AAFP Initiatives Should All Be Focused on Triple Threat

New initiatives by medical associations can help patch up wounded members, but are not solutions for the systemic dysfunction impacting tens of thousands of members. AAFP gains high marks for wonderful resource materials and this will likely be the same to address burnout, but their efforts to address burnout will not prevent burnout. To prevent burnout, AAFP must go upstream. Triple Threat is the cause of burnout.

Burnout is due to the Triple Threat challenges of
1. insufficient revenue,
2. increasing cost of delivery, and
3. worsening complexity.

Stress is not the problem. 

Stress is inherent in the life of a medical student, resident, and family physician. We were taught about ratios of stress over support. Stress must be balanced by support in patients, in physicians, and in team members. Too little

  • in dollars, 
  • in other support, 
  • in numbers of team members, 
  • in numbers of physicians and clinicians, and 
  • in satisfaction with regard to what we do drives our problem areas. 
Lack of support costs us. It steals our team members and our time - and our ability to care for patients the way that we know is best. The family physicians in the media and in articles are erupting in reaction to this problem that can be a chronic daily irritation or it can be The Dark Side Killing Doctors.

What We Have Here, Is a Failure in Perspective

What primary care physicians and clinicians and team members see as important 
and what associations, foundations, and government see as important 

are often entirely different. 

More Patchwork Initiatives Are Not the Solution

More departments of FM, more student interest groups and meetings, more Keystone gatherings, more FMExperiences, and more government interactions have not resulted in a solution. Primary care has too may patches now. New costly initiatives arise at annual meetings and from staff or leaders in between sessions. Family medicine needs real solutions, not more patches to address morale problems, turnover, shortages of workforce, and other consequences of Triple Threat.

Those serving on the front lines in stressful and complex care situations need support - 

not added complexity as in the last decade of practice design changes.

AAFP must

  • Choose to support those who deliver primary care. 
  • Design all possible resources to gain this additional support for family physicians, primary care, and access to care lacking for most Americans.
  • Expend all possible resources to gain this additional support for family physicians. 
  • Choose not to stress out delivery team members by supporting policies that complicate primary care needlessly.

The Michigan Blue Cross intervention was not about primary care medical home. It invested up front in primary care - with measurable improvements in costs as the result. Is it a shock that more and better support would result in such improvement?

AAFP should stop support of areas not evidence based for improvement, especially pay for performance where there is significant improvement in outcomes and definite evidence for discrimination against those who care for the most challenging patients - which is mostly family practice.

AAFP should not support the micromanagement bandwagon as this hits all three Triple Threat areas. Triple Aim does much the same.

Stress, burnout, morale problems, increased turnover, higher cost of each turnover loss, and the increasing unnecessary burdens arising from new designs can all be addressed - via Triple Threat focus.

Family physicians are hurting, specifically, and for the reasons of Triple Threat impacting family physicians in where they are and who they serve and the limitations to what they can do.

Burnout resulting from Triple Aim can imperil Triple Aim as recently noted in Annals of Family Medicine.

Guidelines have become a problem instead of a solution. 

"We have insisted on a more rigorous research base to inform clinical decisions; it is now time to insist on more uniformly rigorous clinical practice guideline development."

Time as the Target Indicator

Time has been indicated as a key problem area for primary care physicians. Half of the primary care work day is tied to Electronic Records. We steal time and try to manipulate time or replace time, but these are maladaptations that steal what we value.

The result of Triple Threat is that we are losing what we value most -
time with patients, time with team members, time with family, and time for ourselves. 

We Are Losing Office Family Physicians, Primary Care Retention, and Access to Care Battles

Leaders should not deny the facts of declines in what we are and what we do as family physicians. If family medicine hopes to remain the only remaining primary care source to retain at least half of graduates in office primary care, it must increase support as the challenges and complexities will remain. This is a sad compromise for a primary care source that was once dependable for 85 - 90% office primary care for a career, but the damage has been done and will continue until AAFP, foundations, other associations, and health care designers realize what we already realize and begin real treatment rather than band-aid attempts.

The Diagnosis is Triple Threat, the Treatment is Reversing Triple Threat 

The treatment that we must have in family medicine is significantly increased revenue and decreased costs of delivery so that we can address increasing patient, practice, and community complexity. The revenue must be enough to cover our support and the support of enough team members to deliver the care. Ideally this allows us to be in place such that we can help the community to develop more resources and new resources for better outcomes for our patients in ways that clinical interventions cannot address. Most Americans most in need of care also need Triple Threat addressed so that they can have access to care, local health care dollars, more jobs, better jobs, social determinant improvement, and local health care leadership to address the determinants of health.

AAFP must not worsen Triple Threat
  • ...by promoting changes that stress its members and our delivery team members.
  • ...by promoting clinical and digital clinical interventions that cannot improve outcomes - outcomes determined predominantly outside of our practices and within our ability to help only with outstanding support to allow us to work beyond our practice walls - the opposite direction of recent decades
  • ...by failing to recognize what most family physicians recognize, that the designs have substantially worsened primary care in the past decade with declining support and worsening complexity
  • ...by adoption of innovation, digitalization, certification, and regulation that worsen all three components of Triple Threat and worsen our well-being. We cannot tolerate stolen productivity, meaningless distractions, massive increases in cost of delivery, and complexity increases beyond just aging patients, more chronic disease, worsening patient situations, more challenging environments, and declining public health, mental health, women's health, and general surgical services. These also are best addressed by addressing Triple Threat to each of these.
This is particularly true for the half of family physicians that deliver care where it is most needed, where Triple Threat has driven off IM, PD, MPD, NP, and PA to levels far below half of active graduates while driving off over 20 percentage points of office family physicians with higher percentages to come.

Does it matter to AAFP that lack of support drives off members from what we were trained to be as well as driving off membership?

If the diagnosis is lower morale, lower productivity, higher turnover of physicians or team members... The treatment is addressing Triple Threat.

AAFP could lead the true reforms that are most needed by addressing Triple Threat and leading others to do so in public health, mental health, women's health, and general surgical specialties that are also in decline by design. Since we represent 90% of local services for most Americans, 


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