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Friday Jul 12, 2019

We Can't Leave Health Care Policies to Chance

During my tenure on the AAFP Board of Directors, I have had the privilege of attending more than a dozen chapter meetings and regional events. Each meeting is unique in its design and focus. What I enjoy most about these travels to various regions of our great country is meeting with family physicians on their home field. I can more vividly remember a member's personal story of passion or frustration having stood in their community.

[boardwalk chance card and tokens]

During my president-elect year, the number of invitations I have received from chapters has increased dramatically. One of the most common questions members ask me is, "How do you still find time to see patients in your practice?" I often sense that their real question is, "Are you still practicing medicine? Can you, as an AAFP leader, relate to my daily challenge of being a family physician in the trenches?"

The genesis of this post occurred during a recent visit to the New Jersey AFP Fam Med Forum and House of Delegates. As I was leaving my home in Dayton, Ohio, I walked past a table where my Monopoly game had been left open. I set my luggage down for a moment to look at the property names on the board. I had forgotten about the historic connection between this classic American board game and Atlantic City, N.J., which was once known as "the World's Playground."

The famous boardwalk was built in 1870 to keep visitors from tracking sand from the beach back to the doorways of hotels, restaurants and railway passenger cars. The six-mile long, herringbone-patterned boardwalk is the longest permanent wooden structure in the world. With any luck, I thought, I would have time to take a walk on the boardwalk, the most prized property in the game.

Prior to my arrival I had done my usual homework, visiting the chapter's website to become familiar with member interests, leadership, resources and culture. There I found an overview of the NJAFP Fam Med Forum. In an effort to increase involvement of the 200-plus Forum attendees, the NJAFP's House of Delegates was separated into four sessions interspersed throughout the Forum's CME programming. Participants could earn CME credit during the weekend events while also learning about the significant challenges impacting the practice of medicine on a state and national level.

During the second session of the HOD, a representative from CMS gave a presentation on Primary Care First. New Jersey will be a pilot region for this initiative. During the Q&A, several members expressed concern about the evolving complexity of this payment model. In response, it was mentioned that the AAFP had provided significant input into how Primary Care First was constructed. I expressed my appreciation for the shout-out regarding the AAFP's involvement but clarified that although several components of Primary Care First incorporated principles supported in the AAFP's Advanced Primary Care Alternative Payment Model,(8 page PDF) they are not one and the same. This resulted in the CMS presenter acknowledging that the Primary Care First model remains in its formative stages of development.

During my visit I had conversations with many NJAFP members, like Tom Shaffrey, M.D., who passionately described the mounting layers of administrative challenges that denied him the joy of owning an independent solo medical practice. I also spoke with Cindy Barter, M.D., who shared her concerns regarding New Jersey's status of having one of the highest maternal mortality rates in the nation. I shared these and other stories directly with the AAFP Board of Directors in my chapter report, which I prepare after each of my visits.

While preparing this report, I recalled an article shared with me several months ago by former NJAFP president Robert Eidus, M.D. The article, "Arm in Arm with Righteousness,"(peh-med.biomedcentral.com) was written by Iona Heath, M.D., and published in Philosophy, Ethics, and Humanities in Medicine. The title comes from Joseph Conrad's 1913 novel Chance.

Conrad wrote, "You know the power of words. We pass through periods dominated by this or that word -- it may be development, or it may be competition, or education, or purity or efficiency or even sanctity. It is the word of the time. Well just then it was the word Thrift which was out in the streets walking arm in arm with righteousness, the inseparable companion and backer up of all such national catch-words, looking everybody in the eye as it were.”

Heath wrote in her 2015 article that new buzzword is "quality." The problem with such words, she said, is that "they all too seldom have real substance and all too often become slogans used in the exercise of power."

The article goes on to cite an eloquent comparison of the corporate treatment of human beings as both subjects and objects. Paul Plsek, a systems engineer, compares throwing a stone to throwing a live bird. Objectively, we can calculate the trajectory of a stone thrown from the ocean's shore. The stone is an object that can be measured with scientific precision to predict where it will land and sink into the ocean. Unlike the stone, a bird of the same weight as the stone is a subject that when thrown with the same force and trajectory will flutter erratically in an attempt to avoid landing in the ocean. The bird, unless its wings are bound, is not predictable. A buzzword like "quality" cannot capture the outcome of such an experiment.

Likewise, our patients are not objects that fit neatly into measurable corporate quality measures. Those who want medicine to adapt to a business algorithm create what they perceive as predictable stones (i.e., payment models) that will achieve precise quality outcomes. However, physicians face the challenging task of managing patients whose health and outcomes are variable -- and unpredictable -- because of their unique social determinants of health.

This is our frustration. Our daily task is to not treat patients as objects to be measured. Our duty is to lift each of them up, back to a state of wellness. This is not an exercise measured in quality; it is the healing art of medicine. This is our passion.

On the afternoon prior to my departure from New Jersey, I took my long-anticipated walk on the boardwalk. I will never be able to look at my Monopoly game again without thinking of the taste of the saltwater taffy, the aromatic smells of the beachside eateries, dodging the rolling chairs on the boardwalk or the interesting variety of inhabitants strolling along the shore.

As I ended my walk, I paused to look back at the mass of humanity juxtaposed along the Atlantic Ocean. I thought about my time spent with AAFP members. I thought about their passions and frustrations. I have heard similar concerns expressed by members from the Atlantic to the Pacific coasts. Our patients are not objects who can be bound and tossed into an ocean of quality measures. Like the stone, the patient/physician relationship will sink if we permit this idea to go unchallenged. As is the case with the bound bird, our profession would drown in an ocean of administrative burden.

In the end, I realized that although the AAFP does not hold a monopoly on every major health care decision being made in our country, the needs of the many are much too critical to allow any of us to sit idle and watch health care being played like a game while changes are left to Chance or a legislative roll of the dice.

Gary LeRoy, M.D., is president-elect of the AAFP.

Posted at 11:07AM Jul 12, 2019 by Gary LeRoy, M.D.

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