Third Quarter 2014 The Scope of Family Medicine A Publication of the Alabama Academy of Family Physicians • www.alabamafamilyphysicians.org

President Boothe Q&A PG 6

Colorectal Cancer Screening in Alabama PG 12 2 The Scope of Family Medicine

1305-12.indd 1 2/26/14 12:18 PM 1299-11.indd 1 10/31/13 2:15 PM

The Scope of Family Medicine Fall 2014

Officers *Julia Boothe, MD, President *Drake Lavender, MD, President-elect Pamela Tuck, MD, VP Southeast (’15) Jarod Speer, MD, VP Northeast (’16) Boyd Bailey, MD, VP Southwest (’17) Tracey Jacobs, MD, VP Northwest (’18) *Mike McBrearty, MD, Treasurer Jeffrey E. Arrington, Executive Vice President (*indicates member of the Executive Committee)

Board of Directors *Tom Kincer, MD, Chair Vikus Gupta, MD, At Large (’15) Beverly Jordan, MD, At Large (’16) Michael Goodlett, MD, At Large (’17) Nelson Cook, MD, Calhoun County Branch Allen Perkins, MD, Gulf Coast Branch Lisa Columbia, MD, Jefferson County Branch Contents Ashley Butts-Wilkerson, MD, Resident Chapter President President Boothe Q&A...... 6 Nick Tinker, Student Representative Groups Prepare to File Applications for Congressional District Reps RCO Probationary Status...... 8 Steve Donald, MD – District 1 Deanah Maxwell, MD – District 2 Stabilizing Physician Workforce Is Basis for Kim Owens, MD – District 3 Mark Tafazoli, MD – District 4 “Bump” Extension...... 9 Laura Satcher, MD–District 5 Logan Casey, MD – District 6 Presenting ... the AAFP Awards!...... 10 Ray Brignac, MD – District 7 2014 Alabama Academy of Family Physicians AAFP Delegates Fall Forum Agenda...... 11 Steve Furr, MD (’15) Melissa Behringer, MD (’16) Colorectal Cancer Screening in Alabama...... 12 AAFP Alternate Delegates Politics and Unlikely Bedfellows...... 14 Jerry Harrison, MD (’15) Tonya Bradley, MD (’16) Classifieds...... 17 Consultants Directory...... 18 Scope Managing Editor Jeffrey E. Arrington Thank You, Advertisers...... 18 Alabama Academy of Family Physicians 19 South Jackson Street Montgomery, Alabama 36104 334-954-2570 Toll-free: 877-343-2237 Like us on Facebook! Fax: 334-954-2573 [email protected] Follow us on Twitter! www.alabamafamilyphysicians.org

Mission: The Scope of Family Medicine is intended to provide timely and useful information of interest to our chapter members, as well as provide informa- tion about the policies and activities of the chapter.

Advertising Policy: Advertising is accepted that is deemed to be in harmony with the mission of Scope and the interests of the members of the Alabama Chapter. Advertising of tobacco and alcohol prod- ucts is expressly prohibited. Additionally, material The Scope of Family Medicine is published by Innovative Publishing. that is found to be unethical, misleading or morally 10629 Henning Way, Suite 8 • Louisville, Kentucky 40241 • Phone 844.423.7272 • Fax 888.780.2241 objectionable is also not permitted. Innovative Publishing specializes in creating custom magazines for associations and businesses. Please direct all inquiries to Aran Jackson, [email protected]. The views and opinions expressed in Scope do not necessarily reflect the policy of the Alabama Acad- emy of Family Physicians. Published September 2014 • 2014/3 2014 Published September www.innovativepublishing.com President Boothe Q&A

Dr. Julia Boothe received her undergraduate degree in biology from the Univer- sity of Alabama. She completed her medical school training at the University of Alabama School of Medicine in Birmingham, Alabama. Dr. Boothe was a Rural Medical Scholar at the College of Community Health Sciences in Tuscaloosa, Alabama, and she earned a master’s degree in public health from the University of Alabama at Birmingham School of Public Health. She completed her residency training at the Tuscaloosa Family Medicine Residency Program, Tuscaloosa, Alabama, in June 2005. Dr. Boothe became board-certified in family medicine in July 2005. She is the owner of and practices at the Pickens County Primary Care in Reform, Alabama. The Scope of Family Medicine recently had an opportunity to sit down with our new president and get to know her a little better.

What was the reason you chose a career surgical physician’s assistant. I had some great in family medicine? conversations with a PA and an orthopedist As a fifth-grader, I did an extra-credit project who helped me decide surgery wasn’t for me while studying “the body” about the pulmo- and supported my confidence in choosing nary and circulatory systems. After learning to go to medical school. As an undergradu- how interesting those systems were, I was ate student at the University of Alabama, I hooked. The body and all its intricacies were worked in medical records at Capstone (now very interesting. As soon as I was able to start University Medical Center) and was able to volunteering (13 years old) at the local hospi- be around medical students, family medicine tal, I volunteered every summer. It was over residents and attendings. I then knew family 25 years ago, so I was able to offer my time in medicine was going to be for me. the operating room at West Alabama General Hospital (now Northport DCH). I was drawn What is your favorite part of to the interesting cases and had the opportu- family medicine? nity to talk quite often with multiple surgeons I love the continuity of care. The benefit (when dressed out in scrubs with masks, hair of practicing in a rural area is true “family caps, etc., they really didn’t know how young medicine.” I have multiple entire families that I was). It was a great time of exposure that I care for — it sure makes the family history helped me make a very educated choice to be much easier to document. I most enjoy my cialty clinic patient, but I was with her and her a primary care doc. Initially, I wanted to be a time in the exam room with my patients. If I family through an episode of septic arthritis in could just do that all day, it would be perfect. the hospital, so they switched and started fol- The reality is, there are many other things lowing with me in my private family medicine that must happen for that time to remain. My clinic. When I finished residency and moved patients represent all walks of life, and their to Carrollton, she and her entire family fol- problems run the gamut of The Washington lowed me — I was actually geographically Manual. It’s a very challenging practice, but even closer to her. I continue to care for her I wouldn’t change a thing. I never have a dull and her family and have been with her through day, and I know my patients need and appre- various complications that are encountered ciate me and that I am where God has called by sickle-cell patients. Over the years, I have me to serve. taken on her grandparents, great-grandparents and other extended family members. Seeing Is there a particular patient encounter her through the years is very rewarding, and from your early days that you still think as she grows up before me, it reminds me how about today? important it is for us to always advocate for There are so many. One that sticks out is prob- our patients and that we as physicians must ably the longest-running encounter that I’ve do our best every day for every patient. Years had. As an intern in Tuscaloosa, I encountered ago, she didn’t arrive with an advocate in a young sickle-cell patient with acute crisis the health care setting but has developed that who had some complications. She was a spe- through the years.

6 The Scope of Family Medicine Where do you see the practice of family medicine in 10 years? If only any of us really knew. My hope is that family medicine will lead the front of primary care as health care delivery continues to evolve. As primary care providers “from the womb to the tomb,” we are situated in a great position to advocate for all of the citizens of Alabama and America through the process of change that we are entering in health care. I see us working more with patients to help them make decisions specific to their needs. Right now, we more often refer to algorithms than use the art of medicine to make choices. Going forward, I see there being many more choices on the front end; patients are going to have more cost choices that they are not used to having to make. We, as family medicine providers, will have to educate ourselves more and more to help our patients as consumers rather than just as patients.

Dr. Boothe lives in Coker, Alabama, with her husband, Aubrey, and their two children, Laura Adelynn (12) and Sarah Beth (7). Please join us in welcoming your 2014-2015 president, Julia Boothe, MD.

Alabama Academy of Family Physicians 7 Medicaid

Groups Prepare to File Applications for RCO Probationary Status Representatives of the organizations wishing to apply for status as a probationary regional care orga- nization in Alabama met with Agency officials and consultants in Montgomery on July 22 to review the application process and receive preliminary data. Twelve organizations have submitted a Notice of Intent to apply for probationary certification.

Dr. Don Williamson, chair of the Alabama Medicaid Transition is unique compared to other states, with no other states operating Task Force, provided an update to the group on pending changes a risk-based program in the same financing environment. to the state’s administrative code and on decisions made thus far. Most recently filed rules include provisions on network adequacy, “I want people to understand that there is a unique balance that we provider standards committees and reimbursement rates. are trying to achieve between CMS requirements and the desire to transform the Alabama Medicaid program,” Doyle said, noting Other key decisions have been made as well, he said, noting that that balance is also needed between federal requirements and the a decentralized approach to claims payment and to data collection Agency’s financing system. will be used although the Agency will need to determine how to access that data for its needs. He also emphasized the dynamic nature of rate development. “There are still a number of components of the RCO program that “We looked at centralizing claims payment and looked at the idea are still under development. As we go through the rate develop- of centralizing data functions,” Dr. Williamson said. “After talk- ment process to determine capitation rates, we will be in the in ing with the people interested in being probationary applicants, it process of incorporating additional decisions so that we can match was clear that they felt they needed both access to the data and to the rate to the risk,” he said. be able to process claims. Medicaid will need to figure out how to crosswalk that data, because we will need access to common data sets so we can compare and contrast across RCOs.”

He also emphasized that RCOs will be required to serve patients throughout a region and not just a subset of the region. “An RCO has to be able to serve patients regionwide,” he said. “That may create some challenges, but it otherwise prevents cherry-picking and adverse selection.”

Alabama Medicaid Medical Director Dr. Robert Moon provided clarification on submission deadlines and changes made to the on- line RCO portal to streamline the application process.

Applications received by August 1, 2014, are eligible for proba- tionary status as early as October 1, 2014. Applications submitted by September 30, 2014, may be granted probationary status by January 1, 2015, at the Agency’s discretion.

Probationary certification allows applicants to not only demon- strate their commitment to the RCO program but also to manage a Health Home program in advance of full-risk requirements, Dr. Moon said. Medicaid’s Health Home program currently operates in four regions of the state to help Medicaid recipients with com- plex or multiple medical conditions improve their health outcomes while reducing the cost of care to the state.

Tim Doyle, senior actuary with Optumas, the Agency’s actuarial consultant, emphasized to the group that Alabama’s RCO program

8 The Scope of Family Medicine Stabilizing Physician Workforce Is Basis for “Bump” Extension

Medicaid-enrolled primary care physicians who qualify for en- “This limits your ability to do a lot of other things,” he said. “If hanced payments known as the “bump” will continue to receive those you’re going to move patients out of the emergency room into physi- payments through September 30, 2015, State Health Officer Dr. Don cians’ offices or into other care sites, you have to engage that other Williamson announced. 78 percent and make reimbursement reasonable so that they will participate. The ‘bump’ came along at a time to help us stabilize our The “bump” refers to the Affordable Care Act requirement that state physician workforce as we are trying to undertake a major transfor- Medicaid programs increase, or “bump” up, in payments to certain mation of our Medicaid system,” he said. physicians for specified primary care services beginning January 1, 2013, through the end of 2014. Funding for the additional payments in 2015 is included in the Agency’s 2015 budget approved by the state Legislature. Eligible While the additional payments were originally triggered by the Af- physicians include board-certified family medicine, pediatric fordable Care Act, the decision to extend the payments for an ad- medicine, general internal medicine and related specialties, or ditional nine months was more about ensuring that the state had eligible physicians who can verify that 60 percent or more of the an adequate number of primary care physicians as it prepares to Medicaid codes they billed in the previous year were primary care implement major Medicaid program reforms, Dr. Williamson said. codes and certain codes associated with vaccine administration listed in the ACA. Health departments, federally qualified health Physician participation in the Medicaid program is a concern, he said, centers (FQHCs) and rural health clinics are not eligible for the because approximately 22 percent of enrolled primary care physicians fee increase. now receive 90 percent of all claims payments. The other problem is that Alabama has health professional shortages in 62 of its 67 counties.

Alabama Academy of Family Physicians 9 Presenting … the AAFP Awards!

he Alabama Academy of Family Physicians (AAFP) is pleased to announce the establishment of several awards to recognize our physicians. Beginning this year, the AAFP will honor outstanding individualsT in the Alabama health care industry who truly exude the characteristics of a quality family physician or future family physician, with awards presented at the AAFP Fall Forum, December 13-14, Embassy Suites, Hoover, Alabama.

For more information on the academy awards available for nomi- The FAMILY MEDICINE EDUCATOR OF THE YEAR nation, including more detailed descriptions, please review the award is designed to recognize an individual who has made out- information provided. standing contributions to education for family medicine in under- graduate, graduate and continuing-education spheres. Each award category will be under the auspices of the AAFP Nominating Committee. The Nominating Committee will annu- Eligibility ally solicit and accept nominees through all appropriate avenues The nominee for this award must be an active AAFP member in available. Again, individuals may be nominated by others or may good standing who spends at least 50 percent of his or her time be self-nominated. All nominations will be due to the AAFP office, in patient care. All previously nominated physicians who weren’t located at 19 South Jackson Street, Montgomery, Alabama 36104, no selected are eligible for reconsideration but must be renominated. later than 11:59 p.m. on Friday, November 21, 2014. Winners will be contacted after a decision has been made, and a formal announce- Nomination Supporting Materials ment will be made to the AAFP membership following. • The nominator must submit a cover letter summarizing why he or she believes the nominee should receive this recognition and ALABAMA ACADEMY OF FAMILY PHYSICIANS LIFETIME include sufficient specific data to provide a working knowledge ACHIEVEMENT AWARD of the nominee’s educational efforts. The nominator should also Nomination Supporting Materials discuss the contributions of the nominee to his or her home, local • The nominator must submit a cover letter summarizing why and regional educational institutions. he or she believes the nominee should receive this award. • The nominator must submit three letters of recommendation, including: The nominator should include specific examples of how the o A letter from one of the nominee’s former students or nominee has distinguished his or herself in at least one of the residents who can showcase support of the nomination by following areas, with such accomplishments recently occurring stating how the nominee contributed to his or her education or throughout a lifetime of service: o A letter from a family medicine educator from another o Distinguished service to the Alabama Academy of Family institution who can attest to why the nominee should be Physicians awarded this recognition o Distinguished service to the specialty of family medicine o A letter of recommendation from another individual who o Distinguished service to the community at large, including the has personally worked with or has been taught by the local, state, national or international levels nominee and can verify the nominee’s contributions to • Nominator must submit at least one letter of recommendation family medicine education from another individual familiar with the nominee’s credentials (no family members) in support of the nomination

10 The Scope of Family Medicine The OUTSTANDING FAMILY MEDICINE RESIDENT OF THE YEAR award is to recognize a family medicine resident (PGY-1, PGY-2 or PGY-3) who exhibits qualities of exemplary patient 2014 Alabama Academy of Family care, demonstrates leadership among his or her colleagues, displays a commitment to the community at large, contributes to scholarly ac- Physicians Fall Forum Agenda tivity, and has dedicated himself or herself to the specialty of family December 13-14 medicine through involvement in the AAFP and American Academy Embassy Suites Birmingham/Hoover of Family Physicians, service to his or her residency program, and/or other family medicine organizations.

Eligibility The nominee for this award must be a resident member of the AAFP at the time of nomination. Note: Residents who have graduated with- in one year of a nomination being submitted are eligible to receive this award.

Nomination Supporting Materials • The nominator must submit a cover letter/statement summarizing why he or she believes the nominee should receive this recognition and include specific examples of how the nominee meets the criteria listed in the award description. • The nominator must submit two letters of recommendation, including: o A letter of recommendation from the nominee’s residency program director. Note: If the residency program director is the nominator, please submit a letter of recommendation from Saturday, December 13 2:55-3:15 p.m. another residency program faculty member. 7- 8 a.m. Break to View Exhibits o A letter of recommendation from an individual — such as a Registration/Continental Exhibit Hall physician colleague, a hospital administrator, a patient or a Breakfast community leader — who has personally worked with the Pre-Function Area 3:15-4:15 p.m. nominee and believes the nominee deserves this recognition. Common ENT 8-9 a.m. The FAMILY PHYSICIAN OF THE YEAR is selected annu- HIPPA Compliance 4:15-5:15 p.m. ally from nominations by AAFP members. The award is presented Pediatric Vaccines to a physician who exemplifies the tradition of the family doctor and 9-10 a.m. the contribution of the family physician to the continuing health of Dementia 5:15 p.m. Alabama citizens. Adjourn 10-10:20 a.m. Eligibility Break to View Exhibits Sunday, December 14 The nominee for this award must be an active AAFP member in good Exhibit Hall 7-8 a.m. standing who spends at least 50 percent of his or her time in patient Continental Breakfast care. All previously nominated physicians who were not selected are 10:20-11:20 a.m. Exhibit Hall eligible for reconsideration; however, he or she must be renominated. Pain Management Update 8-10 a.m. Nomination Supporting Materials 11:20 a.m.-12:20 p.m. SAMs Session (Asthma) • The nominator must submit a cover letter summarizing why he or she PCMH believes the nominee should receive this recognition, as well as the 10-10:30 a.m. nominee’s accomplishments and contributions to the continuing health 12:20-12:55 p.m. Break to View Exhibits of Alabama citizens, including participation in community affairs. Strolling Lunch Exhibit Hall • The nominator must submit three letters of recommendation, including: Exhibit Hall o A letter from one of the nominee’s patients in support of 10:30 a.m.-noon the nomination 12:55-1:55 p.m. SAMs Session (Asthma) o A letter from the nominee’s physician colleagues, hospital Dermatology administrators, etc., who can attest to why the nominee should be awarded this recognition 1:55- 2:55 p.m. o A letter of recommendation from a community leader to showcase Drug Resistant Hypertension the nominee’s participation in community affairs

Alabama Academy of Family Physicians 11 Colorectal Cancer Screening in Alabama

Colorectal cancer is one of the most preventable diseases from a quality perspective. Yet in Alabama, colorectal cancer is the third most common cancer diagnosis and accounts for over 8 percent of total cancer deaths in the state.1 In fact, colorectal screening rates for Alabama continue to fall below the national average, particularly in rural counties. According to Medicare claims data, just over half (51.47 percent) of the population is up to date, and the rate for African-Americans is only 47 percent.2 Given that over 1.3 million Alabamians are eligible for colorectal screening, based on American Cancer Society guidelines, this leaves a large population unscreened and at risk. Additionally, as the “age wave” surges, the eligible population due for colorectal screening will continue to climb.

n 2013, the Alabama Department of The SECAP revealed some interesting As part of its participation in the National Public Health (ADPH) explored just trends in Alabama. For instance, according Colorectal Cancer Roundtable (NCCRT), I how real the problem was in the state. to survey responses, incomplete colonos- the AAFP signed a pledge to help raise Under its FITway program, the ADPH copy procedures are mainly (82 percent) colorectal cancer screening rates to 80 per- requested that an expanded endoscopic the result of poor bowel preparation. Also, cent by 2018. “80% by 2018” is a move- capacity survey be performed in Alabama. when it comes to sedation or anesthesia, 76 ment in which dozens of organizations have The Alabama Survey of Endoscopic Capac- percent of sedation used was either opioids/ committed to eliminating colorectal cancer ity (SECAP) report revealed the number of benzodiazepines or propofol and was deliv- as a major public health problem and are colorectal screenings and follow-up exami- ered a majority of the time by an RN or a working toward the shared goal of reaching nations being done and compared it to CRNA. Even more interestingly, SECAP 80 percent screened for colorectal cancer by the number needed to screen the eligible estimates there are 514,421 unscreened 2018. NCCRT was established in 1997 as a population of Alabama. A full copy of the people in Alabama, with 200,376 having national coalition dedicated to reducing the SECAP report is available through the FIT- income below 200 percent of the federal incidence of and mortality from colorectal way program at the Alabama Department of poverty level. cancer in the United States, with the ulti- Public Health. mate goal of increasing the use of proven colorectal cancer screening tests among the entire population for whom screening Comparison of Unmet Need and Unused Capacity is appropriate. for Colonoscopy in Alabama, by Region – Base Case* The question becomes: Can we do this in Alabama? A portion of the above-noted Unmet Need Need as a Percentage unscreened could be screened with better of Unused Capacity** utilization of current colonoscopy capacity. 1. Northern 108,526 317% Increased utilization would be accomplished with improved scheduling and bowel prep, 2. East Central 90,731 396% among other elements. Given better utiliza- 3. Montgomery 55,203 502% tion of current capacity, SECAP estimated 4. Southern 101,237 718% 455,013 people will remain unscreened. 5. Birmingham 58,592 317% Capacity is simply an issue that must be 6. West Central 40,724 447% addressed, whereas access is a function of available health professionals and distribu- Total 455,013 141% tion of facilities and equipment. *Includes all necessary screening and diagnostic follow-up to positive FOBT and flex sigmoidos- copy screening procedures but does not include surveillance colonoscopies In the base case to the left, the use of screen- **Values over 100 percent imply a shortage of procedures to screen the average-risk unscreened ing tests is based on the current pattern of population. In other words, 718 percent means the unmet need is over seven times as much as the screening test use (8 percent FOBT, 4 per- unused capacity.

12 The Scope of Family Medicine There is a direct correlation between more advanced the U.S. Preventive Service Task Force and the American Cancer Society. Shifting colon cancer stages at the time of diagnosis and the screening from colonoscopy to FOBT/FIT would ease the burden of screening colonos- distance in which a patient must travel to access health copies. SECAP estimates that if all of the care.3 Access to colonoscopy facilities and equipment unscreened population were given an annual FIT, then the need for colonoscopy would is of great need in rural Alabama, a factor that drop from 455,013 to 27,264. However, this solution would only partly address the warrants immediate attention. state’s need, with access in rural communi- ties remaining an area of concern. cent FLEX, 88 percent colonoscopy), and just increase overall capacity in Alabama, The issues around colorectal cancer screening further variation is noted for colonoscopy because capacity is needed largely in rural are broad and complex, but access to quality capacity by region. parts of the state, where access remains an screening must be addressed. This includes issue. There is a direct correlation between increasing the capacity and locations of the Simply put, the capacity for the state to meet more advanced colon cancer stages at the providers offering quality colonoscopy. its current colonoscopy needs would require time of diagnosis and the distance in which a fourfold increase in the number of physi- a patient must travel to access health care.3 References cians performing the procedure across the Access to colonoscopy facilities and equip- 1. Alabama Department of Public Health. (2013). 2012 Alabama Cancer Facts & Fig- state. In some individual regions, the need ment is of great need in rural Alabama, a ures. Montgomery, AL. is much greater, a demand that will continue factor that warrants immediate attention. 2. Medicare claims data available through Ala- to grow as the population in Alabama ages. bama Quality Assurance Foundation. One readily available solution to address 3. Massarweh, N., Yi-Ju, C., Chang, G., Haynes, We must take into account the distribu- these capacity issues would be a dramatic A., You, N., & Feig, B. (2014). Association between travel distance and metastatic disease tion of the facilities and providers with the increase in use of high sensitivity FOBT or at diagnosis among patients with colon cancer. equipment to offer colonoscopy to their fecal immunochemical test (FIT). Both test Journal of Clinical Oncology, 32(9), 942-948. communities. It will not be enough to options meet the recommendation of both

Alabama Academy of Family Physicians 13 Politics and Unlikely Bedfellows The History of Graduate Medical Education in Family Medicine in Alabama and the Pivotal Roles of Gov. George Wallace and Dr. Gayle Stephens by Karl Kirkland, PhD, Director of Behavioral Medicine, Montgomery Family Medicine Residency Program, Clinical & Forensic Psychologists, PC, Montgomery, Alabama

“Politics makes strange bedfellows.” tors. Wallace grew to be an astute populist Democrat. He was an extraordinary politician. He was relentless in his pursuit of victory. — William Shakespeare, The Tempest; and Charles Dudley Warner He was always strongly tied to rural Alabama. He was committed to improving access to education and medical care in Alabama. Alabama’s famous four-term governor, George C. Wallace, Ameri- To this end, he actively campaigned to build the extensive system ca’s most successful third-party presidential candidate, is maligned, of community-based family medicine residency programs and to misunderstood and mischaracterized by most historical accounts as ensure that the Legislature appropriated adequate funding to reach a narrow-minded bigot who is remembered only for his segrega- these goals. tionist political stances in the late 1960s. However, his actual his- tory and public record reveal that his “racism” was both a horrible My Connection to This Story mistake (which he acknowledged) and an unfortunate early political position that he chose to assume in order to become “electable” in I am an LA (lower Alabama) native, born and raised in rural Escam- the deep-South 1960s world. bia County, Alabama, the land of many creeks (both bodies of water and Native Americans) and perhaps the most fertile county in our Gov. Wallace set national records in his second and third terms great state for Alabama’s treasured state tree: the longleaf pine tree. (1971-79) as Alabama’s governor in the area of funding for sec- ondary education. In his second and third terms, Wallace spear- I am the son of rural politicians in that both my parents were probate headed the development of 20 junior colleges and technical schools judges, with strong connections to Gov. Wallace. My brother, a for- throughout the state of Alabama. He also led a similar movement to mer Alabama state senator (Reo Kirkland Jr.), worked for Gov. Wal- build and fund eight community-based family medicine residency lace in the mid- to late 1970s. I was raised to be a lawyer or a county programs in an effort to deal with the shortage of primary care doc- politician, but I fell for the twin muses of philosophy and psychology tors, particularly in rural Alabama. and followed my heart and my head in a different direction.

Gov. Wallace’s political philosophy has been described as populist, As a clinical psychology intern at LSU Medical School and Char- Southern “Yellow Dog” Democrat philosophy. A “Yellow Dog” ity Hospital of New Orleans in New Orleans in 1979-1980, I had Democrat was historically defined in terms of party loyalty, e.g., the great privilege of meeting and working with another early someone who would vote for a yellow dog if it was a Democrat or, leader in family medicine, Dr. Gerald Gehringer. Dr. Gehringer alternately, someone who would rather vote for a yellow dog than a gave me the opportunity to do a formal rotation in the LSU Family Republican. Wallace’s retirement from politics paralleled the rise of Medicine Clinic on Claiborne just off Canal Street. This was possi- the Republican Party in the South. bly one of the first behavioral medicine rotations for psychologists in family medicine in the country, and it also led to Dr. Gehringer There is ample evidence that Gov. Wallace “changed” in his views introducing me to his “Alabama” friend, Dr. Gayle Stephens. My of the world, and in particular his views on race. This evolution goal then became to return home to my native Alabama and work occurred after his near-fatal encounter with Arthur Bremer while as a psychologist in family medicine. Dr. Stephens helped me get campaigning for president in a Maryland parking lot in the spring several interviews in Alabama in several of the eight residency of 1972. He subsequently apologized to the NAACP. For example, programs that Gov. Wallace had funded (the Montgomery, Bir- by the time of his last run for governor of Alabama in the spring of mingham, Huntsville and Anniston programs). I was fortunate to 1982, he garnered 90 percent of the African-American vote while be hired in the Montgomery program and have the honor of con- retaining his traditional base. There is also evidence that Gov. Wal- tinuing to serve that program 34 years later. I have the great honor lace was responsible for the development and funding of multiple of working for Dr. Tom Kincer, past president and current chair community-based family medicine residencies throughout the state of the ALAFP Board of Directors and surely the most organized of Alabama in the mid- to late 1970s. Addressing the shortage of and dedicated program director I have encountered. The program family doctors, particularly for rural Alabamians, was a central part I started my career in was located in the old Professional Center of his platform. Hospital, fourth floor, on Church Street in beautiful downtown Montgomery, where our new federal courthouse now stands. The George Wallace’s paternal grandfather was a “country doctor” who program director then was Charles T. Moss Jr., MD, a crusty U.S. frequently allowed his grandson to accompany him on his “coun- Navy physician who had honed his early procedural skills on an try rounds.” Gov. Wallace grew up from very humble beginnings aircraft carrier in World War II. and was acutely aware of Alabama’s perennial shortage of doc-

14 The Scope of Family Medicine In the late 1990s, the program I worked for faced closure, due in part ter for the History of Family Medicine (sponsored by the Society to the fact that the line-item appropriations that had carefully been of Teachers of Family Medicine) in Kansas. Gov. Wallace’s papers guarded by Wallace were vulnerable because he was no longer there similarly have just been made available for public research in to protect them. My program director and I sought to collect data Montgomery, Alabama, in the Department of Archives and History. about the success our program was experiencing in placing graduates There is a need and an opportunity to explore the links between in rural Alabama. At the time, I remembered Gov. Wallace’s inter- these two leaders that have never been investigated. est and support, and I spoke with both Dr. Stephens and Gov. Wal- lace separately about their history of support. While they gave great Some leaders, like John Adams and Thomas Jefferson, realized that encouragement, there was little either could do, and several of the they owed something to future generations because of the enormity programs closed, some to never reopen again. I was more fortunate. of their past contributions. As a result, we have the benefit of hav- My program closed but then reopened at a different hospital. ing their papers and their wonderful exchanges of letters to review. Similarly, these two great leaders left their papers for the mutual At the time, I wrote an article (Kirkland, Brantley, & Handey, 1989) benefit of many generations to study. Having had the privilege of published in Alabama Medicine (with two peer faculty members) knowing them both in life, I know they would be pleased to hear about the Montgomery program’s effectiveness in reaching Gov. of this discussion but would pretty quickly move the discussion to Wallace’s clearly stated goals: keeping doctors in Alabama. I inter- “What are y’all doing to address the shortage? Are there more doc- viewed Gov. Wallace and Dr. Stephens but had to do so separately tors in Wilcox County than there were in 1975? How about Barbour because Gov. Wallace’s health was beginning to decline. I was unable County? Lowndes County? Conecuh? Clarke? How are the infant to objectively confirm many links that would have demonstrated the and maternal mortality rates? Are the roads any better? Are there governor’s sincere commitment to rural medicine. There were many mental health services available?” unanswered questions at the time that now may be available through their archived records. Our data was used to help demonstrate our suc- First-time access to the actual records of two of the most important cess in the area of retention and to lobby for the program to reopen. leaders of the family medicine movement in the Deep South reveals The program reopened and is thriving today. Gov. Wallace died Sep- objective evidence of what has heretofore only been anecdotally tember 13, 1998, and Dr. Stephens died February 20, 2014. reported. Results of this comprehensive survey and literature search provide objective, empirical evidence for historical purposes of the For the first time, the private papers of these remarkable men are degree, amount, type and actual frequency of support provided for available to the public. Dr. Stephens’ are available through the Cen- graduate medical education by direct appropriation and line item in

Alabama Academy of Family Physicians 15 the state budget; confirm Wallace’s steadfast support; and explore leaders introduce bills or simply would have the projects placed and document the nature of what must have been a very interesting in his budget plans for the session, only to have the appropria- relationship between two great leaders from vastly different worlds tions removed as the budgets would move through the two cham- with the same goal: improving access to family physicians for some bers. Several sources point out that UAB was not particularly of the most impoverished areas in the country. The same leader supportive of the idea of community-based generalist training who brought shame to the state of Alabama for his “stand in the because of the intense interest in specialization at the time. schoolhouse door” also deserves enormous credit for working with a well-recognized hero in the early days of FM in Alabama. Thus, it was an uphill battle that was decisively won only because of the absolute persistence of the two early FM heroes. Think of the lives that have been positively affected by the joint efforts of these Gov. Wallace set national records in his two unlikely cohorts. We must continue to honor them and many others who joined them and continue to join them in their efforts to second and third terms (1971-79) as Ala- address the health care needs of all Alabamians. bama’s governor in the area of funding for secondary education. In his second and Current interviews (2013-2014) were conducted by this researcher with early third terms, Wallace spearheaded the devel- leaders in the Alabama family medicine movement. These leaders included: opment of 20 junior colleges and technical 1. Donald Overstreet, MD, director, Selma Family Medicine Residency Program 2. Larry Dixon, executive director, Alabama Board of Medical Examiners, schools throughout the state of Alabama. retired Alabama state senator 3. Sam Saliba, MD, faculty member, Selma program, later director of the Montgomery program 4. Kenneth Yohn, MD, retired physician, Barbour County, Alabama Results tell a consistent story. Gov. Wallace teamed up with an 5. Richard “Dickie” Whitaker, lobbyist, Medical Association of the state unlikely partner with a very common interest: Gayle Stephens, MD. of Alabama Together, they covered the spectrum of needs: Dr. Stephens, with 6. Gov. Albert Brewer, current professor of Law, Cumberland School of Law, the spectrum of knowledge and experience concerning the practi- Birmingham, Alabama cal and institutional requirements for starting a statewide network 7. Lt. Gov. Jere Beasley, former lieutenant governor and current CEO of Beasley, Allen, Crow, Methvin, Portis & Miles, P.C. of community based training programs; and Gov. Wallace, who 8. McDowell Lee, former legislator and longtime secretary of the Alabama had the heart, drive and political power/savvy to make plans into state Senate approved legislation and line items in the final versions of state- 9. Tom Kincer, MD, program director, Montgomery Family Medicine Pro- approved budgets. gram, and Board of Directors chair, Alabama Academy of Family Physi- cians (2014). 10. Jeffrey Arrington, managing editor, The Scope of Family Medicine, the UAB was growing by leaps and bounds through federal grant money journal of the Alabama Academy of Family Physicians in a manner that affected both the medical school and the city of Birmingham (Scribner, 2002). However, the bulk of this growth These interviews supplemented earlier interviews conducted by this exam- was under the rubric of increasing medical specialization. Few were iner in 1988-89 with Gov. Wallace, Dr. Gayle Stephens, Clyde Cox, Dr. interested in primary care and the shortages of doctors in rural Ala- Richard Hill, Dr. Gerald Gehringer, Dr. Charles Moss, Dr. Kirven Brantley and Dickie Whitaker. bama. Here, Dr. Stephens and Gov. Wallace found their common ground. The result was creating and protecting the avenue of fund- The results of multiple reviews are based upon oral interviews, reviews of sev- ing the community-based family medicine residency program(s). eral doctoral dissertations and reviews of archival records (Wallace Collection, Alabama Department of Archives and History). Records from the archives of these leaders, as well as collateral contact data derived from interviews conducted by this writer with References the above sources, revealed a consistent story: Gov. Wallace and 1. Gibson, S.N. (1980). Public policy in the expansion of higher education in Alabama: 1963-1978: A case study of the politics of higher education. PhD Dr. Stephens worked together consistently to secure ties between Dissertation, University of Pittsburg, School of Education. Paul Masoner, the knowledge base of Dr. Stephens about the “how-to” needs and Committee Chair. practical pathway to the creation of the three-year programs and 2. Kirkland, K., Brantley, J.K., & Handey, G.M. (1989). Family medicine edu- Gov. Wallace’s political power to ensure the line-item funding in cation in Alabama: How one residency program is meeting the early goals. the budgets each year. In a manner similar to the way in which he Alabama Medicine, 59, 26-29. 3. Randall, J.C.J. (2001). spearheaded the creation of multiple junior colleges and technical A kudzuing of colleges in Alabama: The prolif- eration and balkanization of higher education in Alabama. PhD Disserta- schools, Gov. Wallace pushed and prodded and “got his way” in the tion, University of Alabama, Department of History. Clark Culpepper, effort to fund and create multiple community-based family medicine Committee Chair. residency programs. 4. Scribner, C.M. (2002). Renewing Birmingham: Federal funding and the promise of change: 1929-1979 (Economy & Society in the Modern South). Athens, GA: University of Georgia. Multiple sources confirm that this was the prime interest of these two great leaders. Gov. Wallace would have his legislative floor

16 The Scope of Family Medicine Classifieds Great Opportunity for a Career Montgomery Family Medicine Residency as a Family Medicine Faculty Physician! Montgomery Family Medicine Residency program is seeking a board- certified family medicine physician to join the faculty. This growing, The University of Alabama at Birmingham School of fully accredited, 8-8-8 community-based program prefers that candidates Medicine Huntsville Regional Medical Campus invites have at least two to three years of experience in office-based practice, be applications for a full-time, non-tenure-earning, open-rank skilled in hospital and ICU medicine, and be very well-versed in ALL position in the Department of Family Medicine. Salary is forms of information technology. OB experience is not required for this commensurate with experience and qualifications. As a general medicine position. Typical duties of a faculty member include qualified board-certified/eligible physician, you will join hospital and ICU medicine, private-patient duties, precepting, lecturing, a teaching service with a broad spectrum of patients and scholarly activities and curriculum management. illnesses. In addition to providing clinical training to medical students, you would also serve as faculty for a well- This position offers a competitive academic salary with a production established 12-12-12 family medicine residency program bonus, as well as relocation assistance. EOE. and its family medicine center, recently awarded Patient Centered Medical Home Level II Certification. Bonita Lancaster, FASPR System Manager – Physician Relations/Recruitment, Baptist Health Huntsville Hospital, our teaching hospital, is an 881-bed Montgomery, AL 36117 community-based, not-for-profit institution and the second- Direct: 334-273-4527/866-507-3385 largest hospital in Alabama. The hospital is a regional refer- www.baptistfirst.org ral and trauma center and supports the teaching programs with a medical staff of more than 750 physicians, many of whom participate as volunteer faculty members.

Huntsville is consistently named as one of the best places to live and work by a variety of national publications. With a population of about 400,000 in a metropolitan area, Huntsville is home to several Fortune 500 companies as well as technology, space and defense industries. Our city is regularly named as a premier location for both business and quality of life. We successfully combine the rich heritage of Southern hospitality with innovative high-tech ventures and cultural diversity.

Candidates must have strong recommendations, a love for teaching and demonstrated clinical expertise. You must qualify for licensure in Alabama, medical staff privileges at Huntsville Hospital and credentialing as a physician pro- vider. UAB offers competitive salary, excellent benefits and relocation. A pre-employment background investigation is Family Medicine • Internal Medicine performed on candidates selected for employment. For ben- Pediatrics • Urgent Care efit information, see www.uab.edu/humanresources/home/ Emergency Medicine • General Medicine benefits. UAB is an Equal Opportunity/Affirmative Action Employer committed to fostering a diverse, equitable and Occupational Medicine • Hospitalist family-friendly environment in which all faculty and staff members can excel and achieve work/life balance irrespec- Competitive remuneration, mileage, lodging tive of race, national origin, age, genetic or family medical and malpractice insurance provided history, gender, faith, gender identity, and expression, as well as sexual orientation. UAB also encourages applica- tions from individuals with disabilities and veterans. Letters LOCUM TENENS AND PERMANENT JOBS FOR PHYSICIANS of application and CVs should be sent to Paula Cothren by Karen M. Belk, President email at [email protected]. [email protected] www.BelkStaffing.com • 1.888.892.4DRS Send CV to Fax 256.389.9000

Alabama Academy of Family Physicians 17 1393-4.indd 1 9/12/14 10:38 AM Consultants Directory Changes in

ALLERGY AND IMMUNOLOGY NEUROSURGERY healthcare — Birmingham Allergy & Asthma Neurosurgical Associates P.C. Specialists, P.C. Charles H. Clark III, MD Clara K. Chung, MD, MPH Carter S. Harsh, MD longer days… Carol A. Smith, MD Thomas A.S. Wilson Jr., MD 3125 Independence Dr., Ste. 210 800 St. Vincent’s Dr., Ste. 700 Homewood, AL 35209 Birmingham, AL 35205 I don’t want to 205-943-1197 205-933-8981 www.birminghamallergy.com www.spinebirmingham.com worry about my NEUROLOGY Neurosurgery & Spine Associates malpractice Newton & King Neurology Associates, PC of Central Alabama Rob Newton, MD Robert H. Bradley, MD Wes King, MD F. Donovan Kendrick, MD insurance. 833 St. Vincent’s Dr., Ste. 501 Jeffry G. Pirofsky, DO Birmingham, AL 35205 2065 E. South Blvd., Ste. 204 205-918-0507 Montgomery, AL 36116 334-281-6990 www.ALneurospine.com

More than insurance… A Relationship Thank You, Advertisers

Alabama Department of Public Health, Physicians’ Alliance of America...... 3 Immunization Division...... 4 www.physiciansalliance.com Your patients value your expertise, professionalism www.adph.org ProAssurance...... 2 and high standard of care. So why settle for a medical in- Belk & Associates, Inc...... 17 www.proassurance.com surer that doesn’t offer those same qualities? At Coastal www.belkstaffing.com State Volunteer Mutual Insurance Company...... 13 Insurance, we specialize in relationships with a personal Children’s of Alabama...... 7 www.svmic.com www.childrensal.org touch. We get to know you and your needs so that we The University of Alabama College can suggest ways to help your practice. If a patient files Coastal Insurance Company, Inc...... 19 of Community Health Sciences...... 20 www.coastalins.org cchs.ua.edu a claim, we make you part of the defense team, allowing you to have a voice. Healthcare Workers’ Compensation Self-Insurance Fund.. 15 www.hwcf.net If your malpractice insurer isn’t looking out for you, then who is? Call us today. MagMutual...... 9 www.magmutual.com

Wray Smith | 800-821-9605 [email protected] 18 The Scope of Family Medicine Changes in healthcare — longer days… I don’t want to worry about my malpractice insurance.

More than insurance… A Relationship

Your patients value your expertise, professionalism and high standard of care. So why settle for a medical in- surer that doesn’t offer those same qualities? At Coastal Insurance, we specialize in relationships with a personal touch. We get to know you and your needs so that we can suggest ways to help your practice. If a patient files a claim, we make you part of the defense team, allowing you to have a voice. If your malpractice insurer isn’t looking out for you, then who is? Call us today.

Wray Smith | 800-821-9605 [email protected] Alabama Academy of Family Physicians 19 South Jackson Street PRSRT STD Montgomery, AL 36104 U.S. POSTAGE PAID LOUISVILLE, KY PERMIT NO. 319

Scope Ad Oct 2014.indd 1 7/24/14 2:43 PM