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Sara Kliff, Healthcare Reporter Extraordinaire, to Speak at CFHA's Austin Conference

Posted By Administration, Sunday, September 30, 2012

Prepare yourselves for a treat at next week's conference in Austin: Sara Kliff of the Washington Post presents our opening keynote address. She is a wicked smart writer on healthcare policy who will lay out the current landscape and predict the near future of healthcare reform efforts.

Here is a sampling of her blog to catch you up to speed:

The effect of media campaigns to change health behavior;

Is the Presidential Physical Fitness Test that we all suffered through in elementary school testing the right aspects of fitness?

Health insurance costs grew slowly for 2 years, why are they speeding up now?

A comparison of President Obama and Governor Romney as it relates to insurance reform to cover pre-existing conditions;

An analysis of what has contributed to a recent improvement in the rates of the uninsured

What science tells us about behavior modification from fast-food nutritional labels (would you like a 930 calorie McFlurry with your Big Mac?)

A live video stream of 6 adorable puppies!

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The Great Debate

Posted By Benjamin Miller, Friday, September 21, 2012

Changing healthcare requires an ability to gracefully navigate between competing interests and ideologies. Depending on "where you sit,” what type of change you want may be different than what your neighbor wants. Change is relative, and aims, goals, and objectives are often dependent on who you are professionally and who you work for. Integrating care, specifically behavioral health and primary care, brings out some of the best and worst of this "where you sit” phenomenon.

To this end, CFHA will host a presidential-style debate for the Friday plenary at our October 4-6 conference in Austin. We will grapple with the question: "Will collaborative care be a mainstream healthcare model within a decade?"  To get you excited for this event, our blog today presents the opening statements of our 4 debaters. As the moderator for the plenary session it will be my job to engage these leaders and hear all sides of the argument. Who will win this debate? Whose side will come out on top? That decision is up to you, dear reader.

 

Randall Reitz

Randall Reitz PhD
is CFHA's Director of Social Media and the the Director of Behavioral Sciences at the St Mary's Family Medicine Residency in Grand Junction, CO.

Collaborative care is still a gangly, pre-pubescent David amongst the Goliaths of healthcare. We lack the scale, strength, and resources of the major industry players. That being said we are on the precipice of something great. Within the next decade the clinical, operational, and financial aspects of collaborative care converge to push our model into the mainstream of healthcare:

  • Clinical: We now have empirical evidence published in top scientific journals that demonstrates the proven effectiveness of collaborative care in terms that even the most hardened insurance executive or corrupt government official could not deny.

  • Operational: The simple reality is that we have experienced exponential growth in the adoption of collaborative care operations at all levels of the American healthcare system. We have already conquered the public sector and are within a decade of conquering the entire system.

  • Financial: Our research and policy advocacy has already won the hearts and minds of policy makers. The teeter-totter of policy and payment is already reaching the tipping point at which the laws, regulations, and reimbursement standards will align to insist on financially sustaining collaborative care as a wholly necessary, fully-funded, and central feature of American healthcare.

Paul Simmons

Paul Simmons MD is a faculty physician at St. Mary’s Family Medicine Residency Program in Grand Junction, Colorado. He enjoys Apple products, black coffee, fountain pens and eponyms.


In this group of true believers, I have the honor of standing boldly as the lone skeptic who has not yet drunk of the collaborative care Kool-Aid. There are several reasons that collaborative care will not, unlike flying cars, be mainstream by 2022.

  • First, the collaborative care clan cites supposedly supportive studies that are flawed, biased and not generalizable to the real world. The evidence-based emperor has no clothes.

  • Second, collaborative care will not be able to overcome its own vagueness and impassioned, but unfocused, hand-waving. If advocates cannot clearly and rigorously define what they’re advocating, passion fails to persuade.

  • Third, the fevered dream of collaborative care will be exposed to the harsh, bright light of financial and payment system realities.

Despite these hard truths, I can hardly hope to persuade the diehards who have pledged their lives and fortunes to the cult of collaboration. Disillusionment is difficult, but we should always prefer reality to the pipe-dream of wishful thinking.


AJ Jayabarathan

Ajantha Jayabarathan MD
20 years of practice in primary care, 10 years of working on television and radio, 8 years of association with the Canadian National working group on shared mental health care, 16 years of raising a family while living in Nova Scotia, Canada, inform my opinions of how health care is evolving in 2012.


Yes and No… so states my reading of the tea leaves of time.

In ten years’ time, if Obamacare is actualized in the United States of America, integration of mental and physical health through collaborative, co-located mental and physical health services will become the mainstream model of care. If the injection of funds and faith into this model of care is thwarted by the politics of 2012, the rate of uptake of this model will be slower and the United States might well be left ten years behind as health care evolves because of this model in the rest of the world.

Meanwhile, in Canada, Australia, New Zealand and the United Kingdom, this model of care has already seeded fertile health care fields and is growing in strength, outcomes and diversity. Coupled with the parallel explosions of the information age via the internet, virtual social networks via social media and electronic management of health care it has steadily gained momentum …..and is now unstoppable.


Eduardo Sanchez

Eduardo Sanchez MD is
Vice President and Chief Medical Officer, BlueCross/Blue Shield-Texas

Opining as a health plan chief medical officer, I believe that the health system will have evolved to a collaborative care model by 2022. The direct and indirect medical costs associated with behavioral health, when it is not recognized and not well managed, can no longer be ignored.

Employers and health plans are beginning to appreciate that better employee health status correlates with higher productivity and an upside bottom line and that medical costs decrease and, more significantly, workplace productivity improves when behavioral health is appropriately and "collaboratively” managed. As a result, employers (whether they are corporate America, small business owners, government, and non-governmental organizations) and health plans across the United States will join health care providers and patients to accelerate the realization of a competent, considerate, culturally-relevant, compassionate, collaborative health system.

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Can't Miss Austin Possibilities

Posted By Katherine Sanchez, Friday, September 14, 2012

It has been quite a year, spent planning the 14th annual Collaborative Family Healthcare Association (CFHA) conference to be held in Austin in three weeks. After four years of immersing myself in the collaborative care research literature, I attended my first CFHA conference last year in Philadelphia. Wow! What an incredible, real world synthesis of everything I'd been researching during my PhD program, presented by some of the most prominent names in the literature!

As co-chair of the planning committee, along with Lynda Frost from the Hogg Foundation for Mental Health (a trailblazer in integrated health care in Texas, and nationally) and my fabulous husband, Eduardo Sanchez, I am proud of the conference that we have assembled. And though there are many spectacular aspects to the CFHA conference in Austin, I want to highlight a couple of remarkable opportunities that I find particularly exciting.

Katherine Sanchez

Register today to take part in this amazing national conference that promises to highlight relevant, cutting edge collaborative care innovations on a spectrum from clinical practice to the research literature.
One truly unique offering this year is a preconference site visit to an indisputable leader in integrated health care in Texas, Lone Star Circle of Care. A limited number of registrants will be able to hop on a shuttle and head up to Lone Star's Round Rock "hub” located at the Texas A&M Health Science Center. Lone Star Circle of Care is a Federally Qualified Health Center committed to being a "behaviorally-enhanced patient-centered health care home” that provides care with a focus on underserved populations. Participants will have the opportunity to tour Lone Star's site, where fully-integrated services are provided including behavioral health, pediatrics, adolescent health, family medicine, senior health, and women's services. Participants will hear from various multi-disciplinary team members about the planning, implementation, funding, and current practice of integrated health care at Lone Star. Clinical as well as organizational/administrative perspectives will be included. The all-day workshop is scheduled from 10:45 a.m. to 4:00 p.m., departing from and returning to the Hyatt. Transportation and lunch included.

Another pre-conference workshop unique to Texas will present clinical teams from existing models of integrated care to discuss the art of the "warm handoff.” Physicians and social workers from three distinct settings will discuss their own experiences to help participants think through the various aspects of providing integrated health care and to develop potential models that may fit their particular system. Workshop participants will learn, practice and problem solve several strategies for summarizing and validating a patient's concerns for common types of behavioral health issues. Through role-play and discussion participants will learn how to describe the Behavioral Health Specialist/Consultant and the role that person will play in the patient's medical care. This is a talented group of experts!

Eduardo and I are really looking forward to visiting Austin at its most beautiful time of year. Though we miss Austin terribly, and all its cool things, one thing I don't miss is the heat – except in the fall. There is no more gorgeous time of year. We can't wait to go for a run on the lake, take in some live music, and grab some delicious eats on South Congress. Bringing your walking shoes and your adventurous spirit. You won't want to miss this!

Tomorrow is the last day to register early! CFHA has extended Early Bird Registration through September 15. Register today to take part in this amazing national conference that promises to highlight relevant, cutting edge collaborative care innovations on a spectrum from clinical practice to the research literature.

 

Katherine Sanchez, LCSW, PhD., is an Assistant Professor at The University of Texas at Arlington School of Social Work. Dr. Sanchez practiced as a bilingual clinical social worker for 15 years, primarily in medical settings with monolingual Spanish-speaking populations. Her principal area of research is in integrated health care and the provision of socio-culturally, linguistically adapted models for the treatment of co-morbid mental and physical illness.

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It's Not Too Late to Be an Austin Early Bird

Posted By Lynda Frost, Friday, September 7, 2012

It's hard to believe that the summer is winding to a close. In Texas, that means saying a welcomed goodbye to scorching days and steamy nights. This year, it also means getting excited about hosting the 14th annual Collaborative Family Healthcare Association (CFHA) conference. As the co-chairs of this year's conference, Katherine Sanchez, Eduardo Sanchez and I have spent the last 12 months planning for what is sure to be a dynamic program on the future of integrated health care.

While I could write volumes about our engaging plenary speakers, rich breakout sessions and innovative pre-conference offerings, I am most looking forward to the increased participation of consumers and e-patients at this year's conference. Consumer and patient engagement is central to this year's conference theme, with more than 10 breakout sessions on related topics over the course of two days. In a pre-conference session titled A Catalyst for Integration: The Central Role of Consumer/Patient Engagement in a Recovery-Oriented System of Care, Bill Gilstrap, Anna Jackson and Wendy Latham will explore how activated consumers/patients are essential to quality integrated health care services. And in a plenary on Saturday, nationally-recognized consumers, e-patients and allies can bridge the gap between providers and consumers of integrated health services.

For the first time, CFHA will be presenting an Award of Distinction to a Consumer, Patient or Family Advocate. This award recognizes "an individual, team or consumer run organization which embraces and promotes the core value that the participation of the patient, family, consumer and community are instrumental to the healthcare process and critical to positive health outcomes.” I can't wait to see who will be honored!

The Hogg Foundation is supporting scholarships for Texas consumers to attend the conference and join in the dialogue. We've already awarded more than 15 scholarships, to include travel costs, registration fees, food and lodging. Don't miss out on this opportunity to have your voice included in the discussion about integrated care!

While you're at the conference, don't forget to stop by the Hogg Foundation Wellness Room. Staffed by consumers and e-patients, this quiet space away from the hubbub of the larger conference will provide an opportunity to engage in conversations about the important role that consumers can and should play in our health care delivery systems.

If you haven't registered yet, you're in luck! CFHA has extended Early Bird Registration through September 15. Register today to take part in this energetic national conference that prioritizes consumer voice and participation.

Lynda Frost

Dr. Lynda Frost is co-chair for the 2012 CFHA conference in Austin, TX. She serves as the director of planning and programs at the Hogg Foundation for Mental Health, where she oversees major initiatives and grant programs, leads strategic and operational planning, and manages program staff. She joined the foundation as associate director in 2003. Dr. Frost has a law degree and a doctorate in educational administration from the University of Iowa, a master's degree in international education from Lesley University, and a bachelor's degree in English and American Studies from Amherst College.

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CFHA Comes to Austin. You Should, Too

Posted By Meagan Anderson Longley, Thursday, August 30, 2012

The Collaborative Family Healthcare Association (CFHA) is hosting its annual conference in Austin this year. Lynda Frost, the director of planning and programs for the Austin-based Hogg Foundation, is co-chairing the conference and I’ve had the pleasure of serving with her on the planning advisory committee. I can say with the utmost confidence—you won’t want to miss it.

CFHA promotes a comprehensive and cost-effective model of healthcare delivery that integrates mind and body, individual and family, patients, consumers, providers and communities. Their conference has a reputation for being high energy, content rich and forward thinking. Plenary gatherings will keep you engaged and spark new thinking. The four breakout session tracks allow for deeper learning and include: Organizational & Implementation Issues, Clinical Care & Direct Practice, Consumer & Patient Engagement and Public Policy. Finally, poster presentations offer an opportunity for conversations about innovative research and programs.

If that hasn’t convinced you to register yet, I’ll let you in on another exciting detail – CFHA is offering scholarships for consumers, e-patients and family caregivers. CFHA is committed to the engagement of patients and consumers in the ongoing dialogue about how best to deliver integrated health care across the country. As such, the organization is putting its money where its mouth is (with the support of generous donors, of course!). Read more about who is eligible, how to apply, and what is included by clicking here.

So, what are you waiting for? Register and apply!

 

 


Meagan Longley, a recent graduate of The University of Texas at Austin’s School of Social Work master’s program, joined the Hogg Foundation as a mental health fellow. Previously, Longley served as a social work intern at the UT Counseling and Mental Health Center, where she provided individual and group counseling to the University’s diverse student population. Before returning to graduate school, she spent four years as a program officer at the Austin Community Foundation and one year as a bill analyst for the Senate Research Center during the 79th legislative session. In addition to her master’s degree in social work, Longley earned a bachelor’s degree in psychology and women’s studies at Furman University in Greenville, S.C.

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Mindful Ruminations of a Triathlon Tourist

Posted By Randall Reitz, Friday, August 17, 2012

Prologue:

I write this post in a minivan while driving from Boulder to Grand Junction after my first attempt to complete an Ironman 70.3 race. It includes my internal dialogue during the race, flashbacks, wisdom from the thumping music in the transition area, and announcements from the P.A. system. I hope to convey insights about collaborative care without being too explicit or corny.

1. Swim—samba snare

"Athletes please move to the beach, the race will start in 20 minutes”. Pushed along by a veritable arctic seal mating ritual of athletes in black wetsuits and color-coded swim caps, I descend to Boulder Reservoir.

"O’er the land of the free and the home of the brave!” Wow, a flock of doves, a very nice touch. The crowd claps furiously as the pros plunge into the 1.2 mile swim.

"What doesn’t kill you makes you stronger, live a little longer!” Eight waves to go until I start, plenty of time to perseverate. Other than 1980’s Speedo-guy, why am I the only person revealing my knees? Does the ankle-length material provide extra buoyancy and efficiency? If so, why are people evenly split between the wrist-length and the Farmer John arms? This swim is long—even the pros seem to be plodding through the course.

"Cause I told you once, Now I told you twice, We gon’ light it up, Like it’s dynamite.” "In wave 6, we welcome a number of military heroes, including (name) who lost 2 limbs fighting in Afghanistan and now leads a military program to train other veteran amputees to compete in triathlons”.

Wading, waiting in water for the countdown for my wave, "On my mark, 3, 2, 1, have a great race!”

OK, hold back a little, let the faster swimmers go first. This is a long race, no need to try and win it all in the first minute of the swim. OK, start with freestyle and attempt to maintain it for at least 10 minutes. You can do this.

I get kicked in the head and my goggles get lodged under my nose. Uh oh, this feels all too familiar. A flashed mental image of my first open water triathlon: impenetrably murky lake, aspirated water, tightness in chest from a wetsuit I borrowed from a guy who weighs 140 lbs. Ten minutes of dread, panic, and self-doubt.

OK, you can do this. Tread water, empty goggles, get them back on, and you’re off. I can barely see a thing. Even the buoys seem miles apart. Check watch, how can it only be 1 minute so far? Crap, my high-dollar goggles are already fogging. Need to get back on track. OK, breaststroke: easier breathing, get a glimpse with every stroke. Now back to freestyle, now breast stroke, now freestyle. Only 3 minutes? Tread water, spit in goggles, rub out the fog. Treading is exhausting. I’m not going to make it. I need to flag down 1 of the wave runners to take me back to shore. No, just swim until the first turn. The first leg is always the hardest of the 3.

OK, I made it to the turn. I get swum over by a person in a pink cap. What? How can I already be getting lapped by someone in a wave that started 5 minutes after mine? I’ve only been swimming 15 minutes. I am a miserably slow swimmer. Where is that wave runner?

Just focus on your breathing: right-left-right-breath, left-right-left-breath, right-left-right-breath. Hey I know this rhythm, I practiced it yesterday. Quick image of the first-ever Colorado Brazilian Festival that was celebrated in Boulder the day before. I’m in the drumming workshop, practicing the snare drum’s every-third-beat accents: RIGHT-left-right, LEFT-right-left, RIGHT-left-right. OK, just practice the snare. Swim mindfully, BREATHE-left-right, BREATHE-right-left, BREATHE-left-right.

I still can’t see a thing in these goggles, I’m only halfway done and exhausted. This must be how Matt feels each time we train together. I see myself at the Colorado Mesa University pool, my first time training with my friend, "Matt”. I provide a few pointers, dive-in, swim across and back, and see he is still standing in the chest deep water. He informs me that he’s never been a swimmer. I coach a little more and he performs a halting, thrashy, 25-yard swim with his head never going under water. I encourage him a little more, suggest a 10-minute regimen, and take off on my own. I swim 500 yards while noticing that he hasn’t swum at all and eventually disappears from the water. I walk to the locker room where I find him setting on the bench looking despondent. We talk for a few minutes, then walk back to the pool together and I swim by his side for the rest of the work-out. Flash forward 2 months to Matt’s first sprint triathlon, in which he was the slowest swimmer (and the only person to mix-in the back stroke), but he finished.

OK, 2 legs down, 1 leg of the swim to go. Just get through it and you’ll be fine. Hey, this snare drum breathing is also like the samba steps I learned yesterday:

Left foot back, right foot forward, left foot forward.

Right foot back, left foot forward, right foot forward.

Left foot back, right foot forward, left foot forward.

LEFT, right, left. RIGHT, left, right. LEFT, right, left. How did those crafty Brazilians figure out that the feet and drums should move together? Man, I’m self-talking constantly. It’s like I’m doing self- therapy in the lake. I wonder if this is what it’s like for one of my patients with panic disorder to go to Walmart on a Saturday? I must be a jerk in the exam room. I can’t imagine enduring this trauma each day of my life. Does it really ever get easier? Nietzche and Kimberly Clarkson were wrong. If I swam open water every day, it would make me stronger, but it’d definitely also kill me. Fade to a counseling session from 10 years earlier with a patient with OCD. He explains his metaphor for OCD therapy. "It’s like living in a house full of cockroaches. You know they’re there, but will only see them if you sneak into the kitchen in the dark of night and turn on the light. You need to continually expose yourself to your worst fears to overcome them.”

Flash further back to swimming lessons in Dallas as a kid. Each summer morning the surface of the pool was covered in floating "June bugs” that would cling to my hair and back and occasionally get swallowed during a breath. Exposure therapy is not for sissies. That’s the last thing I need to be thinking about right now: cockroaches floating in the reservoir. BREATHE-left-right, BREATHE-right-left. Hey, this would make an interesting blog post.

Hit the beach running. "You’re on the right track, baby. You were born this way!”

2. Bike—Boulder sustainability

After a leisurely 10 minutes in the transition area (don’t ruin the physical endeavors with a haphazard transition!) and I’m on the bike. "Our lead rider just finished the first of the two 28 mile laps.” I merge onto the county road just in time to be blown by a hard charging phalanx of super-fit pros. I’m never going to see them again, but I’ll take dry hot air over murky cold water any day.

I’ve been spinning for 10 minutes and averaging 14 miles per hour. Extrapolated over a 56 mile ride, that’s exactly 4 hours. That is way too long for my goal of less than 8 hours total. It’s not looking good. But, now downhill: 18 mph, 20 mph, 25, 31, 37. Thank you Jesus!

OK! The first aid station. I approach a line of volunteers, each holding out a food item and calling out: "Gatorade!” "Water!” "Gu!” "Bonk Breakers!” "bananas!” "Chomps!” I call back "Gatorade!” and a volunteer steps out to the road with a full Gatorade squirt bottle (cap already opened). I lean in, grab it without slowing down, and slide it into the water bottle holder. I yell out "Chomps”, receive a bag of energy gummies, tear them open drop all of the contents in my mouth and drop the bag in the garbage heap at the far end of the aid station. What a slick operation that was. Like an idealized collaborative clinic. I’m the primary care doc surrounded by teammates of other disciplines eager to help me out without slowing me down.

I see a man holding a box roadside about 200 yards ahead. Look at that dude’s dread-locked beard. It’s as thick and ropey as DaVinci’s iconic Moses statue. What is dude doing? Cool, he’s handing out whole organic peaches. Boulder definitely comes as billed.

Hey, I’m 30 minutes into my ride and haven’t yet used my clipped-in up-pedal. I need to get into that groove. Help me samba: UP, left, right. UP, right, left. UP, left, right. Was that a twinge in my hamstring? Be careful brother. Don’t even think that, you might increase the risk of cramping or pulling something. Don’t picture a pink giraffe. Don’t picture a pink giraffe.

Look at that guy’s bike: all carbon, super-light tires, self-adjusting derailleur, aggressive profile. And, I just blew right by him. Based on his calf number he’s only 24. I love passing younger people on super expensive gear.

Lots of Obama bumper stickers, haven’t yet seen a Romney. Boulder definitely comes as billed.

I approach the last aid station of the 1st bike lap. This one is sponsored by the Boulder Triathlon Club. The volunteers are all-decked out as disco superheroes. So, if this is the BTC, who is staffing the aid station. Maybe it’s the WAGs. What’s the male equivalent of a WAG…a BAH?

"Ain’t no mountain high enough! Ain’t no valley low enough!” Sing it Diana! OK, passing through transition area after first lap. I averaged 18 mph for 1:35. That’s a better time than I’d expected. I need to pace myself on the 2nd lap so I have legs for the half marathon.

Pace-Your-Self,

Pace-Your-Self,

Up-Right-Left

Up-Left-Right

The second lap seems easier than the first. That’s a good definition of self-efficacy—re-tracing a familiar path. Up-Right-Left, Up-Left-Right…Hey, what was that twinge in my hamstring? OK, stop the up-stroke.

I look to my left where there is a female rider with "You’re stronger than you think” written on her arm in marker. That’s a good narrative. I wonder where that came from: a therapist, an athlete self-help book? Facebook? Is she competing for sport or for therapeutic reasons?

There seem to be a lot of similar gear. I wonder what of it is empirically-supported and what of it is unproven fold tradition, or worse—shameless marketing? Pressure socks, that funky body tape from the London Olympics, the disk wheels from the Los Angeles Olympics, triathlon handle bars, the lycra bike short/tank-top combo that everybody (except for me) is wearing. I like the triathlon handle bars with water bottle and straw that pokes up inches from the rider’s mouth, but worry I’d get a chipped tooth or black eye.

"Boom, Boom, Boom, Even brighter than the Moon, Moon, Moon.” Katy Perry signals the end of the ride. 3:10, exactly the same pace as the 1st lap. Feeling good. "Welcome back our first female pro, Liz Blatchford of Australia who finishes in 4:07:48!”

3. Run—Broken down, but not beaten

Call my W(AG) in the port-o-John. Re-apply Boudreaux’s in strategic places to prevent chaffing. Apply nipple bandages. After another 10 minute transition I’m off on the run. Just before leaving the area I stop at a station of speedy volunteers with medical gloves slathered in sunscreen who wipe down my face and arms. This race has 2 categories: triathlon pro and triathlon amateur. Apparently, I’m in my own category: triathlon tourist.

The first mile of the run is always the hardest. The transition from bike legs to run legs is brutal. I just need to do two 6.5 mile laps. You’ve done dozens of half marathons before…just never after swimming and biking.

Well, that wasn’t that bad, the first mile only took 8:50, which would equal…under 2 hours for the full run. Legs and lungs are feeling strong. The calf number on the walking man in front is a 75. Holy cow, I’m just now passing old dude in the run? "Fantastic job!”

Good, the first running aid station. I’m saggin’. "Gatorade!” "Chomps!” A volunteer holds out a sponge. I grab it, drench my head in the ice cold water, and drop the sponge in the pile. "Fantastic!”

I feel a twinge in my lower right knee. Uh-oh, that’s the IT band. Not a good sign with 9 miles to go. Flashback to 6 weeks of pain and abandoned runs after an IT band inflammation 2 years previous.

With the mile 5 aid station in view the IT Band flares horribly simultaneously with cramps in the calves and lower quads of both legs. No!! OK, just gimp into the aid station and see how you feel afterward. "Gatorade!” "Bonk Breaker!” I quickly down both. Still hobbled, I grimace past the sponge volunteer, who pipes-in with "You look like you could use a sponge, sir.” I’m not a family doctor, I’m a freakin’ surgeon! I just scowl and someone hands me a sponge. OK, let’s try running a little….Ouch, no, too soon. Let’s walk to that next bridge and see how it feels.

OK, a little better. I run for 3 minutes before giving-in to the returning cramp and IT band pain. I follow this same pattern through the end of the first lap of the half marathon.

"We are the champions, my friends." I love that song, but not…right…now. I’m feeling more like "you got blood on you face, you big disgrace, kicking your can all over the place.” Or is it "And another one’s gone, another one’s gone, another one bites the dust”?

OK, Reitz, pull it together. Find a way to finish this race in 1 piece. Six miles to go, what would I tell my chronic pain patients? Manage the pain; strive for optimal performance without pushing so hard that I break down.

Looking up the trail I see a young runner wearing what appears to be a diabetic pump. I strain to catch up with him. "Is that a pump?”

"Yeah, we have a whole team of diabetics running today. Are you diabetic?

"Nah, my brother is”.

We chat for about 5 more minutes, until he tells me that his legs are failing him and needs to pull-up. I run ahead another minute and pull-up myself. Over the next 5 miles we repeat this pattern: I pull-up, he catches up to me, we run together a little then he pulls up. I run a little further, then pull-up.

One mile to go, the pain is unbearable, I can’t go more than 200 yards without walking. I…will…not…finish this race walking. What would I tell my patients? Breath into the pain, breath into the pain. Breath into the pain…

Well, that was a crock of new age pseudoscience.

I walk until my diabetic friend catches up to me. We walk together until we can hear the music thumping and then run the last 300 yards to the finish line together

"Get up, get down, put your hands up to the sound. Get up, get down, put your hands up to the sound.

Everyday I’m shufflin”

Done!

Drop plastics in the plastic bin, organics in the compost bin, and garbage in the trash bin. Boulder comes as billed.

   ***

Thank you Boulder,

Thank you Jesus,

Thank you samba,

Thank you snare,

Thank you grimacing surgeons,

Thank you inspirational marker tattoo,

Thank you evidence-based practices,

Thank you folk traditions,

Thank you rich young athletes who are slower than me,

Thank you older athletes who are faster than me,

Thank you diabetic kid who finished alongside me.

 

Boulder Ironman 70.3
Randall Reitz , PhD, LMFT is the Director of Social Media of CFHA and the Director of Behavioral Science at St Mary’s Family Medicine Residency in Grand Junction, CO. When younger, he liked to trail run. Now older, his body appreciates cross-training. He posts his ideas at CFHA's Collaboblog and tweets at @reitzrandall.


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Ch-ch-ch-changes

Posted By Lisa Zak-Hunter, Thursday, August 9, 2012
Throughout our lives there are times when we realize the permanency or magnitude of the change we’re experiencing. I’ve had the great honor (or horror?) of going through a few of these watershed moments in a relatively short time. Yikes! The first moment was during a very positive conversation at the end of a 2 day interview for the job I now hold. I had somehow managed to survive the cross-country interview at 9 months pregnant and was beginning to see that my patience through two years of job hunting was likely going to be rewarded. Fast forward 2 weeks to what turned out to be my last pregnancy check-up. After informing me I was about a week away from labor, the midwife returned and said I needed to go home and rest because they were going to induce me in a few hours. Three months and one bundle of joy later, I was sitting in orientation for my new job, in a new state, with a new baby. My identity as ‘pregnant woman’ had become ‘mom’ and my identity as ‘graduate student’ was suddenly ‘faculty’. I’m acutely aware of the process I’m undergoing to integrate these new and monumental roles and the challenges this presents.

Integrating the various personal and professional opportunities feels like being at an all you can eat buffet with a salad plate. There are many options--almost too many. As a parent, there is a ridiculous amount of choices for child toys, room décor, clothes, schooling, activities etc. Then, there is what all the experts (from the other parent at the grocery store to the child development specialist) say is the ‘best’ way to raise a child. There are child and parent personalities intermingled in family dynamics. Within this framework, a parent entangles how to do best by their child. Throughout the day, I pay attention to whether our daily activities best capitalize on my child’s current development and appropriately support and challenge her growth. I get bombarded by parenting newsletters and emails with suggestions that further enhance my choices for child rearing. It’s exhilarating and exhausting.
An intersection of motherhood and work: new baby, new office furniture.

An intersection of motherhood and work:

New baby, new office furniture.


Establishing myself as a professional is no different. There are so many different opportunities that were not afforded to me as a graduate student. I am torn between loving the newfound freedom of ‘new professional’ and yearning for the security of ‘graduate student’. Now, I feel more in control of my work load and what I decide to busy myself with during the day. I have more choices and the freedom to make them. Yet, the lack of constant accountability is unsettling. If I need to leave in the middle of the day for a meeting, I inform my colleagues, realizing full well this is a courtesy on my part. If I were to not show up for class, not only would my professor wonder, but my fellow students would as well. I can guarantee someone would be checking in to see where I was.

I am also learning how to prove myself and my abilities. As a young woman, mother, and mental health professional working in medicine, I see how some of the cards are stacked against me. I try to anticipate questions and assumptions about my profession and personhood while learning the culture of my new work environment. Despite my preparation, I have been asked if I plan to continue working full time or if I will work part time to care for my child/future children. The question seems innocent, but I doubt someone would ask a male physician the same. I have also been mistaken for a resident and support staff. On the other hand, I have been encouraged to be selfish about my career and focus on activities that enhance my professional development. Some of the physicians introduce me to others as Dr. Zak-Hunter instead of Lisa. I have spoken with faculty who are excited about what I offer the residency and are interested the small changes I’d like to make within my first month or so of hire. I have plans for my advancement and am learning who to contact to get started.

Then, there is the intersection of these two roles. I have had more time to develop my role as ‘mom’ than ‘faculty’. Because of that, I am more cognizant of how being mom affects my new position, instead of vice versa. I missed the first new resident meeting that the behaviorists run because my daughter’s doctor was late. I wondered what type of impression I was leaving and how missing a meeting may impact my relationship with the residents. I also love getting texts and voicemails about how my baby’s doing during the day. It helps me stay connected with her. Sometimes I worry that others may perceive it as taking away from my work- even though it takes about 5-10 minutes of my day. I also wonder how supportive the fast-paced nature of medicine will be over time when I continue to take a few daily breaks to keep my milk supply up. Nursing is important to me, but how will this priority impact others’ views of my competency and collaborative abilities? These uncertainties are reflective of my personal struggles to adjust, integrate, and confidently own these new roles.

All together, this is a time of great change and opportunity. I walk the line between feeling the need to charge forth with confidence and retreat into my office, uncertain which of my ideas are valued and how to present them. I enjoy having the best of both worlds. Despite some of my uncertainty and desire to establish myself, I am excited by what each day holds. I have a fairly clear idea of my personal and professional goals and how to achieve them. So, as I stand at the big buffet, I decide that I am not limited to that salad plate. There’s a variety of dishes from which to choose. I simply need to decide what I am in the mood for that day and how it will come together to create a balanced diet over time.

 

Lisa Zak-Hunter, PhD is behavioral science faculty with the Via Christi Family Medicine Residency in Wichita, KS. She earned her PhD in Child and Family Development, specializing in Marriage and Family Therapy, from the University of Georgia.

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Requiem for Family Medicine

Posted By Paul D. Simmons, Thursday, August 2, 2012
Family medicine is a young specialty, a mere forty-three years old (1). Unfortunately, family medicine will be extinct before it reaches its 70th birthday if current trends continue and—although I write as a family physician who educates family medicine residents and loves the idea and ideals of family medicine, I say—this might not be a bad thing. Several forces, both from within and external to family medicine, are conspiring to make us irrelevant, unnecessary and obsolete. We’ve all seen the Match Day trends (2). Each year until 2010, fewer medical students pursued training and careers in family medicine, and the slight increases over the last few years are largely attributable to more family medicine residency positions available. We cannot fill our available positions with US graduates. Many of those who match in family medicine are trained in a shrinking spectrum of skills. Many new graduates quickly jettison any broader skills they may have had in the name of work-life balance (3). Across the country, specialists and insurers implicitly or explicitly argue that family physicians cannot and should not be doing surgical (or non-surgical) obstetrics, endoscopy, minor surgery, ICU care or hospital medicine (4). We are often complicit in this effort to minimize our domain of practice, again in the interest of lifestyle or avoiding liability.

As our skills and practice scope are diminishing, a wave of mid-level practitioners (i.e., physician assistants and family nurse practitioners) are moving into primary care medicine (5,6,7). They share many of our same skills, are able to prescribe and order just as we are in a growing number of states, and are paid less. Most of these so-called "physician extenders” do excellent work and are viewed as equivalent to physicians by many patients. It is inevitable that health systems, policy-makers and third-party payers will soon realize—with dollar signs in their eyes—that these practitioners are inexpensive physician substitutes rather than physician "extenders.” All of the skills, more empathy and a similar scope of practice without the egos or paychecks of physicians.
Paul D. Simmons
Our support for the Patient-Centered Medical Home (PCMH) model, while predicated on admirable ideals, could easily be speeding our demise.

Sadly, family physicians are ill-equipped to resist our own demise because we lack a clear sense of what, exactly, it is we do. Not only does the public have little sense of how a "family doctor” differs from an old-fashioned "GP” or an internist, many of us have a difficult time explaining the distinction apart from defensively sputtering, "We’re a specialty, too!” Family medicine, some say, takes care of 90% of medical problems that present in the outpatient setting. Of course, so do internists (for adults), pediatricians (for children), and emergency physicians (for everyone). Family medicine, some say, provides continuity of care over the lifespan. Perhaps thirty years ago this was true. Now, however, vanishingly few family physicians will spend a career in the same location, taking care of the same population.

Even more troubling, however, is a deeper sense of inadequacy within the family physician’s psyche. Yes, I take care of adults, but can I really do so as well as an internist? Yes, I take care of children, but can I really do so as well as a pediatrician? I may deliver babies, but can I really provide the same quality of care as an obstetrician? If the reader balks at these questions, consider: if your wife were to experience a pregnancy complication, and you had the option, would you ask for an obstetrician or a family physician? If your child was suddenly struck with serious illness, would you bring her to a pediatrician or a family physician? We claim we are "equal” to our specialty colleagues—yet when serious or complex illness strikes those we love, we may find we have been playing doctor and we want a Real Doctor to step in to save us. Do patients sense this as well?

The larger medical world certainly seems to have detected our impotence. Family physicians exert minimal or no influence in determining our own payment structure, nor are our protests taken seriously. The Accreditation Council of Graduate Medical Education (ACGME) frequently ignores or delays our specialty’s recommendations or intentions (8). The AMA/Specialty Society Relative Value Scale Update Committee (RUC) continues to perpetuate an unjust payment model despite our protests (9). Family physicians are not the doctors that come to mind when patients think of disease-detecting, mystery-solving "experts” at the Mayo Clinic or Cleveland Clinic, nor do many tertiary- and quaternary-care institutions see a significant role for us in their delivery of medical care. Our medical journals are of comedically dubious quality, and we seem to be best at publishing, if anything, within the review article genre (10).

Our support for the Patient-Centered Medical Home (PCMH) model, for example, while predicated on admirable ideals, could easily be speeding our demise. The PCMH model rests on the idea of team-based care, where many of the functions previously carried out by physicians are delegated to nurses, medical assistants and case managers. This is intended to free up the physician to deal with the "hard” cases for which we are best suited. The problem is: we are not best-suited. The endocrinologist is best-suited to deal with the complicated, uncontrolled diabetic patient that cannot be brought under control by the nurse practitioner’s efforts. Similarly, the cardiologist is best-suited to deal with the refractory hypertensive; the gastroenterologist with the complicated hepatitis C patient. The family physician, in the PCMH model, is an unnecessary (and expensive) middle-man who has very little to add to the best management efforts of a high-functioning team operating with evidence-based protocols and guidelines. Inevitably, someone in authority will realize this cost-saving, simplifying fact.

While our specialty shrinks and delegates itself out of existence, some of us take refuge in the ridiculous romanticism of "biopsychosocial” or "patient-centered” or "holistic” flag-waving—as if patients would rather have sympathetic hand-holding than competent, efficient, expert medical care. That’s all fine, of course. We’re generally nice people. But while we’re spending our collective efforts on patient focus groups, learning acupuncture, satisfaction surveys, lifestyle balancing acts and "restoring the mystery” to medicine, our colleagues in internal medicine, pediatrics, obstetrics, critical care, surgery and emergency medicine are taking care of actual seriously sick people and showing that they can do a better job of it than we can. Perhaps we should step aside and let them get back to work.

REFERENCES:

1. Piscano, NJ. (n.d.) History of the Specialty. From American Board of Family Medicine website. Retrieved from https://www.theabfm.org/about/history.aspx.

2. Porter, S. (2012) Family Medicine Match Rates Increase Slightly. AAFP News Now, American Academy of Family Physicians. Retrieved from http://www.aafp.org/online/en/home/publications/news/news-now/education-professional-development/20120316matchresults.html.

3. Kotmire S. (2012) Shrinking Scope of Practice Raises Questions About Future of Family Medicine Training. Leader Voices Blog, American Academy of Family Physicians. Retrieved from http://blogs.aafp.org/cfr/leadervoices/entry/shrinking_scope_of_practice_raises.

4. Should Colorectal Surgeons and Family Doctors Perform Colonoscopy? (2012). Gastroenterology.com, retrieved from http://www.gastroenterology.com/featured/should-colorectal-surgeons-and-family-doctors-perform-colonoscopy.

5. Rough G. (2009). For many, a nurse practitioner is the doctor. Arizona Republic. Retrieved from http://www.azcentral.com/news/articles/2009/02/21/20090221nursepractitioners0220.html.

6. Horrocks S, Anderson E, Salisbury C. (2002). Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. British Medical Journal 324: 819-23. Summary retrieved at http://apps.who.int/rhl/effective_practice_and_organizing_care/SUPPORT_Task_shifiting.pdf.

7. Flanagan L. (1998). Nurse practitioners: growing competition for family physicians? Family Practice Management 5(9): 34-43. Retrieved from http://www.aafp.org/fpm/1998/1000/p34.html.

8. Wood J. (2012). Changing training standards for maternity care. Leader Voices Blog, American Academy of Family Physicians. Retrieved from http://blogs.aafp.org/cfr/leadervoices/entry/changing_training_standards_for_maternity.

9. AAFP Opts to Remain in the RUC (2012). AAFP News Now, American Academy of Family Physicians. Retrieved from http://www.aafp.org/online/en/home/publications/news/news-now/inside-aafp/20120313rucdecision.html.

10. Van Driel L, Maier M, De Maeseneer. (2007). Measuring the impact of family medicine research: scientific citations or societal impact? Family Practice (2007) 24 (5): 401-402. Retrieved from http://fampra.oxfordjournals.org/content/24/5/401.full.

 

Paul D. Simmons, MD FAAFP, is Extremely Junior Faculty at St. Mary's Family Medicine Residency in Grand Junction, Colorado where he serves mainly as a negative example for malleable trainees. He practiced family medicine, including obstetrics and endoscopy, for several years in rural eastern Colorado and Wisconsin before joining St. Mary's. His interests include antique Jungian archetypewriters, obscure eponymous diseases, superhero movies, Sherlock Holmes and misanthropy.  He will debate the future of collaborative care during a keynote address at the CFHA Conference in Austin, October 4-6, 2012.

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My Trip to the Doc

Posted By Peter Fifield, Thursday, July 26, 2012

My primary care physician referred me to an orthopedic surgeon to finally figure out a solution to fifteen years of chronic bilateral ankle pain. I was optimistic but after 15 years of failed alternative methods including physical therapy, acupuncture, shambala, voodoo medicine and a bit of old fashioned "suck it up” I knew it was most likely not going to be great news. I met with the doctor and within a few minutes of examining my ankles he nodded with confidence then sent me off to get x-rays with the promise that we would discuss my treatment options upon return.

I returned to the exam room and waited, socks off, feet on the cold tile floor. He returned and assured me that as far as my ankles go, my fears were true; "You’ve got minimal tread left…about a thousand miles left on those sixty thousand mile tires”. His metaphor was clear. The course of treatment for Acquired cavo-varus deformity [aka "minimal tread left”] was going to include a fairly benign first step of physical therapy combined with orthotic inserts. No big deal. But if this process did not work I was to have a bilateral operation which he informed me would require five weeks of bed rest for each ankle and if this was unsuccessful then, "complete ankle replacement” or as a last resort there was always fused anklesas an option. The standout bold type in the preceding sentences was all my brain absorbed.

After "fused” I shut down. All I heard was the waning ostinato of "wahwahwah wahwah wah”; similar to what I’m sure Charlie Brown heard from his phantasmalteacher. In my head I was running through all of my options regarding how I was going to continue living my life as I know it with fused ankles. How can I keep running, hiking, skiing, mountaineering, surfing, etc?, All these things I love to do. How do I keep being who I am with this set of threadbare tires I’ve got? I’m embarrassed to say I think I would have been less reactive to news of a death in the family.

After "fused” I shut down. All I heard was the waning ostinato of "wahwahwah wahwah wah”; similar to what I’m sure Charlie Brown heard from his phantasmal teacher. In my head I was running through all of my options regarding how I was going to continue living my life as I know it with fused ankles. How can I keep running, hiking, skiing, mountaineering, surfing, etc?, All these things I love to do. How do I keep being who I am with this set of threadbare tires I’ve got? I’m embarrassed to say I think I would have been less reactive to news of a death in the family.

After "fused” I shut down.
All I heard was the waning ostinato of "wahwahwah wahwah wah”

 

It has been a few days now and I’ve managed to relax a bit and problem-solve the situation with a clearer head. However, I cannot help but reflect back to that moment in the doctor’s office trying to think of what I would have done differently if I were the one giving me the "bad” news. As an integrated behavioral health provider who consults with patients on a daily basis about medical issues, what could I have said or done that would have changed my experience?

I keep coming back to two different interactions—the first being with the podiatrist, the other with my mother. The podiatrist could tell that I was bummed and offered me some story from his youth dealing with "bad knees” and how he had to stop playing basketball. Not to be callous, but I have never been able to shoot, nor dribble a basketball and to be honest; I did not care if he could either. This basketball reference did nothing for me. I retreated. My mother, in her very sincere, genuine and overly pragmatic way offered me this: "that must be hard sweetie” followed by "Aren’t we glad you are not sick like Amy,”a high school friend of mine recently diagnosed with cancer. Strike two!

Please don’t misconstrue my sarcasm for antipathy towards my doctor, my mother, or my high school friend. I do consider myself blessed in most aspects of my life. I am grateful that my knees are good and I’m cancer free, but really neither of these things has anything to with troubleshooting my ankle recovery. Sympathy is not what I needed, nor wanted. Thinking back, what might have worked better was a bit of empathy, followed by some problem solving assistance. Second I wanted to play more of an active role in deciding what the treatment was going to be or to at least to feel like I did. Intellectually I knew that the emotional child in me was standing in the way of recovery, but in reality I wondered if I could just up and change all my activity?

Then what? If I was to remove something so important in my life (such as exercise) what was I going to replace it with? And, if I found that something, what would it take to actualize it all? Lastly, at some point I wanted to be asked if I had any questions. After I realized my brain had been shut off for the past five minutes, I had a lot of them.

This visit galvanized my faith in Motivational Interviewing as a very effective way of "being with" a patient. Sympathy, apathy and antipathy do nothing for bonding with a client. The relationship is created between the provider and the patient through the use of empathy for it helps in fostering the patient’s autonomy and hopefulness. Figuratively pulling up next to a patient and reflecting back to them their difficulties with the current situation and offering empathy in accordance to their experience. How could my doctor or my mother help if they had the same feelings and ideas about this situation? What may have been beneficial was a provision of a shared experience yet through a different lens; a different point of view based on similar, yet clearly different, experiences.

Using the examples once again from the doctor and my mother we can hopefully glean some insight into a better use of their words. The doctor, instead of leading into an unsolicited story of his declining athletic prowess could have led with a simple reflection "I can tell this is going to be hard for you" and then followed with an open-ended question "when I went through something similar playing basketball in my youth, I had a hard time too. How could I help you figure this out?". The difference between these two versions is slight, but very important. First, the reflection offers up empathy letting me know he is on my team, second, the request to offer suggestions encourages me to invite him in, become refractory to his attempt at aligning with me. I believe this slight modification would have changed my reaction to him and I could have left with a plan; thus giving me confidence that I could pull this off. From him I needed a plan. Regarding my mother, although she was just trying to make me feel better,she could have stopped at "that must be hard". Sometimes less is more. I Love you mom!



Pete Fifield is the Manager of Integration and Behavioral Health Services at Families First Health and Support Center; an FQHC in Portsmouth NH. Read more of his CFHA blog posts here.


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Build Your Cathedral

Posted By Randall Reitz, Thursday, July 19, 2012

This blog post is taken from my comments to the incoming class of residents of the St Mary’s Family Medicine Residency in Grand Junction, CO. The setting was the Devil’s Kitchen trail in the Colorado National Monument during our annual orientation hike.

Long ago, there was a traveler who came upon three men working with stone. Curious as to their labors, the traveler approached the first worker and asked, "What are you doing with these stones?” Without halting, the worker responded, "I am a stonecutter and I am cutting stones.”

Not satisfied with this answer, the traveler approached the second and asked, "What are you doing with these stones?” The worker paused for a moment, wiped his brow, met the traveler’s eyes, and stated "I am a stonecutter and I am making money to support my family.”

Having two different answers to the same question, the traveler made his way to the third and asked, "What are you doing with these stones?” The worker thought, laid the chisel on the stone, engaged the traveler with his smile, and declared, "I am a stonecutter and I am building a cathedral that will bless my family, friends, and townsfolk for generations.” 

This oft-told tale seems particularly poignant in this setting. We talk today in a natural formation that belies both its name and its natural provenance. Rather than a devilish pile of random rocks, to me it is the closest structure Grand Junction has to a timeless cathedral.

Devil's Kitchen in Grand Junction, CO
Within this serene space, we reflect on the beginning of your vocation as a family physician. Over the next three years, your training will offer experiences that could easily inspire the perspectives of each of the stone cutters. First, there will be times when your duties feel like laborious, mindless stonecutting. Second, as this is the first time you’ve been employed as a doctor, you are now straddling the worlds of the learner and the paid staff physician. And third, each of you brings with you a vision of why you chose this noble, yet demanding profession.

While each of these perspectives is reasonable and grounded in the truth, I assert that your time in residency will be more fruitful, meaningful, and agreeably fast-paced if you approach it as the third stonecutter. He benefits from vision, passion, and ownership of his craft. To build your cathedral, you will need to hold-on to all three.

Fortunately, there exists a detailed blueprint for your cathedral that will guide you through this process. Revisiting the blueprint will lift your eyes to the spires and away from the inane hassles. You designed the plans yourself, about one year ago as you were preparing to apply for residency programs. Each of you wrote a personal statement in which you described in vibrant terms why you had entered medicine and why family medicine was the ideal specialty for you. For some it was a passion for enduring "cradle to grave” human interaction. For others, it was the intellectual challenge of a comprehensivist practice. And for others, it was a mission to bless the under-served of rural America and third-world countries.

With time (predictably during the winter of your second year), this blueprint might begin to seem corny or naïve to you. The challenges of full-spectrum training and the comments of others in the medical field might obscure this vision. Guard against this disillusionment. Based on my experience with previous classes, I predict that the closer you remain to your initial vision, the more meaning and delight you will derive from residency and your career.

Like stonecutting, family medicine is a worthy craft. Unlike stonecutting, it will also afford a very comfortable life for you and your loved ones. But, the noblest reason to engage fully in your training is to build the cathedral that you initially envisioned. I look forward to witnessing the realization of your plans and to offering a scaffold to your labors.

To build!

 

Randall Reitz
Randall Reitz , PhD, LMFT is the Director of Behavioral Sciences at the St Mary's Family Medicine Residency in Grand Junction, CO.  In addition to training residents he also directs a fellowship in Medical Family Therapy. His scholarly pursuits include medical family therapy, professional development, healthcare ethics, and integrated primary care.


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