The Scope of Family Medicine Is Expanding

Many educators are lamenting today that the scope of family medicine is shrinking.

Joseph Scherger, MD, MPH

They refer to fewer family physicians working in hospitals and doing procedures. Warren Newton, MD, MPH, chair of the American Board of Family Medicine, recently sent out a letter expressing this concern. Such a grave outlook is dangerous to our specialty at a time when we are struggling to motivate medical students to go in to family medicine.

I think just the opposite. Family medicine today is more complex and expansive in some ways than ever before. Sure, fewer of us are delivering babies and doing hospital medicine, but family medicine is first and foremost a primary care specialty. Primary care is expanding and becoming far more complex in this new age of medical homes and the advanced use of information systems.

The Willard Report that set the stage for the transition from general practice to family medicine called for the creation of a new primary physician. That doctor would be the personal physician to individuals and their families. It is that personal physician role that is the essence of our specialty. New models of primary care, from concierge medicine to team-oriented medical homes to populations of patients, are deeply complex and expansive.

What do I mean? Prevention became part of primary care in the 1970s and continues to expand.  Primary prevention includes all efforts to prevent disease, and since lifestyle causes 50% or more of disease, motivational counseling toward lifestyle change is a new and vital part of being a personal physician. Secondary prevention is the early detection of disease and knowing and applying all aspects of the US Preventive Services Task Force recommendations requires good information systems and skills. Tertiary prevention is the prevention of complications of chronic disease and is far more complex than when I finished residency 30 years ago.

Chronic illness drives about 75% of all health care costs so effective management of these problems is vital to our health care system. The routine visit of a type 2 diabetic patient is far more complex than before and requires much more time. Acute problems are still a major part of family medicine and if we are available to our patients online, we can manage or coordinate care much more efficiently. Relationship-centered care calls on us to know our patients well and provide the counseling services our patients need to deal with what life brings to them, attending to the biopsychosocial and spiritual dimensions of illness.

So, let’s stop this talk about the scope of practice of family medicine shrinking. I am grateful to have more time to take a deep dive with my patients and be their personal physician with much greater complexity and effectiveness than ever before. Let’s train our residents to do the same and show off this rewarding specialty to our students. What can be better than being a family physician?

STFM’s Secret Is Out: We Care About Research

Psst…want to know a secret? STFM wants to be the authority in innovation and research in medical education. Kind of cool, right?

Stacy Brungardt, CAE STFM Executive Director

The problem is, this really isn’t supposed to be a secret. Despite our commitment to research in activities and dollars, STFM can improve on communicating how high a priority this is for the Society. Our interest in research generally remains a secret that is known only to those who sit on our Research Committee and Board of Directors. For the sake of the discipline, STFM needs to be seen as a leader in promoting research activities that have an impact and a place where faculty are inspired and learners are engaged in the generation of new knowledge.

To gain this presence, we need the right combination of scholars and resources, and, yes, communications about what we are doing. We have some brilliant scholars within our membership who work hard to review journal manuscripts, develop skill building research sessions at our conferences, and collaborate with CAFM Educational Research Alliance PIs.

For the resource piece, STFM invested more than $300,000 last year to advance scholarship through the following initiatives:

  • Family Medicine – Submissions continue to rise for STFM’s flagship journal.
  • Annals of Family Medicine – STFM is third largest financial contributor to Annals.
  • Grant Generating Project – STFM is one of three financial partners in the Grant Generating Project.
  • CAFM Educational Research Alliance – Currently six manuscripts have already been submitted for publication from CERA, and we anticipate several more within the next 2 months. This is all within the first year of existence of CERA. We’ve only scratched the surface of the potential of this initiative.
  • Fifty four podium presentations and 180 posters at our annual meeting – including skill building sessions and educational and clinical research findings. Every year, one of our four plenary slots is reserved for research. We also have dozens of research posters at our other conferences.
  • Best Research Paper Award – The list of research leaders on this list is impressive.
  • Research Advocacy – This is still in its infancy, but advocacy for increased research funding is now an advocacy priority for the family.
  • National Research Network – Our Conference on Practice Improvement is the home for presentations and meetings of the National Research Network. We see a great linkage between practice improvement and the translation of the research coming out of the network.
  • Family Medicine Research wiki – The Group on Research in Residency offers a great but relatively unknown resource to help build research capacity. Topics include: Getting Started with Family Medicine Research, Journal Clubs & Critical Appraisal, Scholarly Projects in Residency Training, IRB Issues and Participant Safety, Writing A Research Paper, Reviewing a Manuscript, and more.
  • Management Contract with the North American Primary Care Research Group – STFM provides the staff to run NAPCRG. We do this because we believe that NAPCRG can do things that STFM can’t to advance the generation of new knowledge.

There is much more that needs to be done to move forward the scholarship of our discipline. STFM should lead research initiatives that align with our educational mission and collaborate with others to develop our faculty and learners’ skills in educational research and innovation.

Please help us spread the word.

It IS Possible to Assess Competency

Anyone working in family medicine graduate medical education knows that the bar is being raised by the ACGME, as well as by society in general, to demonstrate that our residency graduates are truly prepared to show “sufficient competence to enter practice without direct supervision.” This is not a new standard for graduation, but the rigor with which we must prove residents’ ability is getting tougher.

Dr. Cullison

Sam Cullison MD STFM Member

Some of us (like me) were in the field when Dr David Leach first announced the six competencies in the late 1990s. We were warned that requirements would be progressively increased and that proving competence would require more than verifying time and clinical exposure, with faculty sitting around a table venturing abstract opinions based on recall and the group dynamics of the moment.

However, there is good news in all of this. We are being challenged to prove we know what we are talking about when we say a resident is ready to graduate. Being challenged to defend one’s beliefs is nearly always a good experience, since it requires reassessing assumptions and asking ourselves why we believe what we assert. And to build on that good news—assessing competency is not as tough to do as one might think. I am now a year into chairmanship of the Residency Competency Measurement Task Force, chartered by the Council of Academic Family Medicine and administrated by the Society of Teachers of Family Medicine. I came to the role with a lot of leadership experience but not much competency in competency measurement and tools. Fortunately, I have learned a lot from the other task force members and read tons of books and articles. I have decided that this can be done.

So, what is it going to take?

We have created a web-based Resident Competency Assessment Toolkit. I think it does a good job of walking faculty and directors through the tools available for competency assessment and how to use them.

A couple of general observations:

  • The tools can be simple to use.
  • One tool can be used to measure more than one competency. For example, I can use direct observation, (watching a resident care for a patient), to analyze medical knowledge, patient care, communication, and professionalism in one sitting.
  • You can decide how many tools you want to use to measure any given competency.
  • Multiple faculty watching a single resident provide care to different patients over different times accumulates a body of information on competency that is both valid and reliable, especially if forms are used to record findings and faculty have been trained together to create common standards.
  • Feedback is valuable when received from sources outside the faculty: staff, patients, peers, and students.
  • Learners love feedback, and more of it more often “normalizes” it and takes away the stress.
  • There is no perfect form; do not spend time searching for “the holy grail” of perfect forms. Find one already in use elsewhere, modify as you must, and then start using it—frequently and by many assessors.
  • Faculty need to work together to reach common definitions of competency. Otherwise, faculty assessing the same clinical events will reach very different conclusions.

GO FOR IT!!

Should Students Be Introduced to Family Medicine Sooner?

I often laugh when I reflect on what my vision of a family doctor was before I started medical school. To me, family doctors were “cough and cold” physicians who would see routine, uninteresting patients every 5 to 10 minutes, earning a minimal salary compared to their specialist colleagues. They had a broad scope of practice and, because of that, needed to refer complicated cases to specialists.

Carllin Man STFM Student Representatve

What was I thinking?

Having no formal exposure to family doctors in my preclinical curriculum, I received a broader introduction to family medicine during FMIG lunch hour sessions. While indulging in a free lunch, I came to realize that family medicine is not what I thought it was. I learned that family doctors are competent in a multitude of procedures, from incision and drainages to IUD insertions to mole excisions. They do all this while also delivering babies, treating coagulopathies, and managing chronic pelvic pain.

But unexpectedly, what struck me during these seminars was the sheer enthusiasm expressed by the family doctors. They looked truly happy and made it clear that they enjoy what they do. Many of them spoke of the great work/life balance they’d achieved and how family medicine allows them to be flexible in their professional lives, while still providing vital clinical services to their community.

What other specialty can boast all these things?

I often wonder if I would have chosen family medicine if I hadn’t attended the FMIG lunches. Gaining a true understanding of family medicine in my first year definitely affected how I looked at the other specialties during my clinical rotations. I have to believe that interest in family medicine would increase somewhat dramatically if medical students learned the true nature of family medicine earlier in their preclinical years.

Engaging the Family Medicine Community Through Social Media

Benjamin Miller, PsyD University of Colorado, Denver

This past December at the Conference on Practice Improvement, I had the opportunity to experience one of the most significant benefits of social media—the connections. Many of us involved in social media often talk about the importance of engagement. We know that without engaging, there is not a high likelihood we will establish a relationship with the person we are connected with.

Mark Ryan, MD, has written about how his conference experience was enhanced through relationships he established through Twitter. Social media has power, and this power can be realized through the meaningful connections and ongoing engagement in a larger health care community.

And make no mistake, social media can play a significant role in family medicine.

For example,

  1. Social media allows for everyone, everywhere to get involved
  2. Social media allows for timely action (advocacy – take SOPA as an example)
  3. Social media allows for seamless communication (eg, between providers, patients and providers)
  4. Social media technologies are often the first step in creating meaningful relationships
  5. Social media can be an organizer
  6. Social media can disrupt.

To offer a real life health care example of the power of social media in family medicine, consider what happened when Mike Sevilla, MD, used the social media platform to raise awareness around the pending cuts for graduate medical education. Mike’s #saveGME campaign was prolific. He was able to simultaneously educate masses through Twitter and Facebook the importance of these funds and encourage them to act. He used his connections through social media to make an impact on something that was important to him as a family physician and educator.

Looking back at Mark’s post and seeing what happened with Mike’s advocacy effort, I began to understand the true power of social media—what happens when we use these social media relationships to actually connect. What happens when these online “social” connections lead to real life engagement? What happens when we meet in real life and see that behind that avatar there is a person who can make a difference—a person that we can relate to?

While many involved in social media may have made this connection some time ago, it was not until the Conference on Practice Improvement while sitting at a table with Fred Trotter (@fredtrotter), Gregg Masters (@2healthguru), Jay Lee (@familydocwonk) and Mark Ryan (@RichmondDoc) that the true feeling of connection and how we could collectively change something in health care was felt.

In your family medicine role, are you connected to the health care community that exists outside of the walls of your residency? If not, you may want to test out those waters sometime soon as you never know what meaningful connections you will make that can help shape the future of family medicine.

Everybody Oughta Make a Change

Change in the weather, change in the sea,
Come back baby, you’ll find a change in me.
Everybody, they ought to change sometime,
Because sooner or later we have to go
down in that lonesome ground.—Eric Clapton

Listen to the song at http://www.youtube.com/watch?v=yc954MtcJkA

Stacy Brungardt, CAE STFM Executive Director

Anybody out there love Eric Clapton? What a talent to be an artist who can entertain and give a message.

This song speaks to the value of change. At STFM, we’re working to embrace change, not just for the sake of change, but because you can either react to change or be proactive and guide change for the future you envision.

How are we doing this? By scanning the environment, asking tough questions of ourselves, talking to stakeholders outside our leadership, and taking a hard look at what we do well and what we strive to become.

For example, we’ve taken on online education. We’re not great at it yet. It takes us a long time to develop online programs, and we don’t have great processes in place for measuring their relevance to members. But we believe that STFM has to be great at providing other types of education beyond our outstanding meetings, so we’re willing to struggle through this learning.

Changing our logo is another example. After thoughtful research and conversations, we realize the logo doesn’t communicate the level of professionalism that STFM and this discipline should expect. We plan to celebrate how well our logo has served us and give it the retirement it deserves. You can expect to see some new logo ideas in February.

My New Year’s resolution for STFM is to preserve what is special about STFM and make the right changes for moving the Society forward.

Thank you for making these changes with us. It is an honor to serve you and the values you represent.

We’re Listening – STFM Logo Take Two?

Jeri Hepworth, PhD, STFM President, & Stacy Brungardt, CAE, STFM Executive Director

Thanks to all of you who have commented on our logo drafts. As we discussed at the Board meeting, your input is an important part of our vetting process.

Please allow us to clarify this process.

The current logo has served us well, without question. It is a statement to members about our values.  However, as we increase our role with others, an internally-focused logo is not useful and can be detracting. Our role in medical education, transformation of health care, and advocacy work with governmental bodies and other professional organizations requires us to move forward with communications and messaging that convey the importance of the Society. Our recent communications audit tells us that others outside our membership (and even some within) don’t see our logo as one that communicates a professional, progressive organization. We celebrate our current logo, its history, and our founders who developed it. A new logo doesn’t undermine or ignore that history.

Your comments are part of an important vetting process that includes our membership, Board, and staff. The two logos that were presented are not the final logo choices, and we have not spent extravagantly in the design process.

Here’s what we are learning from our feedback gathering process.

  1. Our members read our communications. Within 24 hours, 1,522 of you had opened the email, 689 had clicked through to the web page, and 701 had clicked through to President Jeri Hepworth’s blog post. It’s good to know our messages are reaching you.
  2. Our members are engaged and feel a real connection to STFM. If you weren’t connected, you obviously wouldn’t care what our logo says/looks like.
  3. Your suggestions are constructive. You didn’t just say, “I don’t like it,” you explained why, and provided recommendations. Overall, we didn’t get the sense that most of you are opposed to change, per se, you just don’t like the change direction.

We wish we could sit down with all of you and have a conversation to listen, learn, and discuss. It’s clear that many of you want a family symbol in the logo, and we understand how important the family and the relationships it represents mean to STFM. But, we’ve also had members tell us that the definition of family is changing, and the three-person image is not inclusive of all families.

If we show a family, how does that image differentiate us from, say, a family services agency, a church, a community park, or a YMCA? If we add a medical symbol to the family, perhaps we’re then showing family medicine, but that seems like it might make more sense for an AAFP logo. We’re really about education, so do we add a book or an apple to the family and medical symbol? That would be one busy logo.

Then, consider the logos for organizations that have probably invested mega-bucks for logo research. How do golden arches visually represent cheap hamburgers? And what does Walmart’s star/flower say about discount retail? Wouldn’t a picture of a car be a more literal logo for Mercedes than a triangle? Do we really need to repeat what’s in our organization’s name in images?

Logo design principles say logos should be simple, relevant, scalable, and memorable. Your feedback indicates we may have missed the mark on “relevant.” So, we ask you to continue to share your comments, below. This is a process and everyone at STFM is listening closely to what you’re saying.