Jeffrey Walden, MD
As both physician and educator working primarily with underserved patients, I have seen time and again how the idealism in caring for patients can fall short of reality when working in our current health systems.
While it may be tempting when confronted with these shortfalls to take the easy path towards cynicism, our patients deserve better. As do our learners—it is never too early to model right behaviors when educating medical learners on various ways to tackle health disparities. And one of those ways is through patient-centered advocacy.
Remember the Stories
This past weekend I was fortunate to attend the 2018 Family Medicine Advocacy Summit in Washington, DC as a recipient of the STFM New Faculty Advocacy Scholarship. The Summit proved a great opportunity to learn more about advocacy in general, as well as the importance of putting patient stories first.
The conference ran for 2 days. The first consisted of a full day of learning about current issues in healthcare, including changes in advanced payment models, updates on health coverage in the media, strategies to engage with legislators, and the requisite discussion of opioids. As an AAFP-organized conference, Summit topics skewed heavily towards changes in the health care landscape in the United States today and how these changes affect the practicing family physician.
Despite the policy-laden tone of several presentations, the main takeaway of the day was, when dealing with legislators, to take a step back from our daily lives as clinician-scientists and do what we do best in family medicine—remember the whole patient. As physicians, data and evidence drive our medical decisions. But what really impacts policy-makers are stories of patient’s lives.
Lawmakers may hear about the escalating costs of health care in this country and the number of people who die daily from opioids; however, this cannot compare to hearing the details of how a recently laid-off mechanic can no longer afford a lifesaving antibiotic or the futile attempts to comfort a heartbroken mother who has just lost her son to drug overdose.
Putting Learning into Action
The 2nd day of the conference provided the opportunity to practice what we had learned as Summit participants broke off and met with lawmakers from each of our own states. The AAFP had already chosen the main focal points for the day, a relief for those of us who had not previously engaged in direct advocacy with lawmakers. This also meant we as physicians spoke in a unified, non-partisan voice.
Three main bills formed the main talking points. First, we promoted the Primary Care Patient Protection Act of 2018 (HR 5858), a bill that modifies the Health Savings Account law to include up to two primary care visits in any high deductible health plan with no cost sharing for the patient. High-deductible plans have become a popular way to shift the cost to “the consumer” (i.e. the patient), but what may look good on paper doesn’t always translate well to reality. High out-of-pocket costs often force patients to delay seeking care and extend lapses in health care maintenance, often with the unintended result of driving up the cost. As we reminded lawmakers, patients actually fear the costs associated with their illness more so than the illness itself—a sad state of affairs in our resource-rich country.
The other two main talking points dealt with attacking the opioid crisis and decreasing maternal mortality. For opioids, we promoted two bills: the ACE Research Act and CONNECTIONS Act, two policies geared towards expanding chronic pain research and improving state prescription drug programs. To learn more about why the United States has such a high rate of maternal mortality when compared with other industrialized countries, the Preventing Maternal Deaths Act seeks to improve maternal and child health by expanding state-based maternal mortality data collection.
Finally, and exciting for those of us in academics, we also urged our Senators to co-sponsor a bill put forward by Senator Gardner from Colorado. The Rural Physician Workforce Production Act of 2018 seeks to address the geographic maldistribution of primary care physicians in the United States by expanding training into rural areas while also maintaining current rural Teaching Health Centers.
Family Physicians as Agents of Change
Lawmakers in Washington can find themselves far removed from everyday Americans. As family physicians, we hear daily our patients struggles and stories, making us ideal advocates for those who otherwise have no voice. We know that many working-class Americans often must decide between food, putting gas into their cars, or taking care of themselves, and we know how often health slips down the rungs of hierarchical needs.
Becoming an advocate for our patients—whether on the local, regional, or national level—can be a profound tool family physicians can use to improve our patient’s health.
The day after returning from DC, I met with a patient suffering from high blood pressure, chronic pain, and an inability to afford physical therapy. I mentioned my time in DC and how we had promoted payment for alternative methods to treat pain beyond narcotics, such as massage and physical therapy. She listened and nodded, without responding. I completed my exam, made my recommendations, and ended the visit.
As I started to leave the room, she called out to me: “Doctor, one more thing—I just want to say thank you for taking the time to go and speak out for us patients.”
Her thanks, more than any other part of the weekend, reminded me the importance of advocating for our patients and inspired me to continue this work.
STFM Blog 
Hard work across preparation, admission, medical school, and family practice residency with rural training emphasis and sites can certainly increase the probability of an instate location in one of 74 counties that still have workforce and are lowest in primary care in Nebraska. The UNMC efforts resulted in 16 times greater probability of county location of need (all except 6) for those choosing the preferred family medicine career choice as compared to UNMC students not choosing FM.
But the workforce in these counties was not changed in capacity. In fact the FM docs basically replaced other FM, GP, and IM primary care. The NP and PA increases were also minimal. The names and the initials changed, but the result instate in a county of need stayed the same.
This what you should expect in 2621 counties lowest in workforce nationwide with concentrations of elderly, poor, Medicare, Medicaid, high deductible, Veteran, and worse private insurance plans along with lowest social determinants.
No matter what you do in training, the financial design ultimately shapes workforce capacity to deliver care. Even worse, these counties have had 1 billion a year subtracted by HITECH to MACRA to PCMH leaving 30 billion where 38 billion a year once existed.
The leadership of the families of family medicine has to realize that the financial design is the only fight to win – and not by creating another complex payment design or more costly performance based plans that cost too much and penalize those caring for populations with inherently lower outcomes.
It is in the literature – but it is more politically correct to believe the assumptions regarding value, innovations, incentives, certifications, and the power of training.
Those who market digitalization, innovation, certification, consultation, and regulation have yet to demonstrate the worth of the substantial costs incurred, with 30 – 100% higher costs per primary care physician where workforce, finances, and access are already least.
Do No Harm can be direct. It can also redirect as seen in distractions from a focus on real solutions – real health reform cognitive vs procedural and payment equity. This is not the current design that sends least payments for the basic generalist and general specialty workforce that provides 90% of local services where half of Americans have half enough. It is not the design that sends 15% to 30% less payment for the same service for small practices and small hospitals facing the greatest challenges with the least support.
Do No Harm must also include future family physicians. We should not promote a career without successfully providing the necessary support for that career and for the team members to share the load and turn family practice from most burned out to most fulfilling.