Reflections

Now that my sleep deprived self is back in Boston I wanted to share some final reflections:

Through this conference, the importance of family medicine became very apparent. From the opening talk on family medicine's contributions and roles to the different workshops that explain family medicine's approaches to the plethora of family medicine residency programs at the exhibit, the different structures that make up family medicine became apparent. And family medicine no longer seems like the "dead end" road that it has been touted as by so many. There are academic tracks, rural tracks, urban tracks, international opportunities, double board with preventive medicine tracks, residencies with dual MPHs or MBAs.

I entered into this conference not really with a directed purpose. I wasn't a fourth year medical student desperately trying to impress residency directors at the exhibits, I wasn't a delegate fighting for an elected position on AAFP (I wasn't, unlike Marcel, trying to blog every second of my time at the conference). But I came away with a better sense of the scope of family medicine and the impact it has on individuals and families' lives. Mentally, I revisited my med school applications and looked at my motivations for becoming a doctor throughout the conference - and I realized that family medicine and my motivations fit like an fitted enzyme-substrate complex.

NC'08...We're all in this together

As the last couple of sessions draw to a close, the crowds are getting scarcer and scarcer. MS-4s have walked the exhibit hall floor in their sleep, chanting "Hi, I'm a 4th year student at____, and I'm interested in ______. Tell me about your program." Residents know the lines and have perfected their responses and the way they will integrate the variety of brochures, freebies, and posters into their sales pitch. The military recruiters are still in full dress. Conference organizers are taking down the now-outdated session posters. The last of the Monopoly-like food tickets are being used at the food stands. Yes, the the 2008 AAFP National Conference for Residents and Students is almost over.

People attended sessions ranged from "Reading a 12-Lead ECG" to "Financial Planning for Residents and Students." In doing so, as with most conferences, a sort of group culture was developed. With the conference theme being "Global Health," one of the major group perspectives was that the field of Family Medicine has the unique position to be a potential coordinator & bridge-maker for groups from different backgrounds that need to work together in the field...whether that is internationally or domestically, in rural or urban environments, or with people of all ages, genders, and ethnic backgrounds.

Given this movement of students/residents/faculty/practitioners, Boston University School of Medicine has a great potential to become a bastion for Family Medicine, and thus, the future of medical practice. We have strong international collaborations, a history of working with community clinics in Boston, an excellent School of Public Health only steps away, and integration into a hospital with progressive programs in health care that have national renown. Perhaps Boston University faculty, residents and students can be a major force at the 2009 AAFP National Conference.

Yes, the sessions were interesting, the variety of residency programs was impressive, and the featured speakers were inspiring. However, the most important and immediate result from this conference was the personal bonding that occurred between people interested in providing primary health care for other people. MS-4s discovered people and programs that they only dreamed existed. MS-2s connected with students, residents, and faculty members from their own schools and in sharing trials and experiences, emerged more unified and optimistic. This showed that there's a great potential for changing the world, and changing ourselves, if we choose to work together.

MBA for "MD-ummies"

The University of Missouri-Kansas City Family Practice Residency program offers a MBA that's integrated into their 3-year program. The residency director and one resident, both who have completed the MBA program, gave their version of the...
Top 10 Things a Medical Resident and Student Should Learn from an MBA.

#1 Change Management
#2 Marketing
#3 Leadership
#4 Economics
#5 HIPAA/EHR/Technology
#6 Outsourcing & Offshoring
#7 Quality
#8 Balance Sheet
#9 Advocacy
#10 When you don't know why something is the way it is...Money is the answer.

The skills that they talked about directly related to the practice of Family Medicine. They made a strong argument for understanding these concepts, if not for getting an MBA. It was stressed that the residents who got an MBA didn't do so to go into finance or insurance or some other higher-paying job, but to be more effective in their current positions as administrators, patient advocates, and physicians.

Given some of the ties between BUSM and the BU School of Management, it might be interesting for FMIG to host a workshop/lecture on the "Business of Family Medicine."

Workshop: Dental Emergencies and Procedures

Two months ago I would have wondered why a workshop on dental care was relevant to a medical conference. But having researched on the effects of dental problems for the past 7 weeks, I was delighted that such a workshop was included!

Why is dental care important to a family doctor?

• dental problems is the most common childhood disease (40% prevalence)!
• rural communities and minority groups often do not have access to dentists
• dental pain can interfere with intellectual, social, emotional development and daily functions
• even in places where there are dentists, family doctors often serve to screen for dental problems in check-ups
• the teeth are a part of the body and affect the rest of the body holistically; it cannot be looked at in isolation from the rest of the body by dentists only

The speaker was from rural Maine where almost no one has access to dental care and he does dental screening, extractions, anesthesia and other basic dental procedures. He spoke about diagnosing different dental problems and discussed that antibiotics are over prescribed by most medical doctors for dental problems when they are not effective.

To learn more about oral health to treat your future patients: www.fmdrl.org or stfm.org/oralhealth.

Global Health Panel

This panel is talking about Global Health in general and the Family
Physician's role in health care internationally. They mention WONCA (http://www.globalfamilydoctor.com), an international organization or organizations of which the AAFP is a member.

Q&A:

A comment was made by a student from Alabama about the importance of recognizing underserved populations domestically that have very similar problems to those internationally.

(applause)

Q: What value does an "outside" health care professional offer to a population internationally?
A: The goal is not to bring US system abroad, but to listen to the community and provide necessary resources for the local population. This includes education and material support. The first step is listening.

Q: What is the Family Medicine community doing to be more known in the field of Global Health?
A: WONCA is part of the WHO and are trying to implement policy to promote FM. There is also a lack of individual promotion of work being done by Family docs internationally.

Some publication that were mentioned:
- "Health System Change: the contribution of Family Medicine" (WHO & WONCA)
- "Directory of Residencies with International Rotations" (AAFP)

Closing Remarks:
We have a responsibily to promote FM without paternalism & arrogance. We have a lot to learn about health care as a human right, about equity in a society, and about population medicine. So, at the end of the day, let's make sure that wherever we go, that place is better off for us having been there.

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Comments:
The Global Health movement is combining international health with health of underserved populations domestically, realizing that they have similar challenges. I can imagine that the next step in this logic is really redifining "health care" as a human right. That a human is a human is a human, no matter the geography. That the health of a population, as determined by system-wide structures, matters to the health of an individual. I see Family Medicine as uniquely poised to lead the way in this movement and that's why I am choosing this path!

Family of Family Medicine

This is part of the BUSM family of Family Medicine. We are medical students and residents. We are dedicated to serving our people. And we love eating steaks, ribs, chicken, beans, and corn together in Kansas City while at the AAFP National Conference.

It's great to be able to share insights and experiences across medical class lines. There's so much to be gained from sharing and reflecting! As it turns out, many of the other FMIGs at other schools have structured programs for this kind of contact: mentors, combined academic activities, and combined social activities.

There's so much potential for our own group at BUSM. Both Sebastian and I have noticed this from the few interactions we've had here, starting with the FMIG Leadership Development seminar on Wednesday, that we have a great opportunity for our FMIG to develop and grow. We want to bring a positive culture of Family Medicine to BU School of Medicine. With what started at this conference, let's create a family of Family Medicine at BUSM!

List of free things to date

-2 USB flashdrives (1 GB and 512 MB)
-1 nonfiction book
-1 water bottle
-1 shot glass
-4 golf tees
-1 plastic buffalo toy
-1 back massager
-1 t-shirt
-1 scrub top
-1 lanyard
-2 lights
-too many pens and highlighters
-1 pocket book on interpreting ECGs
-1 frisbee
-guide to common outpatient problems

Small Session: Dealing with Drug-Seeking Behavior

After showing a brief ER clip featuring a patient who threatens the ER docs with a gun to get an analgesic drug injection, there's a presentation on drug addiction. They mention 2 articles, Addiction Part 1 and Addiction Part 2, published in American Family Physician that are highly recommended.

They are doing a simulated encounter...
It's a packed room yet volunteers are hesitant. A 2nd year med student has volunteered, but was then replaced by a "more experienced" resident.

The point of the exercise, which featured two patients with different backgrounds an appearance (i.e. Biker and lawyer), was to highlight how backgound cannot necessarily predict likelihood of drug seeking behavior.

It's helpful to see this behavior in a simulated setting so that the experience is dynamic and real, yet can be paused and analyzed by our trainers. I would love to see this kinf of session done in a small group setting at school. Perhaps HBM could feature more simulations so that students can practice both sides of the encounter and get inside the psychology of both roles.

Health Care for All: the AAFP Plan

This was the title of my morning's workshop. AAFP has developed a plan that focuses on the medical home. The medical home model is based on health care being centered at a primary care office whether the actual health care takes place in the primary care office. I.e. the patient always has a person to talk to abouthealth care and keep track of their records.

It does seem to be lacking in details in terms of reimbursement but it is a good idealistic model to begin with. The President of AAFP presented and was very enthusiastic about it!

Small Session: Models of Global Health Education

This is a presentation of the "Shoulder to Shoulder" model where they
developed a partnership between community and medical academia for
global health work. They have a long-term relationship with a
population in Honduras. This allows for increased impact and more
effective use of resources.

One of the big questions that the organization is trying to answer is,
"What is the best way of training future physicians to work on Global
Health?"

Tip: "If you need something from a job, get it before you start."
that's how he got funding to do global health education from an
academic position.

2005-2006 survey of global health opportunities in Family Med
Residency Training

Important to learn about systems-based perspectives in health.

Factors that don't determine involvement:
- administrative support
- school location: urban, suburban, rural
- length of non-GH rotations (ex. Surgery)

Main point: there are many opportunities for Global Health training
within Family Medicine Residencies.

"Never doubt that a small group of dedicated individuals can change
the world, indeed it is the only thing that ever has"
-Margaret Mead

Q&A:
Q: Is there formal coordination with MPH Programs?
A: No. Usually students take an extra 2 years to complete.

----------
It's great that a Family Physician can train to be prepared for
systems-based and individual health improvement both domestically and
internationally.

Residency Exhibits

Yes, that's a motorcycle at the booth. I'm not sure what it has to do
with family medicine, unless there's also a helmet there as well.

It's cool to see so many programs turning out in one place: New
Mexico, UC San Diego, Morehouse, Albany...and yes, BUSM!

It really makes you feel that it's all possible. You can shape your
own path.

"Small things with great love"

That is a famous quote from Mother Teresa and the key to a successful life in medicine.

That is what Dr. Morsch spoke about today in this morning's lecture. We each have choices to make in our lives and reasons why we make them. We must accept that we cannot do everything but that each day we can make a small difference!

The key question to ask each of ourselves:
Why did we want to become physicians and how are we going to live that out in our lives and relationships?

Enough said. Back to the conference!

"Why is family medicine the most important?"

Arriving at the Kansas City Airport, I saw only cornfields. But my expectations were quickly fulfilled when I checked in at the hotel and was offered free champagne (or sparkling cider).

Each talk I have attended so far has made me question my motivations, ask the deeper questions and look at the bigger picture. The first talk last night examined the importance of primary care, in particular family medicine. Family doctors, Dr. Roberts, argued contribute the most the people’s health. And he showed that through epidemiological studies: increasing family doctors in a population lowers morbidity and mortality while increasing specialists increases both! I learned that we need to focus on the serving each individual person holistically. To see what each person really wants from you as their provider. Heroic medicine is what is popularly publicized in the media: we hear about the woman saved by an innovative heart surgery or the military helicopter rescues of people in flooding situations. We don’t hear about 50,000 children immunized against rubella or the long-term support physicians that go into flooding situations and help people re-establish the management of their chronic illnesses and provide emotional support. We need to focus on these long-term management treatments. That is what our patients need and we need to learn to serve the people we work with.

Small Session: Rural health care

Facts:
- 90% of physicians in rural areas are Family Doctors
- If you took all family docs out of non-shortage rural areas, 70%
would become shortage areas
- Family docs are best equipped to meet varied needs of rural population

How does one make it work?
1) One can really shape their practice to what they enjoy doing. The
speaker has done her own C-Sections.

2) Also, although it's hard to hide from patients, patients are
incredibly loyal. People care for one another and there's time for
building relationships

3) Can implement the "Medical Home."

4) You get to see the big picture. See patients at little league,
picnics, etc. So you get to treat the disease and the whole patient.

5) Marriage between docs is possible, but not easy.

6) Reimbursement is just as good as or better than urban colleagues.
Higher for a hospital-owned clinic. Clinic refers back to
hospital...stay local and supports hospital.

7) Call limitations. Used "Docs who Care" to supplement on call. Can
be reduced to as little as once per week and one weekend per month.

8) More mid-level practitioners. Can get two mid-levels for the price
of one doc. Can really support each other and complement each other's
work.

9) How to get here? Choose your learning path and don't lose your
focus. Pay attention to all rotations as you will be applying all
skills and lnowledge that you gain. Choose residencies/experiences to
best prepare you for being the "only" doc in town.

10) Choose your town wisely. Know who you are, who your spouse is, and
who your children are. Visit without them knowing you're there. Get a
feel for the lay of the land.

Some myths about Rural Practice:
- you will be poor
- you will be paid in livestock & pie
- you will always be on call
- you have to do everything

Little foxes to watch for when choosing career path:
- Know your personal limits. Your marriage and family must be more
important than medicine at all times. There's a high divorce rate.
"Medicine is a jealous mistress." Patient is friend and friend is
patient. Need to define roles in different settings. Can be very
difficult to handle this balance.

- Know the boudaries of you medical knowledge. Have a good referral
team. Find the people you are comfortable working with.

- be wary of benefits/incentives

- You will be expected to be a leader in your community. This can be a
reward for some and a challenge for others.

Questions from audience:
Q: Do you have to pay more for malpractice insurance if you have a
greater scope of practice?
A: Yes, but it depends on the state

Q: Why did you reduce your scope of services?
A: Personal priorities and comfort level. It's important to define
your own niche.

Q: What are challenges in moving from big to small towns?
A: Speaker had a process of adjustment. Greatest challenge was not
having restaurant and other cultural opportunities. There's evidence
to show that docs that come from urban setting have larger retention
in rural setting than those that come from rural setting.

----------------

Review:
Overall, this session was valuable for busting myths about rural
practice. I think a lot of people remove this possibility without even
investigating or testing the water. In today's connected world, I
imagine that rural practice is increasingly rewarding for those who
are afraid of losing touch with the urban culture. Rural USA also
presents a huge opportunity for social justice work. You can make a
huge difference in your community. You can be on the school board and
create policies that directly affect your pediatrics patients on a
systems level. The challenges presented are similar to international
health and are encmpassed in "global" health. How can we tell others
how to do things without doing things right at home?

Dr. Gary Morsch on the Passion to Serve

Dr. Morsch is talking about choice vs. chance in life decisions. "Are
you in Medicine by choice or by chance?" You worked hard as an
undergrad and made many choices to get here. As medical students and
residents you continue to make choices about what you will do.
"Choices are made with a goal in mind."

Remember when you were interviewing for medical school, and you were
inevitably asked "Why do you want to be a doctor?" Think about your
original answer. Is it still the reason why you're doing this?

For Dr. Morsch, it's not about money, prestige, or initials by your
name...it's about changing people's lives.

He made 3 important choices in his life:
1) To go into Family Medicine. It's the specialty that gives you the
greatest opportunity to serve people (applause).

2) To make a difference. You can do many things outside of you
practice to: politics, community service, and anything else you can
think of.

3) To serve. He met Mother Teresa and worked with her off-and-on over
the last years of her life. She wanted him to go to the Home for the
Dying. He thought he could use his medical training to make a
difference. After walking past the men's ward, the women's ward, and
the kitchen, the Sister in charge asked him to bring a pile of garbage
to the city dump. He thought, "This is ridiculous! I'm a doctor. Why
am I hauling trash?" When he decided to quit for the day, he saw
Mother Teresa's words on the wall: "We can do no great things, only
small things, but with great love." That's what Family Medicine is
about, the opportunity to serve one human bring with love.

"Thank you." (applause)

Copies of his book, "The Power of Serving Others" is available in the
lobby for free. He requests donations to his NGO.

What a great start to Day 2!

Good mornng KC!

It's 8:18 and here's the view of the conference center and municipal
exhibition hall from our hotel...the one that serves complementary
champagne upon signing in.

First lecture starts at 8:30am. Stay tuned for more updates!

Live from the AAFP National Conference...Day 1

You can feel the energy at Day One of the AAFP National Conference here in Kansas City, Missouri (not Kansas). The day started at 2:00pm with the FMIG Leadership Roundtable where we met up with other FMIG leaders from Region 4 (Northeastern USA) and talked about ideas and strategies for promoting Family Medicine on our campuses.

The day went on with a lecture on analyzing 12-Lead ECGs followed by a quick nap and brief social period with hor d'oeuvres.

It's nice to connect with 3rd and 4th year students as well as residents interested in Family Medicine from BUSM and from other programs around the country. Tomorrow, the action continues with more sessions and the opening of the exhibit sessions.