Author Archives: stfmguestblogger

The Joy In Family Medicine

TamAnthony

Anthony Tam, MD
University of Michigan FMR

When I look back and think about who I thought a doctor was when I was a kid, I imagined that person taking care of kids, adults, and even pregnant mothers. I saw them as a primary responder for minor injuries and illnesses or even for acute processes. And I looked up to these role models and hoped that, some day, I could be that doctor and role model for others. It wasn’t until medical school that I figured out the role model I looked up to was a family medicine physician.

After doing my clerkship rotation in family medicine, I knew this was the field I wanted to enter. A specific patient I had talked to at the clinic was “Mary”.  Mary had come in for a follow-up on her thyroid medication. Routinely, I went in before the resident I was working with to talk to “Mary” and discuss any issues she had. She suddenly burst into tears about how she has been feeling sad and giving up on life. However, after a long discussion about how much good she had done for her family, kids, and community, she came to the conclusion that she deserved to be alive and should continue helping others.  When my resident came in to review what we had discussed, the first thing “Mary” said was, “Will this be the doctor that will replace you when you are gone?  I felt so comfortable talking to him about my troubles in life and really hope that I can continue seeing him in the future for my care.”  It was this moment when I knew that family medicine was the career path for me. I wanted to be that doctor that builds trust in relationships and provides the care that any person needs, regardless of their economic or social situation.

Family physicians present themselves with great confidence, leadership, and sincerity.  They exude confidence by helping patients make informed decisions on preventive care.  They show true leadership in working with not only other doctors, but also the staff that helps run the clinic. And most importantly, they show true sincerity in making sure each patient feels as though they are being seen by a doctor that cares about them.

How do I know that I chose the right profession?  Fast forward now to my second year in a family medicine residency where I am looking forward to the days I have clinic so I can see the patients I started seeing as an intern. The staff I work with make me smile every day I’m here and I enjoy the time I spend in clinic.  I exit each room with my patients laughing and catching up with their lives as I walk them out to checkout.

The great, long-lasting relationships and trust developed with a patient and the continuity of care are priceless. I am so happy to have matched into an amazing family medicine residency that helps me become the doctor whose hand patients can hold in a time of sorrow, the one who encourages them to make the right lifestyle choices, or maybe even the one who takes care of an injured athlete on the field. I am more than eager to continue my time here with Michigan Medicine.

Top Ten Tips for Getting Promoted

Schrager_Sarina

Sarina Schrager, MD, MS

I can still remember charging my old PalmPilot in order to page through week by week, trying to find the dates of all of my lectures. I was preparing for promotion and felt overwhelmed because I had not kept track of all my work each year. Now I had to collate years of academic projects and lectures, from memory! I knew I was not alone as many of my colleagues were lamenting about the same collection process. The Women in Family Medicine Collaborative has recently collected some tips for promotion which form the basis for this blog post. These tips are geared for people at medical schools, but many will also be applicable for community program faculty as career development. Thank you to everyone who contributed to the list.

I tell the junior faculty in my department that the members of the promotion committee are nice people, people just like you and me, and they want to help you get promoted. No promotions committee gets together and sets a goal of denying people promotion. They want you to succeed. That said, it is your responsibility to be productive, keep organized, and prepare all the materials necessary.

#10—Read the promotion guidelines for your institution. I am calling this number 10, but in reality it should be the first thing that you do after you get hired. Every institution is different. Every tract is different. You need to know exactly what is expected and required for you to get promoted. And re-read these every few years, as medical schools will periodically revise the promotion guidelines

#9—Get organized. After reading the promotion guidelines, get organized! You don’t want to be like me, paging through your calendar to see when you have given presentations and handed in projects. Many people have both paper and electronic files to keep all evaluations, feedback forms, innovative curricula, PowerPoint slides, etc. You may want files titled: clinical, research, teaching, QI, curriculum design, mentees, etc.

#8—Find mentors. Many departments or programs will assign you a mentor or mentors. This is very helpful as you navigate the local system and infrastructure. You may look for mentors in other departments or disciplines, or even look outside your institution for mentors who have similar interests. The STFM Collaboratives and conferences are wonderful places to find mentors as well. Many people have formal mentors (ie, those assigned to them by their department or program) as well as informal mentors (those people you talk to in the hall, or have coffee with a couple of times a year). The Collaborative on Women in Family Medicine has provided me with many mentors through meetings and the listserv—people with whom I have written, presented, and served on committees. Mentors can also be very helpful when you are deciding whether to say yes or no to requests for your time.

#7—Develop two or three areas of scholarship. As family doctors, we all have many interests. But, in order to develop a story about yourself for your promotion, having a few themes makes sense. When you are early in your career, it helps to focus on two or three areas of scholarship. That way, you are able to develop a portfolio of work on each of the areas and demonstrate that you are an expert. Once you are promoted, there is nothing to say that you can’t change your focus and develop two or three different areas.

#6—Make everything count twice. Promotions committees look at quality of work as well as quantity of work. Don’t let your work get lost. Using the same background research, you can transform your presentation into a publication. If you do grand rounds, consider turning it into a review article. If you are working on a QI project, get pre- and post-data for comparison. You may be able to present or write about it.

#5—Keep your CV updated. Some people update their CVs as soon as a paper gets accepted or they do a presentation. Other people have a scheduled time every month, or every 6 months to add new activities. You may want to keep more than one CV—one that is long and includes everything (including students mentored and community talks and activities), and another that is more streamlined. Another suggestion is to make sure to date each CV, so that you always know the most recent one. Some people keep a CV saved on a Google drive so that they can update it from any computer.

#4—Find collaborators who can help increase your productivity. Many of us work with residents and medical students. Take advantage of their requirements for scholarly activity. Also, working with colleagues on research or a clinical review will make the work go faster and be fun. Have an idea for a presentation? Send a message to the STFM Collaboratives looking for co-presenters. It is a great way to meet people who have similar interests (see #2).

#3—Promote yourself locally and nationally. You need to demonstrate that you have a reputation outside your institution. One way of doing that is to volunteer to participate on working groups, committees, or conferences. You can go to your local AAFP chapter or join a national advocacy group. Pretty soon, you will be given more responsibility in the organizations.

#2—Network and build relationships. No matter how introverted you are, networking is a part of our jobs and vitally important for promotion. Most institutions will require you to have at least one “arms length” letter of recommendation for promotion. This is a letter from someone outside of your institution who doesn’t have a vested interest in your promotion. It should not be your residency faculty, or someone you worked closely with at a previous job, but someone you may know peripherally from your time on a committee, or a work group.

#1—Do your job. Do a great job. Follow your passion and successful promotion will follow. Be diligent about scholarly productivity and it will be obvious to the committee that you are a committed, energetic, and valuable member of the faculty.

The Seven Words That Can’t Be Said by the CDC: Hints at Policy Inclinations

morleycp

Christopher Morley, PhD

Recently, the Washington Post reported that the Trump administration was attempting to prohibit the Centers for Disease Control and Prevention’s (CDC’s) use of seven words in official documents being prepared for the next budget cycle, including the terms “vulnerable,” “entitlement,” “diversity,” “transgender,” “fetus,” “evidence-based,” and “science-based.” Each term aligns with hot-button issues in American politics that represent anathema to right-wing populist sentiments. The first four terms appear to target programs and research that focus on disadvantaged groups and social safety nets (vulnerable, entitlement, diversity, and transgender). One term may quickly recall debates about abortion rights (fetus), and the final two terms (evidence- and science-based) are part and parcel of essentially everything the CDC does.

Suffice it to say, there was a public backlash against the “ban,” including speculation about political calculations behind each word. Other public outrage was directed at the appearance of censorship, inspiring social media hashtags, such as #CDC7words and #Censorship. In fairness, a spokesperson for the CDC has described the story as a “complete mischaracterization of discussions regarding the budget formulation process.” However, public, medical, and scientific concerns remain.

Beyond the apparent conflicts between the banning of the seven words and the online statement of mission and roles of the CDC, what are the actual policies that might be affected, or at least targeted by such an alteration of the CDC’s vocabulary? As others have also recently noted, looking closely at how the CDC actually employs the targeted words is revealing. Rather than simply relying on speculation, I conducted a quick content analysis of one document that should be representative of the CDC’s recent budget priorities, the Justification of Estimates for Appropriations Committees of the CDC for Fiscal Year 2017. I ran a word search for each of the purportedly banned terms, to explore how extensively such a document might be affected by the alteration or deletion of these terms, as well as to quickly assess the actual contexts in which these terms are used.

How the Terms are Used 

As shown in the the accompanying chart, “entitlement” does not appear in the 2017 budget narrative, but health-related entitlements are named throughout, (eg, Medicaid and Medicare). The concept of entitlements (a right to something, guaranteed by law) also applies to such programs as the Vaccines for Children Program, which is an entitlement provided by section 1928 of the 1994 Social Security Law. “Fetus” also does not appear, but “fetal” does, referring to birth defects, fetal death, or fetal alcohol syndrome.

The term “diversity” is used with some diversity, but with only seven instances throughout the 2017 document. The context alternates between reference to the Office of Minority Health and Health Equity’s Diversity Management Program, as well as (separately) to diversity in microbial strains, in the context of the rise of antimicrobial-resistant strains of pathogens.

The term “transgender” is predictably used only in the context of broader discussions related to the LGBT community. This may be notable because of the political division between broader LGBT issues (eg, the wide acceptance of same-sex marriage rights), as opposed to specific public debates that apply directly to transgender people (eg, bathroom usage or military service).

The term “vulnerable” is used more widely, in ways a public health professional might expect, referring to “vulnerable populations.” However, the specific vulnerabilities highlight potential conflicts with administration policy stances. For example, over half of the uses refer to those vulnerable to infectious diseases, and the term overlaps with both refugee resettlement efforts, as well as to trends in new cases of tuberculosis, which appear at a higher rate as new cases in “foreign born” individuals. Introducing vaccination to vulnerable populations is an additional theme.

The usage of both “evidence-based” as well as the near synonym, “science-based,” is so extensive that it is impossible to provide a summary that is both succinct and sufficiently detailed. However, many issues where an “evidence-based” approach is described have generated controversy, including screening guidelines for breast or prostate cancer. Beyond the conflict between evidence and public desire for cancer screening (whether it saves lives or not), the term “evidence-based,” and particularly the term “science-based,” both appear prominently in a variety of discussions about vaccination.

Interpretation

If there is a policy-oriented intentionality to the word ban, then there are ominous themes that link seemingly unrelated terms. Five of the seven words are often used in the context of vaccination, and several refer in some way to underserved care. Across several terms, there also appears to be a link to refugees or foreign-born individuals. Additionally, the specific call-out of the term “transgender” from the broader LGBT context may signal the use of this term—and this population—as a political wedge.

On the other hand, if political exigency or ideology, as opposed to a logical, rational process was employed in the identification of these terms, then the potential for accidental damage in the banning of words, and the downstream effects on policy, will have unintended consequences. For example, concern over the term “evidence-based” will affect programs across the entire CDC; an ideological irritation with the concept of “diversity” will not only impact the broadening of representation in positions of authority, but also may impact how the development of new antimicrobial compounds are developed.

This quick analysis is based on a review of one budget justification, covering the current fiscal year. A broader analysis of documents across all of CDC may reveal other themes in the logic behind the selection of terms by the administration. Or, one could simply ask why the seven words named above are poised to become a “no-go” zone for the nation’s top public health agency. With limited hopes for that line of questioning, we are left to extrapolate from content, knowledge, and professional familiarity with the terms and with CDC programs.

Regardless, this quick analysis underscores the fact that interference in open conversation about the implementation of public health, whether the result of intentional policy targeting, or simply due to ideological word policing, stand counter to the proper functioning of a national, science-driven agency established to protect the health of the American people.

 

Table: Terms Indicated as “Prohibited” in CDC Budget Requests by Trump Administration, as per Washington Post
Term Count of Uses Note
Vulnerable 24 50% of instances refer to infectious diseases or vaccination; overlap with immigrant (TB) refugee or international (Ebola) issues Targets many populations not favored by the right (poor, HIV infected, environmental exposures), also used in relation to TB control, noting “foreign born” individuals are contributing to a larger percentage of new cases; term also connected with refugee resettlement, a substantial issue in current federal politics in the US.
Entitlement 0 Not used as a term in 2017 Congressional Justification Despite not being used as a term, words referring to health-related entitlements appear throughout, eg “Medicare” appears 36 times often in reference to Centers for Medicare and Medicaid, but 10 usages referring to Medicare itself.
Diversity 7 Used in a variety of ways, including both diversity of programs, including “Diversity Management Program,” which provides “leadership for CDC wide policies, strategies, planning, and evaluation to eliminate health disparities.” This term is used in several ways: diversity of thought and of personnel within the CDC; diversity within society; and unrelated to these concepts, diversity of microbial strains in the context of antimicrobial resistance.
Transgender 10 Used exclusively in the context of HIV programs, almost always in conjunction with identifiers of other populations (eg, men who have sex with men [MSM]) The term is often used in a broader context of LGBT-focused discussions. However, other terms that would have once been “hot-button” issues are not targeted (eg, “homosexual,” “MSM,” etc)
Fetus 0 Not used as a term in 2017 Congressional Justification At least based upon the 2017 budget document, the term “fetus” is not used. Other related terms were searched (foetus, fetal), and “fetal” appears 17 times, exclusively related to Fetal Alchol Syndrome, Fetal Death, or Birth Defects.
Evidence-based 119 119 usages; wide variety of programs The term is used across the document applied to a variety of other terms, programs, and concepts.
Science-based 4 4 usages; 2 in relation to biosafety inspection, 1 related to communication efforts related to vaccines, and 1 related to injury and violence prevention initiatives. Half of “science-based” occurrences (2 of 4) relate to politically sensitive terms: vaccinations, and “injury and violence prevention initiatives,” which might reflect a sensitivity to programs or research on gun violence.