted its margin, but said it would have fallen without the takeover.
Jackson-based Trustmark has $11.9 billion in assets with offices in Mississippi, Alabama, Florida, Tennessee and Texas.
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Republican budget author says his Catholic faith shaped his budget, as some members of the Catholic community criticize him
read more
Why are Republicans waging a war on the Church? Ever since boy genius Rep. Paul Ryan invoked his "Catholic faith" to justify his budget—you know, the one all the Republicans, including Mitt Romney, think is super awesome because it ... Read Post
When Fox bobblehead Megyn Kelly asked Republican Rep. Paul Ryan to answer the Catholic bishops' very pointed criticism of his budget that makes Jesus cry, Ryan gave a shockingly blasphemous response: "These are not all the Catholic ... Read Post
House Budget Committee Chairman Paul Ryan (R-WI) told Christian Broadcast Network earlier this week that the House GOP's budget, which he wrote, was driven by his Catholic faith. "A person's faith is central to how they conduct them... Read Post


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Lauren Graham Developing TV Series Based on Debut Novel
The "Parenthood" star is adapting her best-selling "Someday, Someday, Maybe" into a one-hour drama.
Lauren Graham is taking her story to the small screen.
The Parenthood star, who released her debut novel in April, is developing a one-hour drama based on her New York Times-bestselling book Someday, Someday, Maybe, The Hollywood Reporter has confirmed.
Someday, Someday, Maybe centers on a young woman with six months left on her three-year plan to make a career as an actress in New York City. Graham, who will write the script, will executive produce with Ellen DeGeneres and Jeff Kleeman. Warner Bros. TV and A Very Good Production are the production companies behind it.
Graham's team-up with Warner Bros. TV marks a reunion for the actress, who starred in the studio's hourlong drama Gilmore Girls for seven seasons from 2000-2007.
The news comes after a high-volume of semi-autobiographical fare landed at the networks during development season last year, with several projects (The Michael J. Fox Show, Adam F. Goldberg's The Goldbergs and D.J. Nash's The Family Guide) snagging series orders.
Graham is repped by ICM Partners and John Carrabino Management.
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Hertz Jobs & Careers in Akron, OH
Transporter - HLE (HLE.Transporter - HLE..Operations.Nonex)
Hertz Corporation – Akron, OH
will include but are not limited to; • Transports vehicles from Hertz Local Edition offices to various locations. • Will pick-up and drop-off… Hertz Corporation
Area Manager
Hertz Corporation – Akron, OH
• Create an 'Ownership' Culture with a Focus on Sales and Customer Service. • Challenge… Hertz Corporation
Counter Sales Rep
Hertz Corporation – Green, OH
and accountability are: • Effectively communicate and offer ancillary products and services to enhance customer's travel experience. • Strong… Hertz Corporation
Transporter - HLE (RAC.Transporter - HLE..Operations.Nonex)
Hertz Corporation – Green, OH
will include but are not limited to; • Transports vehicles from Hertz Local Edition offices to various locations. • Will pick-up and drop-off… Hertz Corporation
Mechanic B - Part Time
Hertz Corporation – Reading, OH
The purpose of the Mechanic position within the Hertz Equipment Rental Division is to utilize his/her mechanical expertise to support the needs of… Hertz Corporation
Finance & Insurance Manager
Hertz Corporation – Reading, OH
• Protect the Dealership's assets by performing the following Job Duties. • Follow the checklist's as outlined in the Hertz Policy and Procedure… Hertz Corporation
Hertz Photos
Hertz Reviews
1 person found this helpful
"not paid enough "
- Comp & Benefits
- Work/Life Balance
- Senior Management
- Career Opportunities
I have been working at Hertz
Prosnever have to stay in the office, get to see and talk to different people everyday.
Conspay. hours. taking away overtime as a punishment. making you work overtime on a friday night as a punishment until 8pm. too many 11 and 12 hr days in a row. no work life balance.
Advice to ManagementAdvicedon't roll your eyes at employees, treat a new employee like a NEW employee they don't know anything about the business so you have to start at square 1 and not expect them to know. don't throw car keys at us. don't smoke in the office during or after business hours.
Doesn't RecommendNo opinion of CEO -


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Anthro Zido Ultrasound Cart
Anthro Zido Ultrasound Cart
Weights & Dimensions
Product Type: Carts & Cabinets | Material: Metal; Wood |
Weight Capacity: 150 Pounds | Country of Manufacture: United States |
Assembly Required: Yes |
About the Manufacturer
If you're looking for flexible and modular computer furniture, with a Lifetime Warranty, you'll be able to find what you need from Anthro!Anthro makes furniture for just about any application where you use computers or computer-based equipment. Office furniture, computer desks, home office furniture, electronic workbenches - they've designed them with you and ergonomics in mind.
When Anthro started in 1984, they originally contracted out all their manufacturing. Over time, they have added all the manufacturing modules needed to produce great Anthro furniture in their own factory. That enables Anthro to control quality and delivery so you get exceptional product quickly.
Anthro Zido Ultrasound Cart
Still have questions about this product? We're here to help
Customer Reviews
5 star | 1 | |
4 star | 0 | |
3 star | 1 | |
2 star | 0 | |
1 star | 0 |
adj is not wroking Marilyn Kristian from Los Angeles, CA– Verified Buyer the carts are very well made...a bit difficult to put together alone and couldn't have done it without Brian in step by step support! He is super! THe only thing wrong is the adjustable arm is not working...yes, it is installed just like the diagram..matches the pics. |
Valued Customer from New York– Verified Buyer |


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Europe might be edging out of the recession, but Britain's youngsters can't find work.
One-half of UK young people who are not in full-time education have never held a job, a leading UK think tank said on Wednesday, ahead of the release of the country's official monthly unemployment numbers, which revealed that youth unemployment had risen in the last three months.
Research by the Institute for Public Policy Research (IPPR) showed that employment prospects for those aged between 16 and 24-years-old were hampered if they had gained no experience of paid work while still studying.
The unemployment rate was higher for those who left regular education without experience of paid work, standing at 23 percent, versus 14 percent for those who had previously held paid work.
IPPR's economic analyst Spencer Thompson said, "Gaining experience of the world of work while studying is vital for the future job chances of young people. But fewer and fewer young people are working while learning."
Currently, in the UK, 75 percent of 16-to-24-year-olds who are still in education do not hold a job. In comparison, 60 percent of those in the Netherlands do.
While apprenticeships are popular in some European countries to ease the transition from education to work, they are less common in the UK. The IPPR stressed that U.K. employers were increasingly reluctant to hire and train young people, "and a vocational qualification often guarantees little more than a low-skilled job in the service sector."
IPPR's report came after the Organisation for Economic Co-operation and Development (OECD) reported in June that those aged between 15 and 29 in the UK spend on average 2.3 years unemployed in 2011, compared with 1.7 years in Germany and 1.1 years in the Netherlands.
"These findings show the need for a job guarantee for young people, paid at least the minimum wage, to provide them vital with experience of the workplace," Thompson said.
"By having job experience on their CV when they leave full-time education, young people will be at an instant and much needed advantage when entering the jobs market."
IPPR's findings shed new light on what Wednesday's UK employment numbers actually mean for young people in Britain. The most recent figures from the Office of National Statistics indicated that there were 973,000 unemployed 16-to-24-year-olds between April to June 2013, up 15,000 from January to March 2013.
Last week, Bank of England Governor Mark Carney said he would not consider raising interest rates until the jobless rate has fallen to 7 percent or lower. That would require the creation of about 750,000 jobs, and could take three years, according to the central bank's own forecasts.
Britain's unemployment rate remained steady at 7.8 percent in the three months to June, according to official figures.
But as the IPPR highlighted in its jobs report last year, young people not only suffer from a lack of work experience, but from competition from older and more experienced workers: youths are more than three and a half times more likely to be unemployed than those aged over 25. The report also said that only 6 percent of UK employers recruited those who were straight out of school.
For Thompson, the data further emphasized the need for a job guarantee for young people. "This guarantee would also ensure that those who cannot afford to participate in unpaid work experience placements are not at a disadvantage when it comes to competing for jobs," he said.
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Google's Matt Cutts: Holding A Patent Doesn't Mean We Use That Patent In Search Quality
Google's head of search spam, Matt Cutts, posted a YouTube video talking about a recent SEO misconception that he would like the SEO and webmaster world to "put to rest."
Matt said, just because Google has a search quality or ranking patent it does not mean that the patent was or is currently part of the algorithm.
Matt explained that there was a patent named ranking documents, which we covered in our story named Patent: How Google May Trick Search Spammers. He said that was one example of a patent Google holds that is currently not built into the ranking algorithm.
Mr. Cutts added that "it doesn't mean they are necessarily using that patent." Matt also seemed frustrated that SEOs and webmasters act on those patents and sometimes give up on their websites because of those patents.
In short, Matt wants to convey just because they have a patent or a patent application, it does not mean it is integrated into their algorithms.
Here is the video:
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