Family Medicine is all about helping our patients change their story. We listen to them, do an exam and order any necessary tests, and make a diagnosis. We want to fix the problem and change the course for that patient. Take for example the ER patient who presents with the chief complaint of an elephant sitting on his or her chest. Our minds kick into gear and the adrenaline starts flowing: “Get me a stat EKG. Let’s get an IV in place. Swallow 325 mg aspirin. Draw a set of cardiac enzymes. Give a sublingual nitroglycerin tablet. If the pain isn’t better, give IV Morphine.” All of these things help tell us if this patient is having a heart attack and lessen the patient’s chest pain. My hospital has been participating in a stroke and heart collaborative. We have goals for how long it takes to obtain and interpret an EKG. If we are quick, the patient having an ST segment elevation MI (or STEMI) can be in and out of our ER in 15 minutes and on to a referral hospital with cardiology services available. In fact, Dr. Mike Oller has done that and I rode along in the ambulance with the patient. There is no doubt that patient’s story was changed as he received quick intervention with the cardiologist.
Sometimes it is our technical abilities that change a story. Probably each one of us physicians who does colonoscopies has biopsied or removed a colon polyp that came back as cancer. We or one of our practice partners convinced that patient that a colonoscopy was warranted, whether it was for screening purposes or because of ongoing abdominal pain or to work up a case of anemia. But now we take that information from a pathology report and deliver news that will profoundly change that person’s life.
As family physicians, we learn that there are some stories we can change: treating diabetes, depression, high blood pressure, heart disease, COPD/Emphysema, catching early colon and breast cancers with age appropriate screenings, and the list goes on and on and on.
And eventually we encounter patient stories that we can’t change. Ellen had quickly become one of my favorites. She was in her early 90s and vibrant. She would assist friends younger than her, but with more health problems, by driving them to their doctors’ appointments. She volunteered faithfully for her church. She had even shared a batch or two of cookies at some of those office visits I had with her. And then one day, she needed a CT scan of her abdomen while in the hospital due to some abdominal pain and blood in her stools. While we were looking for signs of colitis or maybe diverticulitis, what we found incidentally was a large mass on her kidney. It was an advanced renal cancer. That day her story changed. We had a heart to heart talk about what this meant and possible treatment options. In the end, she decided that no treatment was the best option for her. She had a strong faith and did not want to spend her remaining days weakened by chemotherapy or possibly suffer complications due to a surgery. She continued to live a full life for a year before quickly succumbing to the cancer that had metastasized.
We have all had a similar encounter: one in which we as the doctor got more out of that physician-patient relationship that the patient did. That one in which the patient teaches us how to live a life well—full of vitality—instead of living a life that is just a numbering of days. I still have a note from Ellen, full of encouragement to me and thanking me for being her doctor, which hangs on my home refrigerator. We in family medicine are among the best at getting our patients to buy into what may best optimize their overall health, but we also understand when we need to engage our patients in conversations about end of life planning. We understand when we can’t change the patient’s story any further.
This past year, the KAFP has had several bright spots that we can celebrate. Our Executive Director Carolyn Gaughan, received a much deserved public health award in Sedgwick County, to honor her years of advocating for public health issues including one that she is very passionate about -- tobacco cessation. One of our members, a past president and delegate, Dr. Mike Munger sits on the AAFP Board of Directors and will be running for AAFP President-Elect in three months. One of our current board members, Wendy Biggs MD, was just selected to be on the board of the American Board of Family Medicine. I have a feeling that she wants to help change the story for the Maintenance of Certification for Board Certification. KAFP hired a new deputy director and Michelle Corkins has already been very helpful to me. In January, we had a successful Advocacy Day that involved a tremendous presentation for the House Health committee. KAFP lobbyist, Dodie Wellshear touched on this in her report during the Member Meeting at the Annual Meeting. Several of our KAFP “All Stars” delivered information in a meaningful way with poise, a touch of humor, and stories from the heart. The information was delivered in a way that the committee understood how big a role family physicians play in the lives of our patients and in the communities in which they serve. Instead of passing legislation that would have allowed completely independent nurse midwives, the chair changed his thought about this and then advocated for bringing any nurse midwife that chooses to practice independently from being licensed by the Board of Nursing to the Kansas Board of Healing Arts. While I understand that some of you may not be happy with this decision, this is much preferable to independent practice with regulation by the Board of Nursing and will allow us to be involved with regulations of independent nurse midwives. I truly see this as a path forward for other nurse practitioner groups. And with changes coming in payment reform: welcome to the headaches of MACRA, MIPS, QRUR, QPRS, and all the other alphabet soup that goes along with physician practices! The KAFP keeps you informed of the latest developments in physician payment changes. This is not something that will go away. Fee-for-service as we know it is coming to an end for most of us. Rest assured that there will be opportunities to make our voices heard as we give feedback about payment reform. Please do so. Help to change the story.
Through the KAFP, I have learned the importance of becoming engaged in the political process. Several times this past year, Carolyn sent a Call to Action email. Each time I emailed my representative, I got a response and that representative voted in a way that benefitted the KAFP and family medicine. I saw firsthand how this really did help to change the story for those issues. Something tells me that this coming year, due to the decisions of our Kansas government leaders, we will have a few more chances to become involved. As our state sinks deeper into financial debt, Medicaid cuts are here July 1. I am not sure how our elected leaders feel this will help advance the health care for those who are the most vulnerable in our state. They need to hear how some physicians may have to make the difficult decision to stop taking Medicaid. The payment is already below the cost involved with seeing that patient for an encounter. They need to hear that for some patients and communities, their health stories could drastically change for the worse. They need to hear how the decision to not expand Medicaid, thus declining federal dollars for the program which now stands at over $1.2 billion, is hurting all of our hospitals, especially critical access hospitals in the rural part of our state, as well as the family medicine physicians who are treating these self-pay patients. My plea is that we will use our collective voice. Call your legislators. Vote for candidates who really will help change the climate of medical care in our state this coming November. Family medicine has always played too nice. We are the specialty that does not want to abandon our patients and leave them without a provider, even if we are getting paid poorly. We need to change the story without hurting those who need us the most.
In addition to advocating on the state level, I hope that you will consider donating to FamMed PAC. This organization supports the goals of family medicine nationally by donating to candidates who support primary care. In April, I joined several others from the KAFP at the Family Medicine Congressional Conference in Washington DC to talk to our U.S. Representatives and Senators about the opioid crisis. We asked that they let us work through this problem on our own, claim some responsibility, and work to change the story from within. We asked them to consider lifting the limit on the number of patients that can be treated with naltrexone for opioid dependence. Thank you to Dr. Chuck Allred for the lifesaving work that he does in this area. We continue to ask for funding for residency teaching centers that place residents in community health centers, often in places that are in desperate need of physicians. We continued to advocate for changes in how residencies are funded so that more family medicine slots can be added to address the primary care needs of our country.
If you are not currently taking medical students in your practice or mentoring college and high school students, I hope that you would consider changing that story. Because my partner, Dr. Jen Brull has been a wonderful mentor to med students, we got one of her former students and her spouse, Drs. Beth and Mike Oller, to join our hospital in Plainville after residency.
Finally, I hope to inspire you by sharing my personal story. Now if you had looked at my rap sheet growing up, you would have thought that I was destined to have oppositional defiant disorder or a conduct disorder at best. At age 4, I was making and drinking some potent screwdrivers at our family’s bowling alley/night club. My Mom did some investigating after I started bumping into the walls. It led my Dad to declare that there was no way in hell I was staying back a year, and so at age 4, I started kindergarten, just barely making the cutoff with a late August birthday. I burned down the family house at age 8. I forced my older brother Lee outside in his skivvies and a blanket on a cold March morning. It was probably payback for all the times I had been unmercifully teased on the school bus or put in a head lock, or given floor burns while growing up. I had been sent so many times to the principal’s office in the 3rd or 4th grade, that I was actually punished with a wooden paddle by Mr. Fritchen, the grade school principal. I still remember having to bend over in his office and feeling the paddle on my backside. I was a recipe for disaster. And in the midst of all of this, I was dealing with feelings that I didn’t have a name for and that I didn’t dare tell anyone about. But somehow, I turned things around and during high school, started achieving highly and was motivated to continue with that through college, med school, and residency.
I have firmly come to believe that all of us have an elephant of some sort sitting on our chest—this thing that keeps us from being our best at changing patient stories.Sometimes it keeps us from working on our own stories. It is not something that a chest pain protocol can fix. For me, that elephant was my sexuality. I wrestled with God about this issue for over 25 years. I begged and prayed and pleaded for this to be removed from my life. But that is not how it works. Once on the brink of feeling that my spirit would break, I have come to the point to where I can finally say it is well with my soul, and that this issue does not define me.
I do not know what each of your elephants are. Some of our elephants are apparent—maybe obesity or a physical challenge and for others it is hidden—maybe an addiction, a struggle with anxiety or depression that has been ignored, struggles with balancing work and family. As family physicians, we care so much for our patients, and we sometimes neglect ourselves. But as your colleague, I want you to know that I care about your story. I want you to be the best family physician you can be, the best advocate for your patients and for the KAFP, and I am sure that each of you feels the same about your friends and colleagues. Your personal story can change.
This coming year, let’s make a pledge. Let’s pledge to become more involved. Send out that letter when you get the Call to Action. Sign up for a KAFP committee. Let us know if you are interested in leadership. Donate to the KAFP Foundation and to FamMed PAC. Make your voice heard at the polls this fall. And promise me that you won’t let the elephant in your life hold you back from being the best you can be, for yourself and your patients. Go, be kind, advocate for family medicine, share your talents, and change the story.
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