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Friday Apr 20, 2018

Advocacy, Like Sailing, Means Navigating Turbulent Seas

I love sailing in Alaska. It's cold, and you have to watch for icebergs and tankers, but the balance between the lift of wind-filled sails and the force of water against keel and rudder calls to me in a visceral way.

[John Cullen, M.D., sailing in Alaska]

Looking for wind coming out of bays and passes. The spray of waves against the bow. It can be frustrating at times because you are not always able to go in the direction you want. When the wind is blowing from your destination, you can't go there directly. The best you can do is 32 degrees to the wind.

There are dangers, too. The water in Alaska is cold, and falling in brings hypothermia in minutes. There also are the aforementioned icebergs. The large ones are easy to avoid, but the small, clear ones are hard to see until you are nearly on top of them. Sometimes there is so much ice in the water that we have to use poles to push it away from the bow to get through. And there are winds called williwaws that come out of nowhere and turn the sea black with their power. If you have a problem, there often is no one who can come quickly to your aid.

My family was sailing from the Knight Island Passage to Naked Island in our 28-foot trimaran when we were caught by a williwaw. The wind rose to 50 mph in moments and waves started to build. It is interesting when the wind is blowing so hard that the distinction between air and water is blurred. Our only option, Cabin Bay, was directly upwind, so we tacked as close to the wind as possible, cutting both the waves and the wind at an angle. Two of my kids were seasick. Another was gleefully bouncing off the walls, floor and ceiling of the tiny cabin. It took hours of zig-zagging until we reached the shelter of the bay. Each tack meant crossing the face of wind and waves, and required precision and teamwork in changing the sails lest we founder.

I was recently at a leadership conference, and those sitting at my table were asked what metaphorical type of transportation our organization was. Many ideas were discussed: trains, airplanes, battleships. For me, the AAFP is a sailboat. Don't get me wrong. I would love to be driving a battleship, heading in a straight line anywhere we want to go regardless of the weather or competing interests. Sadly, this is not the case.

For a non-sailor, the first impression upon boarding a sailboat is a confusion of lines and pulleys. The names are arcane. Even the concepts are new: tacking, jibing, wing-on-wing. Yet the point of all this is a boat that can adapt to conditions to allow a safe and quick passage.

Like sailing in Alaska, our country has incredibly complex and turbulent systems for both health care and government. Even within the AAFP, family physicians practice in such a wide variety of settings and come from such diverse backgrounds and perspectives that reaching consensus isn't easy.

Our family physician numbers are increasing, and yet we are receiving a diminishing percentage of the total health care spend, and the percentage of visits to primary care is decreasing, as well. I think this is in large part due to electronic health records decreasing our productivity, but there are other forces at work, as well. The AAFP is a large organization, yet our total revenue is less than the income of EHR and health insurance CEOs. We have a political action committee, but fewer than 8 percent of our members have donated to it. Meanwhile, those same insurance companies and CEOs can donate as much money to super PACs as they want as a result of the Citizens United ruling. Facility fees make buying private practices lucrative for hospital systems, which can then further increase the price of health care by eliminating competition.

I am not making excuses, just pointing out the difficulties we face in changing our health care system.

Meanwhile, infant and maternal mortality is increasing, especially in rural and minority populations. It has been well documented that investing in primary care lowers overall health care costs and improves outcomes. Our current health care system is not sustainable. We spend a greater proportion of GDP on health care than any other country, and by 2025, if not sooner, half of average income will be spent on health care.

On the other hand, we have an amazing organization that represents 129,000 family physicians and medical students. As family physicians, our core beliefs give us a moral standing not shared by most health care organizations. In fact, the AAFP ranked third in overall reputation among the largest advocacy organizations (regardless of industry) in Washington in a 2017 review that included interviews with more than 2,000 administration officials, congressional staff members and others. The Academy ranked second in influence among all organizations in the same review. Clearly, we have advocacy, marketing and communications teams who believe in the value of family medicine and are effective at getting our message to those who need to hear it.

I feel your frustration with our health care system. It matches my own. I am not counseling patience. This is not the time. I am asking for your involvement at the local, state and national level. Hundreds of our fellow family physicians will be in Washington, D.C., May 21-22 for the Family Medicine Advocacy Summit. We will be talking to legislators and congressional staff about issues important to primary care, including opioids, payment and health care coverage.

Even if you can't be in Washington, you can still be an advocate for family medicine. Today, the AAFP initiated Speak Out campaigns related to tobacco regulation and physician training. Sharing your story with your elected representatives about issues that affect primary care is not only cathartic, it is your First Amendment right.

If you haven't given to FamMedPAC, please consider doing so. I would love to live in a world where political action committees, and especially super PACs, were not part of our political system. Sadly, that is not the world we live in, and we are getting mauled in D.C. by other organizations whose culture mandates that all members contribute to their PAC. We need our PAC to allow us to support candidates who understand the importance of family medicine to our health care system. This year, there are more physicians than ever running or planning on running for national office.

As a specialty, we are facing a stiff headwind and dark and turbulent seas. What I know from sailing in Alaska is that despite the rough conditions, we can go where we want to go. Just not necessarily in a straight line to our destination, and not without teamwork and engagement.

John Cullen, M.D., is president-elect of the AAFP.

Posted at 10:58AM Apr 20, 2018 by John Cullen, M.D.

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