California
FAMILY PHYSICIAN VOL . 6 3 NO.2 Spring 2 012
UCLA’S IMG PROGRAM HELPS FILL THE GAP BETWEEN HISPANIC PHYSICIANS AND UNDERSERVED PATIENTS
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THE SCIENCE OF PRODUCING FAMILY PHYSICIANS – TARGETING WHAT WORKS
23
THE EVOLUTION OF OUR FAMILY MEDICINE REVOLUTION
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HOW PHYSICIANS AND NURSES CAN COLLABORATE IN TEAM-BASED CARE
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10 Questions With President-Elect Steve Green, MD . . . . . . . . . . 18 Clockwise upper right: Steve Green, MD with his staff at Sharp Rees-Stealy Medical Group in San Diego, Dr. Green and friends after a swim, the Green family, Dr. Green addressing CAFP at the Congress of Delegates in Sacramento.
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Officers and Board
Staff
President Carol Havens, MD
Cecilia Awayan
Susan Hogeland, CAE
Cody Mitcheltree
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Karisa Juachon, CPA
Chris Navalta
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Adam Francis
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President-Elect Steven Green, MD
cafp@familydocs.org Jane Cho
Immediate Past President Jack Chou, MD
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Sophia Henry
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California FAMILY PHYSICIAN
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The California Family Physician (CFP) is published quarterly by the California Academy of Family Physicians (CAFP). Opinions are those of the authors and not necessarily those of the members and staff of the CAFP. Non-member subscriptions are $35 per year. Call 415-345-8667 to subscribe.
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4 California Family Physician Spring 2012
H E A LT H C A R E W O R K F O R C E 20 UCLA’s IMG Program Helps Fill the Gap between Hispanic Physicians and Underserved Patients 23 The Science of Producing Family Physicians – Targeting What Works
Nathan Hitzeman, MD
24 Looking at the Evolution of Our Family Medicine Revolution
Jay W. Lee, MD, MPH
26 How Physicians and Nurses Can Collaborate in Team-Based Care
Heather PhD RN Heather M. Young, Young, PhD, and Casey R. Shillam, PhD, RN-BC
6 Letter to the Editor Let’s Not Miss the Boat on the Inpatient PCMH
Cecilia Hernandez, MD
8 Editorial
Michelle Quiogue, MD
Remember Why You Chose Family Medicine
9 President’s MessageFamily Medicine’s Future Relies on Smart Role Models
Carol Havens, MD
10 Political Pulse
CAFP Working Hard to Prepare You for 2014
Tom Riley
12 Student News
You Are Never Too Young to Become a CAFP Leader
13 Resident News
Our Greatest Strength Is Recognizing Our Own Fallibilities Irene Lee-Klass, MD
14 Membership
CAFP Achieves Record High Membership
16 PCMH Corner
Building a Medical Home? Start with the Right Foundation Callie Langton, PhD
18 In The Spotlight
10 Questions with President-Elect Steve Green, MD
27 2012 Congress of Delegates
A Story Best Told in Pictures
Parker Duncan, MD
Sophia Henry
30 Executive Vice President’s Forum Students and Residents are Already Putting Their Stamps on CAFP Leadership
Susan Hogeland, CAE
For the upcoming CME calendar go to www.familydocs.org California Family Physician Spring 2012 5
LETTER TO THE EDITOR
Let’s Not Miss the Boat on the Inpatient PCMH I read the many reflections on the Patient Centered Medical Home (PCMH) in the Fall 2010 issue of California Family Physician. What I found missing was the opportunity for family physicians to be PCMH champions in the inpatient setting. Eight years ago, I submitted my resignation to my medical group’s president and CEO. He asked me to consider helping out the hospitalists by pulling some shifts. To my surprise, I absolutely loved it! As a primary care provider in the hospital, I used my family medicine training to manage very complex medical, psychological and social situations, providing behavioral medicine, community support, spiritual guidance, and coordinating care with specialists, ancillary staff, nurses and administrators. I developed relationships with patients and families and supported the ambulatory primary care physicians who managed their care “from womb to tomb.” I advocated for the needs of patients and families on various hospital committees, ultimately becoming chief of family medicine and director of medical affairs for our hospital. I now work within my health system to transform inpatient chronic disease management, end-of-life care and hospitalist care to a patient-centric model focusing on transitions of care. I still ensure the patients in the communities we serve receive “personal, comprehensive and continuing care for the individual in context of the family and the community.” I am still furthering the aim of family medicine as defined by the World Organization of Family Doctors (WONCA).1 Becoming a family medicine hospitalist was not easy. In 2003, only three percent of hospitalists were trained in family medicine.2 The reasons for the lack of family medicine hospitalists are myriad, including bias against family physicians by hospitals and hospitalist groups, lack of emphasis on inpatient medicine in family medicine training programs and lack of professional support by family medicine organizations.3 However, family medicine training is uniquely suited to the practice of hospital medicine. Family medicine is rooted in initial, continuing, and comprehensive medical care in the context of the family. Hospital medicine provides initial, continuing, and comprehensive acute medical care. This care most often incorporates the family and community to avoid re-admission. The hospitalist functions as the patient’s means of entry into the acute care setting. If referral is indicated, the hospitalist consults a specialist and remains the coordinator of the patient’s health care. Family physicians are uniquely trained to interface effectively with every specialty and service a patient or family could need in the acute setting. 6 California Family Physician Spring 2012
Furthermore, family medicine training underscores the need to avoid fragmentation of care between the outpatient and the inpatient settings. Family physicians serve as the patient’s advocate in dealing with other medical professionals, third-party payers, employers and others, and, as such, serve as cost-effective coordinators of the patient’s health services. These skills are essential for the effective hospitalist. Taking things a step further, hospitalist fellowships now exist to supplement family medicine training. Sutter Medical Foundation in Sacramento has since developed a hospitalist fellowship which provides additional inpatient medicine training including rotations in critical care, hospital-based procedures and inpatient pediatrics. It is time for our professional organizations to advocate for family physicians to serve as hospitalists. We have an ever-shrinking window of opportunity to assure that the principles of family medicine are embedded in the work of hospitalists and in the care of inpatients. We know the hospitalist model is one that is being driven by logistical and economic demands. As more patients are cared for by hospitalists, the lack of family physicians among their ranks will translate to a lack of family medicine presence in our hospitals. Just as family physicians will serve as “quarterback” in the ambulatory world of the PCMH, family physicians must serve as “quarterback” in the acute care setting of the PCMH. This will only occur if family physicians are present as significant care providers in our hospitals. Cecilia Hernandez, MD Sacramento References: 1. http://www.globalfamilydoctor.com/aboutWonca/ 2. Darves B. 2003. Here come the hospitalists. NEJM Career Center. Available from: http://www.nejmjobs.org/career-resources/here-come-thehospitalists.aspx 3. Iqbal Y. 2007. Family medicine hospitalists: separate and unequal? Today’s Hospitalist. Available from: http://www.todayshospitalist.com/index. php?b=articles_read&cnt=62
Editor’s Note: CAFP has a longstanding tradition of supporting family physicians serving as hospitalists and has policies in place that include promoting family physicians as qualified hospitalists, continuing medical education, job search assistance and promoting family physicians’ scope of practice to include hospitalist practice. For more information see our policy manual in the About Us section of www.familydocs.org.
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EDITORIAL
Michelle Quiogue, MD
Remember Why You Chose Family Medicine When did you decide to be a doctor?” “Why did you choose to be a family physician?” I recently had these questions posed to me by a group of eighth graders who are part of Kaiser Permanente’s Hippocrates Circle program. To spend the day with enthusiastic young people who have just started to dream of a career in medicine is to rejuvenate my love for family medicine.
relieve often, and to comfort always,” as originated in the 1800s by Dr. Edward Trudeau, founder of a tuberculosis sanatorium. As I explained to these eighth graders about what distinguishes family medicine from other specialties, I felt proud to share with them the rewards of service to others, the privilege of sharing the personal lives of patients and the power of comprehensive, preventive care over a lifetime. I left the event feeling grateful for having chosen family medicine, ready to face another week full of both the high ideals and the more mundane work of the Family Medicine Revolution.
When did I decide to be a family physician? As I spoke to these eighth graders, I dove into memories of applying to medical In this issue, many memschool and residency. bers of the CAFP share To be honest, I had no the work they do for the idea what my life as a “As I explained ... what nascent Family Medicine doctor would be like. Revolution. In recent Since there are no other distinguishes family medicine years, the National Residoctors in my family, dent Matching Program I applied to medical from other specialties, I felt results reflect growing school based on dramainterest in our specialty. tizations on TV. During proud to share [about] the Past AAFP president Romedical school, I travland Goertz, MD declared, eled with close friends rewards of service to others, “Our time is now.” Each in the summer heat of us has a role to play to Kansas City, MO to the privilege of sharing the in building our bench find welcoming kindred strength to insure that the personal lives of patients and spirits at the National pipeline of future famConference for Famthe power of comprehensive, ily doctors will meet the ily Medicine Residents needs of our communities. and Students. I remempreventive care over a lifetime.” Participate in commuber the humidity and I nity events. Reach out remember meeting so to members of Congress many happy faculty and to protect funding for residents. It seemed as if everyone had their families with them at that confer- primary care. Precept medical students in your office. Remember what you wrote in your personal statement ence. I remember a sense of belonging. For me, the and why you chose to become a family physician. As brief time I spent in Kansas City with family physicians current AAFP president Glen Stream, MD urged us in resonated with my idealization of life as a doctor. I his acceptance speech, we must celebrate being family realized that I was hoping to be trained to be a healer physicians and “be part of the unstoppable force of who could meet individuals within the context of their personal and social histories. “To cure sometimes, to family medicine.”
8 California Family Physician Spring 2012
PRESIDENT’S MESSAGE
Carol Havens, MD
Family Medicine’s Future Relies on Smart Role Models
Finally, some good news! The district court judge issued a temporary injunction blocking the 10 percent Medi-Cal payment cuts until there can be a more complete analysis of the impact of those cuts. It’s at least a temporary victory and, hopefully, will be followed by a permanent one. We all know that the state budget problems will not be fixed with cuts in Medi-Cal payment. Unfortunately, we also know that blocking those cuts permanently will not encourage anyone to go into family medicine for financial gain. Finally, we know that the best – in fact, only – way to provide care to the millions of Californians who will be insured under the Patient Protection Affordable Care Act is to have a strong primary care infrastructure. Not only does that improve the quality of care provided, but it also reduces costs both directly and indirectly – directly from reduced redundancy, providing care at the point of first contact, and care coordination, and indirectly through prevention and early diagnosis and treatment before diseases have progressed to need more extensive and expensive care.
All require you to get involved – or continue to be involved. Legislators must hear from us about our value. ACOs will definitely need us. We must take steps to prepare ourselves and our practices for the future – to establish and support our teams, implement electronic health records, continue to get even more patient centered. You have heard it all before, and will continue to do so. But one of the saddest things I have heard from medical students is that they are still being told “you are too smart to go into family medicine.” We must change that perception, and the best way is by being role models. We must show medical students – and pre-med students (is kindergarten too soon to start?) – that family physicians are caring, compassionate, committed to social justice, and, yes, incredibly smart, as well as happy and fulfilled in their practices. It takes a special kind of intelligence to see and integrate the whole instead of just looking at pieces. We must ensure that future physicians don’t see family medicine as the default if you can’t do anything else. Family medicine must be an active choice for physicians who have all the traits mentioned above. And if they don’t have them? Well, maybe they aren’t good enough for family medicine! And, please realize that we are all role models, and that medical students and future medical students are watching and listening to us, even if we don’t have an “official” title or role.
... one of the saddest things I have heard from medical students is that they are still being told “you are too smart to go into family medicine.”
Unfortunately, we also know that strong primary care infrastructure is lacking in California as well as the rest of the country. Quite simply, there aren’t enough of us. And we aren’t training enough of us, so there won’t be an infrastructure in the near future unless something changes. A variety of approaches exist to increase the primary care workforce, but there is no one magic solution. Increasing the number of mid-level providers, increased team-based care, improved payment rates as well as paying for care coordination and counseling, Accountable Care Organizations (ACOs), improved recruitment of medical students into primary care and increasing the number of family medicine residency positions all will help, and all are necessary. None would be enough by itself.
All of us have had role models. Speaking of which, since this is my final column, let me thank all of you for the incredible honor and trust you have given me by allowing me to be your president. I am humbled by you; all of you continue to inspire me to grow and improve and be better. To our future role models, welcome to the family of family medicine – you are truly the best. And way too smart to go into other specialties!
California Family Physician Spring 2012 9
POLITICAL PULSE
Tom Riley
CAFP Working Hard to Prepare You for 2014
As California ramps up for full implementation of health care reform in 2014, one daunting fact continues to haunt Sacramento policymakers: There aren’t enough family physicians to meet the state’s current health care needs. With four to six million newly insureds in 2014, along with an equal number projected in state population growth over the next two decades and the dire need for diversity (ethnic, cultural and linguistic) in our health care workforce, we have the makings of a looming crisis. CAFP is working to prevent this crisis on several fronts: First, we’re advocating for smarter delivery models. Second, we’re sponsoring legislation to ensure that not only is the infrastructure of family medicine education better supported, but also students of family medicine themselves are better supported. Finally, we’re not just relying on the goodwill of civic-minded medical students to meet the state’s needs. We’re reminding policymakers that they must pay family physicians adequately for the services they provide, if they are to have a sufficient number of them. As of this writing, some of the CAFP-sponsored 2012 bills mentioned below have not been officially introduced in the Legislature. Smarter Delivery Models: PCMH Legislation One of our top 2012 priorities is CAFP-sponsored SB 393 (Hernandez). By articulating the principles of the Patient Centered Medical Home (PCMH) in state law, CAFP and SB 393’s nine co-sponsors hope to provide the state with a roadmap for effective coordinated care. How does this bill prepare California for 2014? Physician-directed coordinated care proves that California’s health care workforce can do more with less, but only when it works in a coordinated fashion. Supporting Students, Residents and Infrastructure CAFP will also support or sponsor several pieces of 2012 legislation that bolster incentives for medical students, residents and historically underfunded family medicine programs. Offspring of AB 347 (Rubio) CAFP also joined the California Medical Association this year to sponsor graduate medical education funding legislation. While the “offspring of AB 347” may look much like last year’s CMA-sponsored bill that would have required GME funding in capitation rates paid to managed health care plans, CAFP and CMA are examining several approaches (including all-payer funding) to ensure a more stable and robust source of funding for primary care residencies in the state. Assemblyman Michael Rubio (D-Bakersfield) likely will be the author.
10 California Family Physician Spring 2012
Offspring of SB 635 (Hernandez) In 2011, CAFP supported SB 635 by Senator Ed Hernandez (D-West Covina). Currently, the first $1 million in fines and penalties assessed against health care service plans by the Department of Managed Health Care are deposited into the Stephen M. Thompson Physician Corp Loan Repayment Program. Any amount over the first $1 million, including accrued interest, is deposited in the Major Risk Medical Insurance Fund (MRMIP). The fund helps to provide major risk medical coverage to eligible persons who have been rejected for coverage by at least one private health plan. Coverage expansion of the Patient Protection Affordable Care Act (PPACA) will make this fund obsolete in 2014. This bill would have, instead, transferred funds over the first $1 million each year to the Song-Brown Health Care Workforce Training program. Offspring of AB 589 (Perea) CAFP also supported AB 589 by Assemblyman Henry Perea (DFresno) which would have also used the MRMIP dollars discussed above to create the Steven M. Thompson Medical School Scholarship Program. Improving Payment Without improving fair primary care pay, California’s efforts to ramp up for 2014’s needed health care workforce will fall short. That’s why CAFP will spend a large portion of its legislative efforts in 2012 ensuring that family physicians are paid fairly. Here is a list of our efforts so far: • Opposed Medi-Cal rate cuts • Opposed caps on number of visits and co-pays • Opposed moving all Healthy Families children into Medi-Cal • Urged Department of Health Care Services to provide incentive payments for PCMH • Explored Medi-Cal language services at no cost to providers • Sponsoring (with CMA) 2012 improved immunization payment legislation (Offspring of AB 2093 (V.M. Perez) To get more involved in these and other issues, please join CAFP’s Key Contact program by going to: www.familydocs.org/advocacy/ get-involved/key-contact-form.php. Tom Riley is CAFP’s Director of Government Relations.
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California CaliforniaFamily FamilyPhysician Physician Winter Spring 2012 11
STUDENT NEWS
Parker Duncan, MD
You Are Never Too Young to Become a CAFP Leader Family medicine is about stories – often the ones that involve our standing alongside patients in an exam room or on gurneys or hospital beds. Individual as they are, each patient’s narrative is intertwined with a larger social/political/medical context, which is often as powerful a determinant of that person’s health outcome as any other component of his or her story. Every patient encounter I have had since becoming a resident contributes to the narrative; thanks to my participation in CAFP as a student, I have found a venue and vehicle for beginning to understand the larger context of health and medicine. First and foremost, becoming involved with CAFP fueled my learning more about family medicine as a career choice. The “Holy Grail” of this opportunity is Kansas City, MO at the annual National Conference of Family Medicine Resident and Medical Students (this year’s conference is July 26-28: www.aafp.org/online/ en/home/cme/aafpcourses/conferences/nc.html). If you are in any way ambivalent about family medicine, go to this conference. Spend two full days talking to residents from around the country about their passions and interests, and you will know whether or not you’ve found your specialty. This is far and away the most sensitive and specific test I know for selecting family medicine.
involved. To that end, as this presidential election season will no doubt remind us, having one’s voice heard is often costly. Money talks. A component of championing access to care also includes having access to the political ears that can facilitate the change we need. For that, there is the Family Physician Political Action Committee (FP-PAC). I invite each and every student reading this to begin NOW the habit of supporting FPPAC, in the name of providing excellent patient care. A “Gold” level student contribution begins at just $25 – and that’s enough to get your name in print, which can also generate a whole lot more return on your dollar when it comes to residency application. Parker Duncan, MD is a former adviser with the California Student Association of Family Medicine (now known as the Medical Student Council). He is now a resident with the Santa Rosa Family Medicine Residency Program.
Additionally, becoming a student leader facilitated my participation in that larger context of medicine. As a leader, I was invited to participate in the CAFP’s Congress of Delegates in Sacramento to understand how CAFP (or any self-governing group) develops its guidelines and policies. I participated in a training on “Making a Successful Legislative Visit,” then ‘practiced’ those skills in an actual visit with my local legislator. I met my legislator to encourage him to resist supporting blanket Medi-Cal cuts, which would directly translate into direct harms for many of our patients. My CAFP involvement taught me how critical it is that we as future physicians develop (and maintain) a voice in the shaping of health care. CAFP, through its fantastic and fast-informing advocacy page (www.familydocs. org/advocacy.php), provides a number of ways to get
12 California Family Physician Spring 2012
When Jared Garrison-Jakel, MD was a medical student at UC Irvine, he was an adviser for CAFP’s Medical Student Council.
RESIDENT NEWS Irene Lee-Klass, MD
Our Greatest Strength Is Recognizing Our Own Fallibilities Reading through this year’s inspiring residency applications reminded me of my own hopeful aspirations for a career in family medicine. It got me thinking about the insight I have gained in the transition from student to doctor. Perhaps one of the most valuable lessons during my training has been the realization of how deeply challenging it is to obey the simple instruction stated in our Hippocratic oath … “First do no harm.” I began to notice a pattern of circumstances, affecting all health care providers, which could result in less than ideal care. None came about through ignorance, carelessness or malice. Each was the result of human nature functioning within the constraints of our profession. Consider the following scenarios: • Approaching the bedside of our next patient after a difficult patient or colleague interaction, or in the nth hour of a heavy workload. • Prescribing medications in an environment laden with pharmaceutical advertisements and influence. • Fulfilling family or patient requests that potentially contradict the patient’s best interest. • Choosing the best care plan in light of conflicting studies and the multifactorial nature of individuals. • Missing the red flags of social problems, such as stress or domestic violence, while focusing on immediate medical issues. • Delaying a diagnosis because a patient’s presentation of illness is atypical. • Ordering tests or prescribing medications that are unnecessary or non-beneficial. • Misinterpreting what a patient is describing. • Writing an unclear order, leading to a medical error. • Neglecting to stop a medication that is causing more harm than benefit. • Failing to provide comprehensive care because the service is unavailable, or the patient does not have the proper insurance. • Wrapping up care that needs more time and attention. • Caring for patients in spite of variations in our personal well-being.
Reflecting over these circumstances developed a new level of humility and respect of what it means to “First do no harm.” Our very humanness – our emotions and our physical and mental constraints – is in direct conflict with the ideal, making it a deceptively difficult directive. Fortunately, recognizing our own fallibilities is perhaps our greatest strength.
Perhaps one of the most valuable lessons during
my training has been the
realization of how deeply
challenging it is to obey the simple instruction stated
in our Hippocratic oath … “First do no harm.”
In the medical profession, constant study and a diligent work ethic are unconditional requirements. Collective improvement of the medical system is similarly vital. We would do well to remember to turn our inspection inward as well, and search out that which lies within ourselves that compromises our ideals. With experience and mindfulness we can learn to recognize and improve the manifold factors that weaken our performance. Then we will be most fully prepared to meet the challenge of “First do no harm,” and move forth with renewed energy, confidence and perspective. Irene Lee-Klass, MD is a first-year resident at Sutter Health in Sacramento. She is a member of CAFP’s Residency Council.
California Family Physician Spring 2012 13
Sophia Henry
MEMBERSHIP
CAFP Achieves Record High Membership CAFP reached 8,100 members by the end of the 2011, setting a record in membership since the Academy was founded in 1948. Already the largest primary care only medical specialty society in California, CAFP’s overall membership increased by more than 600 members resulting in 8.5 percent net growth for the year.
membership also increased significantly, by 12.35 percent, while the percentage of residency graduates converting to Active membership rose by 5.88 percent. The future of family medicine is here and it is thriving. It is truly inspiring to experience this surge in membership as it demonstrates a positive trend toward the selection of the specialty of family medicine.
Total Member Count
Not only are we excited to see Active membership grow by four percent, but medical student and resident membership also skyrocketed compared to last year. The 54.4 percent boost in student membership continues to fuel overall membership growth. The increase in student membership was particularly striking, however, as it soared well above the 1,000-mark for the first time! Resident
8500 8000 7500 7000 6500 6000 5500 5000 4500 4000 3500 3000 2500 2000 1500 1000 500 0
n Active n Resident n Student n Life n Supporting n Inactive*
The percentage of active members who renewed their membership also reached an all-time high with 93.3 percent renewing membership, driven in part by a 1.5 percent increase in CAFP’s new physician retention rate. New physicians are defined as those out of residency in the last seven years and represent nearly a quarter our active membership. We have worked hard to offer an expandCalifornia Academy of Family Physicians ing set of resources and support Benchmark Membership Counts specifically for our members transitioning from residency to active practice. This growth trend among all major 8098 categories of membership is rewarding 7432 because it is a strong indication that these efforts are paying off.
December 31, 2010 4962 816 693 773 27 161
December 31, 2011 5164 931 1070 803 33 97
*AAFP moved approximately 60 Inactive members to Active membership in advance of the renewal cycle in an effort to ensure members were placed in the correct category of membership. 14 California Family Physician Spring 2012
The Los Angeles County Chapter tops the list of county chapters with the largest membership, 1,439, followed by Orange County with 585 members and San Diego County with 456 members. The largest net growth was seen in Merced-Mariposa Chapter, which experienced a 59.3 percent uptick in the percentage of Active membership. It’s especially exciting to see this occurring even during these difficult economic times, when many organizations are stagnant or shrinking. In short, CAFP is now bigger than ever in terms of sheer numbers – and we deserve to be heard. With the continued focus on health care reform and the inevitable implementation of key
MEMBERSHIP provisions of the Patient Protection and Affordable Care Act, including measures to increase the primary care workforce and better align payment with quality, we will need even more growth to have a positive impact on health policy and to support legislative advocacy on your behalf. Your continued support and involvement assures a united, strong collective voice. Reaching this milestone was an effort accomplished by all of our incredible leadership, local county chapter officers and executives. Thank you to all of the family physicians who recommended membership to their colleagues and shared their personal perspec-
tives on the value of membership with potential members. A very special thanks to Immediate Past President (and family physician bobble head) Jack Chou, MD, AAFP and CAFP staff for their strong collaboration with the membership department this past year. Thanks to every member of our Academy for your loyalty and support for the specialty of family medicine. CAFP will continue to raise its powerful voice to address your concerns at the Federal and State levels. Sophia Henry is CAFP’s Associate Director of Membership and Marketing.
“Not only are we excited to see Active
membership grow by four percent, but
medical student and resident membership also skyrocketed compared to last year ... CAFP is now bigger than ever in terms of sheer numbers – and we deserve to be heard.”
Live—Work—Play in the Wine Country Family Practice Physician
Sonoma County Indian Health Project (SCIHP) Santa Rosa, CA, is seeking a full-time BC/BE Family Practice Physician to join our team. Obstetrics required. M-F operation with rotating nights & weekend calls. SCIHP is a comprehensive community care facility. We offer a competitive salary, excellent benefits, & an opportunity for loan repayment. For more information, contact Bob Orr at (707) 521-4654; or bob.orr@scihp.org.
California Family Physician Spring 2012 15
Callie Langton, PhD
PCMH CORNER
Building a Medical Home? Start with the Right Foundation For many physicians, thinking back to their medical school personal statement brings nostalgia and thoughts of their own naiveté. What if instead of waxing nostalgic, primary care physicians could look back on their personal statement and be thrilled that they really were able to help others, ensure patients had the best care possible and make the world a better place? It’s possible with the Patient Centered Medical Home (PCMH) — the new model that is transforming the way health care is delivered and is poised to significantly help alleviate the workforce shortage. Primary care was once the foundation of our health care system. Now, nearly one in five Americans lack sufficient access to primary care because of a shortage of physicians in their communities (National Association of Community Health Centers, 2009). This shortage is a result of a yearslong decline in the US primary care workforce, lack of primary care infrastructure and poor access to care services. Factors including low payment rates for primary care services and poor quality of life caused by overburdened patient panels also have contributed to more doctors choosing to train in and practice sub-specialty medicine. This trend has led to a shortage of primary care physicians across the country and contributed to fragmented care, inappropriate use of sub-specialists and less emphasis on preventive care. In addition to supply side issues, demand for primary care services is expected to increase in the near future as health care reform is implemented and our population grows and ages. The US population is expected to increase by at least 18 percent between 2005 and 2025, with the olderthan-65 population growing by 73 percent. Factoring in the increased primary care workload resulting from the aging population, as well as current trends in medical specialty choice, we are confronted with an expected 27 percent shortage in adult primary care physicians by 2020 (Bodenheimer, Chen and Bennett 2009) or an estimated shortage of more than 65,000 primary care physicians by 2025 (AAMC, 2010). Since a minimum of 10 years is required to significantly increase the physician pipeline, the US will need some creative solutions to the workforce crisis. One of these solutions is PCMH — a model that can attract students to primary care if the foundation is built early in their careers. In addition to workforce efficiency, multiple studies have demonstrated that multidisciplinary teams in primary care can improve
16 California Family Physician Spring 2012
care and lower costs for patients with chronic diseases (Bodenheimer, Chen and Bennett, 2009). Although all the benefits of the PCMH are not yet fully understood, what is clear is that institutions with successful transitions to the medical home are seeing increased interest in primary care medicine, more competitive applicants and 100 percent fill rates in their family medicine residency programs. Student and resident enthusiasm for the concept is high and now is the time to begin including PCMH components as a required part of medical education. Transforming a medical school or residency curriculum to the PCMH model isn’t easy, but it doesn’t have to be an all-or-nothing proposition. A few small changes can make a big difference in the quality of care provided for patients and in improved satisfaction for students, residents and preceptors alike. Working with physician educators and leaders from around California, CAFP has developed some quick-start ideas for members to use as jumping off points in transforming their medical education practices into PCMH. You can find these ideas in our online PCMH Resource Center (www.familydocs.or/pcmh.php). Simply click on the “Students, Residents and Educators” box and find the quick-start ideas there. If you are with a residency program, and have implanted any new PCMH training in your program, I would love to hear from you. You can email me at clangton@familydocs.org. Callie Langton, PhD is CAFP’s Associate Director of Health Care Workforce Policy. Citations: 1. Association of American Medical Colleges. The Impact of Health Care Reform on the Future Supply and Demand for Physicians Updated Projections Through 2025 Available at: https://www.aamc.org/download/158076/data/ updated_projections_through_2025.pdf 2. Bodenheimer T, Chen E, Bennett HD. Confronting the growing burden of chronic disease: can the U.S. health care workforce do the job? Health Aff (Millwood). 2009;28(1):64–74 3. National Association of Community Health Centers. March 2009. Primary Care Access: An Essential Building Block of Health Reform).
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California Family Physician Spring 2012 17
IN THE SPOTLIGHT
10 Questions
with President-Elect Steve Green, MD with our Pioneer ACO patients and expect to demonstrate high-quality outcomes along with cost savings. You regularly attend an annual meeting in Texas. Can you share what that meeting is and what you usually try to take back from those meetings to help you evolve as a family physician?
Steve Green, MD and his wife Susan.
San Diego family physician Steve Green, MD will be sworn in as CAFP’s new president during the 64th Annual Scientific Assembly in Indian Wells later this month. Dr. Green practices at Sharp Rees-Stealy Medical Group, one of the first groups to become part of an Accountable Care Organization (ACO). He has been very active with CAFP, also serving on the Family Physicians Political Action Committee (FP-PAC) yet still finding time to swim marathons. California Family Physician caught up with Dr. Green and asked about his road to becoming a family physician – and what family medicine’s future looks like from his perspective.
SG: This is one of my favorite meetings. My friend, Don Cauthen, MD of Scott and White Clinic in Texas, has held this meeting twice a year for several decades. It’s a chance for leaders in family medicine in large multi-specialty medical groups to share what we are doing. It is held at the Dallas-Fort Worth Airport conference center, with people coming from as far as Group Health in Seattle to St. John’s clinic in Missouri. We give the talks ourselves. The idea is to present an issue our own group has had and what we are doing, then get out of the way and hear from the groups all over the country. Topics can be clinical, administrative, leadership and others. Attendance at happy hour is mandatory (drinking is not). You are a member of the FP-PAC Board of Directors. Why should family physicians be politically involved and contribute to our PAC, as well as to AAFP’s PAC? SG: The FP-PAC is the only organization advocating for family physicians and our patients in Sacramento.
What drew you to family medicine? Steve Green, MD: I grew up seeing the same pediatrician from birth through medical school. He knew me and my family and was my role model. I wanted to do what he did for me and my family, only I didn’t want to stop seeing people when they became adults. In medical school, I seemed to relate best to the family physicians. It just seemed a good fit. What does becoming one of California’s pioneer ACOs mean to you and your family physician colleagues? SG: The pioneer ACO makes sense for me and my colleagues at Sharp Rees-Stealy Medical Group. We are a multi-specialty medical group affiliated with Sharp HealthCare. Our culture is one of providing highquality, efficient care in a manner that exceeds our patients’ expectations. We’ve participated in the payfor-performance program as well as in other quality initiatives and have a robust infrastructure to help us. Now we can use the systems we have in place to work Dr. Green enjoys the outdoors even on a cold day. 18 California Family Physician Spring 2012
IN THE SPOTLIGHT It provides a way for our academy to have a voice in California politics. When we ask our CAFP members what they value most from their academy, governmental advocacy is always near the top. Being involved politically is important. Our senators and assembly members are there trying to make things work better in California. They are not doctors and don’t know our issues. If we can educate them, making sure they understand the implications of various bills and policies for our patients, it can go a long way. During your leisure time, you’re a longdistance swimmer. How does that parallel practicing family medicine? SG: There are similarities and differences between family medicine and marathon ocean swimming. Both can have their tough days where one pushes on. There can be a feeling of accomplishment after finishing a hard day. There is continuing education for both, only with swimming, it’s in the pool figuring out why my stroke is messed up sometimes. Usually hypothermia isn’t a risk while practicing family medicine. Probably the biggest difference is while ocean swimming, there are no beepers, no phone calls, no talking. It’s a good way to recharge the batteries. As an athlete, how do you recover from disappointments such as not being able to swim in the English channel when you’d spent a lot of time practicing for that experience? SG: It was annoying not getting to swim the channel last summer, but I knew that was a possibility going in. I enjoy the training, otherwise I wouldn’t do it. Even if I had crossed the channel, I’d be training for another swim now instead. I’m going back in August, and now know where to get the best fish and chips in Dover, so I’m set. You’ve been a CAFP member since 1988. Why do CAFP’s evolving activities remain relevant to its members? SG: CAFP is a great organization. We’re fortunate to have an excellent staff that makes it possible to accomplish so much. Our
members are provided CME, assistance with practice issues and governmental advocacy, among other things. Our committees and activities are a good way to help with family medicine issues, as well as to meet other family docs from around the state. Your San Diego chapter is very active. How has your participation in San Diego affected your service to CAFP? SG: The chapter has a long history in San Diego. We’ve put on a large CME symposium every year for more than 50 years and donate scholarships to medical students, among other functions. It’s been a great way for me to get to know my fellow family physicians outside of my own practice. Over the years, the San Diego chapter has partnered with CAFP in various educational projects. We typically have a large contingent at the Congress of Delegates. Participating in the Congress helped motivate me to get involved with CAFP. What is your message to family physicians in California (who ARE NOT CAFP members)? SG: Hey! Get your head in the game! At least that’s what my 15-year-old daughter Stephanie would say. With everything going on in health care in California, this is not the time to sit on the sidelines. If you believe family medicine is important to our patients, then you have to participate in CAFP. This year, you will be overseeing CAFP’s strategic planning meeting in July. What is the most important thing that can come out of that meeting? SG: The strategic planning meeting is a chance for us to critically look at ourselves and decide on direction for CAFP. We look at the current environment and decide how best to serve our members and our patients. I won’t claim to know what we will come up with as far as new direction, but an important first step is to ask these kinds of questions of ourselves and be sure our members have a good understanding of where we are going. (Right from top) “The Green Family: Stephanie, Aaron, Susan, Steve and Alana.” Dr. Green with fellow CAFP member Robert Peters, MD at a San Diego Chapter meeting. Dr. Green (right), CAFP Assistant Director of Government Relations Adam Francis (left) and CAFP member Patricia Samuelson, MD at the California Medical Association’s House of Delegates meeting at Disneyland Hotel.
H E A LT H C A R E W O R K F O R C E
UCLA’s IMG Program Helps Fill the Gap between Hispanic Physicians and Underserved Patients In California, 36 percent of the state’s population
Celina Diaz: Another key barrier for IMGs is not only having to know and increase their fluency in English in general, but also to learn the jargon and nuances of US medical English. Medicine has its own language in and of itself. So the goal is to learn medical English as well as increase their proficiency in “regular” English all at once.
is Hispanic. But when it comes to the state’s health care workforce, only 5.2 percent of the state’s physicians are Hispanic. Furthermore, nearly 39 percent of California’s 13 million Hispanics are living in medically underserved areas (MUAs), compared to 20 percent of the total population. In 2007, the UCLA Department of Family Medicine developed a program not only to address the state’s disparity, but also to change the demographics and existing shortage of Hispanic doctors by creating the International Medical Graduates (IMG) Program. California Family Physician spoke to family physician Michelle Bholat, MD, one of the program’s co-founders, and program coordinator Celina Diaz, MPA about how the program works. Tell us about your program and what motivated you to start it. Michelle Bholat, MD: When we looked at the IMGs, we discovered that they made up 20 to 25 percent of the physicians practicing in California. Being in family medicine, we wanted to see who these IMGs were. When you look at the top 10 countries from which the IMGs came, not one of them was a Latin American country. Based on that research Michelle Bholat, MD and our interest in working with underserved communities, with their high concentration of Hispanics, in addition to the constant influx of immigrants mostly from Mexico, it made sense to start this program. Hispanic immigrants are more likely to receive care, and will be either uninsured or underinsured, in these health professional shortage areas. The realization that the number of active Hispanic family physicians in California was only 5.2 percent, compared to the state Hispanic population of 39 percent, was our “aha” moment. That’s a huge gap. We were inspired to start this program to help fill that gap.
Celina Diaz
Can you share with us what the program was like in 2007 compared to how it is today? MB: When we started the program in 2007, we were familiar with the Welcome Back Initiative in San Diego and Los Angeles. These programs are open to all nurses and doctors who immigrated from around the world to become part of the health care workforce. We got the idea of putting our program together based on knowledge of the Welcome Back Initiative and having met with Dr. (Patrick) Dowling and another individual, an IMG who was running one of the Welcome Back centers. In just two months, we had about 12 individuals enrolled in Kaplan. We knew that one of the major barriers was money. Until they successfully passed USMLE Step 1, the immigrant doctors and nurses couldn’t get a job. So we were paying them stipends and helping remove one of those barriers so they didn’t have to work outside their fields. We started with that class of 12 and ended with four. It wasn’t a big class; we had to figure out what we needed to do with these individuals. The first thing was to get them through Step 1 – the USMLE. Do you instruct the classes in English or Spanish? CD: In short, once they are part of the program, everything is done in English. Dr. (Luis) Cazal’s pre-prep basic science classes are all in English and, of course, the weekly English class is conducted in English only. Dr. Bholat tells everyone to eat, drink, sleep and dream in English. They are told to watch TV in English, listen to the radio in English and read English newspapers such as the New York Times Health section. Basically, absorb the English language and see how other medical professionals express themselves within the medical community. IMG Program, continued on page 22
20 California Family Physician Spring 2012
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H E A LT H C A R E W O R K F O R C E Photo by Glenn C. Wong
IMG Program, from page 20
and organized are two additional important professional traits. You started this program in 2007. Do you know what those IMGs are doing now? MB: We sure do – they’re all in California. We had one chief resident at UCSF Fresno, and we’ve had two chief residents at UC San Diego. We have a chief resident at UCLA this year. We’re trying to recruit new leaders, not just excellent clinicians. CD: We are continually in contact to update and gather information on career or academic highlights. Our first group of alumni is out there working in the community. They’ve finished residency and they have their first job as family physicians.
The UCLA IMG program not only trains future family physicians, but future leaders as well.
Do you also see this program as a way to change the misconceptions people have about IMGs? MB: Yes. Dr. Dowling and I recently had a meeting about the state of primary care and what is happening to family physicians in the marketplace. We think it’s key for these individuals to realize that they are in this program not merely to get a license to function as a general practitioner. We want them to become board-certified family physicians, and we are instilling the passion and desire for life-long learning.
MB: When it comes to trying to recruit future family physicians, I think the key is that they have a life-long passion for medicine, because medicine is always changing. What you might learn today could be outdated tomorrow. You also need to communicate effectively. As family physicians, we’re the ones orchestrating and coordinating a lot of the care. Being highly efficient 22 California Family Physician Spring 2012
Photo by Glenn C. Wong
With the shortage of primary care physicians, what advice would you offer anyone interested in going into family medicine?
CAFP member Betzy Salcedo, MD is among the IMG program’s class of 2011.
To learn more about the UCLA IMG Program and its curriculum, log on to http://fm.mednet.ucla.edu/IMG/ img_program.asp.
H E A LT H C A R E W O R K F O R C E
The Science of Producing Family Physicians – Targeting What Works By Nathan Hitzeman, MD
At our residency program, Sutter Health Residency Program in Sacramento, the last couple of years have been a godsend of wonderful applicants who value social responsibility, relationships with patients and colleagues, continuity, working in teams and evidence-based medicine. As ubiquitous as the phrase “helping people” is in applications to medical school, applications to family medicine residency are peppered with aspirations of volunteerism, global medicine and helping the underserved. Social consciousness seems at the forefront of discussions these days. Since the Patient Protection and Affordable Care Act (PPACA) was passed in 2010, I have seen more articles on medical homes, cost containment, the Relative Value Scale Update Committee (RUC), health care expansion and Accountable Care Organizations than I have seen in a decade. I do not think these sentiments have been lost on medical students, who traditionally enter medical school idealistic and eager to do a greater social good. An article from the June 15, 2010 Annals of Internal Medicine ranked US medical schools by “social mission.” Schools were ranked on three criteria: number of minority students, number of graduates going into primary care, and number of graduates going on to work in health care shortage areas. The online list can be found at www.annals.org/content/ suppl/2010/06/03/152.12.804.DC1/152-12-804-Appendix.pdf. Out of 141 schools, Western COM ranked No. 21, while the other California schools ranked 64 to 138. Not great on the social mission front. Unfortunately (or perhaps fortunately), this data is from surveys from more than a decade ago. More recent data from the Society of Teachers of Family Medicine shows which schools in California are pumping out the most family medicine doctors. (See Table top right.) What can we do with this information? Now is the time to highlight what is working in medical school education and to inspire more of these great students into our field. What I hear from interviewing students is the importance of mentors and heroes in their training. CAFP frequently highlights family medicine heroes in its publications and monthly on its website. Also critical are student leadership and discussions in Family Medicine Interest Groups. Student and Resident Affairs Coordinator Cody Mitcheltree is a key coordinator for CAFP to continue its outreach to these spawning grounds.
PERCENTAGE OF GRADUATES ENTERING FAMILY MEDICINE Medical School
2006
2007 2008
2009 2010 5 Yr Average
Western University COM 24.3
25
26.7
24.5
19.7
24.04
Touro COM
14.8
23.2
19.7
18.8
23.3
19.96
Loma Linda University
17.5
18.3
13.7
7.6
13.4
14.1
UC Davis
6.4
11.8
11.1
11.8
11
10.42
UC Irvine
9.8
4.3
5.6
5.2
16.3
8.24
UCLA
12.7
5.7
8.6
7.1
4.9
7.8
UCSD
4.9
3.5
15.3
8.3
5.4
7.48
USC
7.6
4.9
3.6
10.3
8.1
6.9
UCSF
3.5
5.8
4
5.5
7.1
5.18
Stanford University
5.9
4.1
2.1
2.4
2
3.3
Student-run clinics introduce students to caring for the whole patient before they enter their third year of residency and go on to witness the often wasteful, fragmented and, sometimes, disenchanting hospital care of revolving door patients. Sacramento is unique in that it has seven student-run clinics through UC Davis, which could explain the high percentages of graduates from this school going into family medicine. A list of student run clinics nationwide can be found at www. studentrunfreeclinics.org by looking under the “Clinic Profiles” tab. Global medicine has long been a magnet for those interested in primary care. Good history taking and physical exam skills go a long way in helping out in countries lacking resources. Schools such as Loma Linda, which traditionally have championed global health and humanitarian service, have many graduates going into family medicine. Other medical schools and residency programs should support these interests. UC Irvine launched the first UC PRIME program in 2004. Today, 305 PRIME students in various UC medical schools are being trained on the needs of underserved populations. My personal interactions with UC Davis Rural PRIME students reveal that many want to go on to do primary care in underserved populations. How long this positive trend lasts remains to be seen. Of course, more efforts are needed to meet our nation’s future health demands. This is a unique opportunity for residency programs to reflect on what their applicants value most and to reach out to one another and to schools to raise family medicine training to a new level, however. Nate Hitzeman, MD is a family physician and faculty of the Sutter Health Residency Program in Sacramento. He is a member of CAFP’s Communications Committee.
California Family Physician Spring 2012 23
H E A LT H C A R E W O R K F O R C E
Looking at the Evolution of Our Family Medicine Revolution By Jay W. Lee, MD, MPH
In the spring of 2011, Family Medicine Revolution was re-born as #FMRevolution. Our collective family medicine consciousness, like the mythical phoenix, arose from the ashes to become “Strong Medicine for America.” We have new tools for engaging strong warriors (or awakening long dormant ones) and for stoking the revolutionary fire within our souls. We are at the precipice of roaring down the historically elusive path of long-needed transformation of our broken, fragmented health care system. Speaking of precipices, let me step down a bit from this poetic precipice (yikes) before I write something overly hyperbolic, and provide you with a historical account of where the Family Medicine Revolution has been – and where #FMRevolution is headed.
Family Medicine as Counterculture In the spring of 1979, G. Gayle Stephens, MD (picutred) delivered a seminal lecture on the emerging specialty of Family Medicine at the Society of Teachers of Family Medicine Annual Conference in Denver. Dr. Stephens observed that the spirit of reform and change in the 1960s fertilized the health care landscape for the birth and growth of our specialty. Indeed, many believed at the time that family medicine would revolutionize the health care system: that the country’s health system woes would be solved by the creation of our specialty. That spirit was exhausted by efforts to legitimize our professional existence and enfranchise us within the House of Medicine rather than on truly reforming the health care system, however.
24 California Family Physician Spring 2012
Family Medicine T-Shirt Revolution Fast forward a little more than 30 years later to 2010. Two Santa Rosa residents, Rachel Friedman, MD (pictured left) and Nicole Mohlman, MD (pictured right), fed up with the academic establishment’s attitude toward our specialty, began to draw up plans for how to bring sexy back to primary car. With help from the CAFP Foundation, they printed T-shirts with a three-fold purpose: 1) to increase the “hipness” factor for medical students considering careers in family medicine; 2) to rally family physicians to proudly embrace the value that we provide to the health care system; and 3) to increase the general public’s awareness of who family physicians are and why family medicine must play a critical, central role in US health care. With messages such as “Family doctors are sexy; we do it all” and “Family Medicine: Use your whole brain,” the shirts were (and continue to be) a huge hit. #FMRevolution In the spring of 2011 (what is it about spring and revolutions by the way?), thenAAFP President Roland Goertz, MD delivered a simple, but powerful, message at CAFP’s Congress of Delegates in Sacramento: “Our
Two Santa Rosa residents ... fed up with the academic establishment’s attitude toward our specialty, began to draw up plans for how to bring sexy back to primary care. time is now.” Inspired, I blogged about this and called upon you, California’s family physicians, to seize the moment. How? By utilizing social media to do what we do best: communicate. My vision was two-fold: 1) that family physicians and other primary care providers embrace this idea that we are better than how the status quo values us and that we need to ‘revolt’ against the fragmented health care delivery machine that exists now to shift the
health care system vector away from volume-based fee-for-service and toward value-based care; 2) that the general public sees this antiestablishment health care reform movement and embraces it. Since then, using the hashtag #FMRevolution, we have witnessed a surge in activity on Facebook and Twitter and in the blogosphere highlighting the importance of family physicians in America’s communities and making a strong case for re-engineering the foundation of our health care system with a robust, dynamic primary care workforce. Another side effect of this social media movement has been a realization that there is a growing community of family physicians, medical students, patients and others who understand the myriad messages about our specialty and help amplify our voice.
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To generate enough force to permanently shift the health care system vector to become patientcentered and, therefore, primary care-centered, we must generate ample acceleration. Join us in amplifying our voice. Long live our #FMRevolution! Jay W. Lee, MD is a family physician at Long Beach Memorial Medical Center Program. He is CAFP’s New Family Physician Director and Secretary-Treasurer.
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HEALTH H E A LT H CARE C A R EWORKFORCE WORKFORCE How Physicians and Nurses Nurses in Team-Based Team-Based Care Care Can Collaborate in By Heather HeatherYoung, Young,PhD, PhDRN and Casey R. Shillam, PhD, RN-BC By
requires new models of care capitalizing of the health care team. More than six eligible for insurance coverage by 2014.
True partnership between nurses and family physicians is the next step in the natural progression of the evolving health care Medical Homes and Community Health Centers are all ways to move toward team-based models of care to deliver higher quality care at lower costs. Many programs emphasizing
the lifespan is increasing. Beyond complex
quality of life and symptoms, and commonly create a burden for support by family members. Individuals and families need the
team and the family caregivers. Programs for All-Inclusive Care deliver a comprehensive set of primary care, home health and social support services while striving to keep frail older adults independent in their homes. These team-based models of care in both access and the quality of care delivered.
the challenges of providing that care. The Future of Nursing: talents, knowledge and experience of nurses. Working in
(IOM) report, Future of Nursing: Leading Change, Advancing Health. This report describes a vision of a health care system that provides access to high-quality care for the most vulnerable
Recognizing the growing complexity of health care delivery
the number of RNs with baccalaureate degrees. This can only occur by increasing academic capacity through preparing more nurses with doctorates to conduct research and teach the next
team-based care. The Future of Nurse-Physician Partnership in Health Care The role of nurses in health care delivery is far-reaching and diverse. Nurses contribute to health at many levels: direct
among all health care professionals. The goal of the California
specialists, faculty researchers and educators, and in health system leadership and policy. These nurses embody a range
for researchers and educators. As members of the health care HeatherM. M.Young, Young, PhD, is the Associate Vice Chancellor Heather PhD, RNRN is the Associate Vice Chancellor for Nursing and Dean and Professor at the Betty Irene Moore School of Nursing at UC Davis. R. Shillam, PhD, RN-BC is a Postdoctoral Fellow at the School ofCasey Nursing at UC Davis. Betty Irene Moore School of Nursing at UC Davis. 26 California Family Physician Spring 2012
2012 Congress Of Delegates A Story Best Told In Pictures
A highly enthusiastic group of delegates, alternates, board members, officers, students and residents attended the Academy’s 2012 Congress of Delegates at The Citizen Hotel in Sacramento March 3-5. New officers were elected, resolutions adopted and important speakers heard from, including Senate President Pro Tem Darrell Steinberg, California Medical Association President Jim Hay, MD and Intel Worldwide Medical Director, Enterprise Solution Sales Mark Blatt, MD. Congratulations to the following elected officers, who will be sworn in at the 2012 Annual Scientific Assembly in Indian Wells. President-elect: Mark Dressner, MD Speaker: Del Morris, MD Vice Speaker: Jay Lee, MD AAFP Delegate: Carla Kakutani, MD AAFP Alternate Delegate: Eric Ramos, MD Nominating Committee Members: Asma Jafri, MD and Kelly Jones, MD Rural Director 2012-14: Veronica Jordan, MD New Physician Director 2012-15: Lisa Ward, MD Secretary-Treasurer: Lee Ralph, MD Carol Havens, MD will step down as President and Steve Green, MD will assume that position. We also thank outgoing Immediate Past President Jack Chou, MD.
Other important family physicians and Academy staff – Bo Greaves, MD; Jay Lee, MD; Carla Kakutani, MD; Larry Shore, MD; Adriana Padilla, MD and Jerry Penso, MD and CAFP Director of Health Policy Leah Newkirk – gave stellar performances at the Town Hall meeting on key health care issues (health care reform, practice transformation, accountable care organizations and health information technology). The “There Oughta Be a Law” session was a hit for the second year in a row, under the guidance of Legislative Advocate Tom Riley and Assistant Director of Government Relations Adam Francis. The prize for the best idea went to medical student Karla Gonzalez who proposed a law to provide financial incentives for medical schools to recruit and graduate students entering “true” primary care. For a report on resolutions adopted at the Congress, please go to the CAFP website at www.familydocs.org/about-cafp/leadership/ congress-delegates.php. Sunday afternoon training sessions were held on advocacy and social media when the business of the Congress was concluded. An AAFP Foundation grant to train the next generation of family medicine activists covered the expense of bringing more than 15 students and residents to the meeting. The icing on the cake was participation by 29 delegates, alternates, officers, students and residents at the March 5 CAFP Legislative Day at the Capitol, a breakfast briefing on three key issues (Patient Centered Medical Home legislation, Graduate Medical Education funding and payment for vaccines) followed by visits to individual legislators. The whole morning was made more interesting by the presence of some 5,000 students, teachers and Occupy protesters, which put the Capitol on high alert. A Story Told In Pictures, continued on page 28
Participants in CAFP’s Legislative Day at the Capitol got a little rambunctious before heading to their meetings. California Family Physician Winter 2012 27
A Story Told In Pictures, from page 27
Clockwise from top: 100 percent of the 2012 CAFP Congress attendees contributed to Family Physician Political Action Committee (FP-PAC) – a new record! CAFP President Carol Havens, MD presents incoming president Steve Green, MD with a beautiful certificate. Speaker Mark Dressner, MD listens attentively to incoming president Steve Green, MD speak. Senate President Pro Tem Darrell Steinberg receives the “Champion of Family Medicine 2012” award from President Carol Havens, MD. Immediate Past President Jack Chou, MD, President-elect Steve Green, MD and President Carol Havens, MD share a good laugh.
28 California Family Physician Spring 2012
Counter-clockwise from left: The residents’ attendance was supported by an AAFP grant for our “Make Your Voices Heard” project. CAFP literally offers a “big tent” for differing points of view – in the Metropolitan Terrace of The Citizen Hotel. President Carol Havens, MD gives Eric Ramos, MD the “Hero of Family Medicine 2012” award. Delegates Suzan Goodman, MD (Alameda-Contra Costa Chapter) and Tara Scott, MD (Sonoma Chapter) at “There Oughta Be a Law” discussion. California Medical Association President and family physician Jim Hay, MD re-ups his membership in FP-PAC – thanks, Dr. Hay!
California Family Physician Spring 2012 29
Susan Hogeland, CAE
EXECUTIVE VICE PRESIDENT’S FORUM
Students and Residents are Already Putting Their Stamps on CAFP Leadership Health care workforce – what a topic. I can’t think of a time in the past 20 years when the prospects for family medicine have been better from a workforce perspective. And, I am happy to report that CAFP is well-positioned to capitalize on the many opportunities arising as the result of the confluence of enactment of health care reform legislation (the Patient Protection and Accountable Care Act – or PPACA) and value-based purchasing pressure on the health care system from employers. If it is reasonable to surmise that two major influencers of medical student and resident choice of specialty are payment and work style, at least some positive steps have taken place on both fronts: Increases in payment for primary care services for Medicare patients have been made (albeit the Sustainable Growth Rate – SGR – potential cuts will far offset them); Wellpoint has announced an increase in payment for primary care services; and Aetna is now paying more to family physicians who have been recognized by the National Committee for Quality Assurance as Patient Centered Medical Homes (PCMH). CAFP has successfully negotiated with a Fresno employer’s self-funded health plan to pay for PCMH services in our practice transformation project there. Transformation to the PCMH, painful though the process may be, also results in improved work style and job satisfaction for those who undertake it, boding well for young physicians who seek a better work-life balance. Let’s look first at some other positive things breaking family medicine’s way: More family physicians than ever are transforming their practices to become PCMHs and thereby positioning themselves to be key players in Accountable Care Organizations (ACOs) established by PPACA. Thirty-six Pioneer ACOs have been identified around the country, with six here in California. Their ability to control costs by lowering hospital and emergency room admissions, among other things, is paramount to their financial success. Who is more skilled at managing the needs of patients with chronic conditions than family physicians and the teams they work with in PCMHs? On the CAFP front, we’ve never devoted more resources to health care workforce policy than we are currently. In 2010, we hired our first Associate Director for Health Care Workforce Policy, Callie Langton, PhD. Callie has worked with the newly re-energized Medical Student and Resident Affairs Committee, first under the chairpersonship of Jo Marie Reilly, MD and, now, under Lauren Simon, MD, 30 California Family Physician Spring 2012
outgoing District 5 Director on our Board. Dr. Simon and her committee are champing at the bit to take on potential graduate medical education legislation in Sacramento; they’re developing an advocacy curriculum for residency programs to ensure we have an activated, motivated set of new family medicine physician advocates in future graduating classes; and they’ve developed a great set of resources about transformation to the PCMH in residency programs. We also have had some of the most impressive student and resident leaders that we’ve ever had in the 20 years I’ve been with the Academy – and that’s saying a lot, because they’ve generally been VERY impressive. With Callie’s help, and that of Student and Resident Affairs Coordinator Cody Mitcheltree, our student and resident leaders have made their respective organizations strong and vibrant. A student and a resident are now serving on our CAFP Foundation Board of Directors. They, along with our Medical Student and Resident Affairs student and resident members, help guide the highly successful Family Medicine Preceptorship Program. We have great student and resident directors on the CAFP Board of Directors, and more residents than ever attend our annual Congress of Delegates to participate in the media and legislative trainings and our Legislative Day
More family physicians than ever are transforming their practices to become PCMHs and thereby positioning themselves to be key players in Accountable Care Organizations (ACOs) established by PPACA. in Sacramento. A newly-graduated resident, Ashby Wolfe, MD, MPH, MPP, has just taken over as chair of our Legislative Affairs Committee! And, we have had tremendous growth among student and resident members. There’s more … but I have a word limit. These young physicians and students see a better world for family medicine and for patients, and so do I. And it’s not just coming; it’s here.
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