{"@context":"http://iiif.io/api/presentation/3/context.json","id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/iiif/b56d21th8x/manifest","type":"Manifest","label":{"en":["Dr. Glen Stream"]},"logo":"https://d9jk7wjtjpu5g.cloudfront.net/organizations/logo_images/000/000/246/original/CenterForHistoryFamilyMedicine_2c_RGB.png?1773344256","metadata":[{"label":{"en":["Rights Statement"]},"value":{"en":["\u003cp\u003eThis item is protected by U.S. copyright and related rights. It is being made available by the Center for the History of Family Medicine as its rights-holder for noncommercial use, including sharing and adapting the work. No permission is required for noncommercial use so long as attribution is provided. All other uses require permission from the Center for the History of Family Medicine.  Disclaimer:  The views presented in this broadcast are the speaker’s own and do not represent those of CHFM or the AAFP Foundation. The information presented is for general, educational, or entertainment purposes and should not be considered legal, health, financial, or other advice. \u003c/p\u003e"]}},{"label":{"en":["Description"]},"value":{"en":["\u003cp\u003eDr. Stream speaks about his time in school receiving his M.D and then his Masters in biomedical informatics. He enjoyed his time on the Board with the AAFP and was excited to learn about the strategic plan happening with FMAH and the Future of Family Medicine projects. With his medical group in Spokane, he managed a $250 million a year enterprise, which correlated to his tasks at FMAH and beyond. He thinks that in the current health care climate there is not enough prevention and wellness and good chronic illness management which are the key skill sets for family physicians in that area, instead it involves way too much late illness care, and salvage therapy for things that should have been prevented.\u003c/p\u003e (summary)"]}},{"label":{"en":["Date"]},"value":{"en":["2016-01-07 (created)"]}},{"label":{"en":["Type"]},"value":{"en":["oral history"]}},{"label":{"en":["Agent"]},"value":{"en":["Dr. Herbert Young (Interviewer)"]}},{"label":{"en":["Format"]},"value":{"en":["audio file"]}},{"label":{"en":["Keyword"]},"value":{"en":["American Academy of Family Physicians","Family Medicine for America's Health","Family Physician","family medicine"]}},{"label":{"en":["Subject"]},"value":{"en":["Glen Stream, MD (personal name)"]}},{"label":{"en":["Language"]},"value":{"en":["english (primary)"]}}],"summary":{"en":["\u003cp\u003eDr. Stream speaks about his time in school receiving his M.D and then his Masters in biomedical informatics. He enjoyed his time on the Board with the AAFP and was excited to learn about the strategic plan happening with FMAH and the Future of Family Medicine projects. With his medical group in Spokane, he managed a $250 million a year enterprise, which correlated to his tasks at FMAH and beyond. He thinks that in the current health care climate there is not enough prevention and wellness and good chronic illness management which are the key skill sets for family physicians in that area, instead it involves way too much late illness care, and salvage therapy for things that should have been prevented.\u003c/p\u003e"]},"requiredStatement":{"label":{"en":["Attribution"]},"value":{"en":["\u003cp\u003eThis item is protected by U.S. copyright and related rights. It is being made available by the Center for the History of Family Medicine as its rights-holder for noncommercial use, including sharing and adapting the work. No permission is required for noncommercial use so long as attribution is provided. All other uses require permission from the Center for the History of Family Medicine. \u0026nbsp;Disclaimer: \u0026nbsp;The views presented in this broadcast are the speaker\u0026rsquo;s own and do not represent those of CHFM or the AAFP Foundation. The information presented is for general, educational, or entertainment purposes and should not be considered legal, health, financial, or other advice.\u0026nbsp;\u003c/p\u003e"]}},"provider":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/aboutus","type":"Agent","label":{"en":["Center for the History of Family Medicine"]},"homepage":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/","type":"Text","label":{"en":["Center for the History of Family Medicine"]},"format":"text/html"}],"logo":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/organizations/logo_images/000/000/246/original/CenterForHistoryFamilyMedicine_2c_RGB.png?1773344256","type":"Image"}]}],"thumbnail":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/public/images/audio-default.png","type":"Image","format":"image/png"}],"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162277/file/295066","type":"Canvas","label":{"en":["Media File 1 of 2 - StreamGlen_01_Access.mp3"]},"duration":3385.5615,"width":640,"height":360,"thumbnail":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/public/images/audio-default.png","type":"Image","format":"image/png"}],"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162277/file/295066/content/1","type":"AnnotationPage","items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162277/file/295066/content/1/annotation/1","type":"Annotation","motivation":"painting","body":{"id":"https://aviary-p-centerforthehistoryoffamilymedicine.s3.wasabisys.com/collection_resource_files/resource_files/000/295/066/original/StreamGlen_01_Access.mp3?1760559042","type":"Audio","format":"audio/mpeg","duration":3385.5615,"width":640,"height":360},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162277/file/295066","metadata":[]}]}],"annotations":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162277/file/295066/transcript/85361","type":"AnnotationPage","label":{"en":["Dr. Glen Stream interview transcript [Transcript]"]},"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162277/file/295066/transcript/85361/annotation/1","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"Side 1: This is side 1, tape 1, of my interview with Dr. Glen Stream, president of Family Medicine for America’s Health. My name is Dr. Herbert Young and I’m conducting this interview on January 7, 2016. And Dr. Stream is on the telephone connected from, where is your location, sir?\n\nI’m currently in La Quinta, California.\n\nWonderful. And I’m at the Center for the History of Family Medicine. So, Dr. Stream, welcome. And do we have your permission to record this oral history?\n\nYes, you do, Herb. Thank you.\n\nWonderful. If you could start by giving us your full name?\n\nSure, Glen with one “n,” middle name Richard, last name Stream.\n\nAnd what are your present titles and positions?\n\nMy day job is I’m a practicing family physician at Eisenhower Medical Center which is in the Palm Springs area of California. And my clinic where I see patients is in La Quinta, California. My organization position is as president and board chair for Family Medicine for America’s Health.\n\nThank you. And could you share just a little bit about your professional background?\n\nSure. As far as medical training, I was originally born and raised in Seattle, Washington and did my medical training there. I attended college at the University of Washington, obtained a degree in microbiology and then went to medical school at the University of Washington School of Medicine. I was very pleased about the strong family medicine presence there. And I stayed in Seattle to do a family medicine residency training at the Swedish Family Medicine Residency Program in Seattle. And then out of residency I practiced in a small rural area in central Washington state, a town called Cashmere and was within a full scope family medicine practice there for six years. I then relocated to Spokane, Washington and joined a large multi-specialty group and had numerous leadership positions within the multi-specialty group. And then a little over two years ago relocated to California. \n\nAnd you also had another degree, I understand?\n\nYeah, I obtained a masters of biomedical informatics degree from Oregon Health \u0026 Sciences University and some of my professional responsibilities at my multi-specialty group, the Rockwood Clinic in Spokane, was as the first medical director for clinical information systems and chief medical information officer. And the position of chief medical information officer is the position I held here at the Eisenhower Medical Center until I stepped down from that to devote time to the Family Medicine for America’s Health project.\n\nThat’s sort of an interesting change from microbiology, with honors, into family medicine, and then with others such as the information area. Any comments on that transition?\n\nWell, first of all, I think it speaks to the breadth of opportunity in family medicine. You can pursue different subspecialty interests. I think we, as family physicians, have a unique perspective because we care for patients across the whole age spectrum, across sort of every location of care. You know, different sites within the hospital but also nursing home and home visits. And I think it would be unlikely that anybody else had as broad a view of the healthcare system as the family physician. I would have to say I enjoyed microbiology but the full truth would be that I knew I wanted to go to medical school from the day I entered college, and so I looked at the degree graduate requirements for different degrees and the entry school requirements for the University of Washington School of Medicine and I chose the degree with the most overlap.\n\nAh, so a very practice approach.\n\nYeah. But that’s me, I’m a logical guy. \n\nHow did you get involved in Family Medicine for America’s Health?\n\nDuring my tenure as an AAFP officer, I was elected to the AAFP board in 2007 and then AAFP president-elect in 2010. So during my tenure as an AAFP officer, the concept came up that as we neared the ten-year anniversary of the publication of the original Future of Family Medicine accord, should there be sort of a look back and a look forward. And so those discussions occurred at the working party meetings, which are twice a year, collaborative meetings of elected and staff leadership of the different family medicine organizations. And it was created initially to investigate both the feasibility and need for a project like that to follow up the original Future of Family Medicine. And I was involved in those discussions and there was good momentum towards doing that. In the creation of what became the FMA Health Strategic Plan, a lot of them work happened just as I was leaving the AAFP board chair position and so I had some time to be engaged. So I, along with Doug Henley, represented AAFP on the project team to sort of create the project. And when that plan was presented to the organizations and approved to go forward, a board was created that initially involved members appointed by each of the eight family medicine organizations participating and I was honored to be selected by the AAFP to represent them on the board. Subsequently, the organization evolved such that the board itself felt that its shear … That’s not exactly correct. We also thought it was clear besides just a board chair, that we needed an executive level type position to lead the project and to coordinate the work of the board and to have day-to-day engagement with the consultants that were involved. And so in January of 2015, so about just a year ago, the board created the position of president of FMA Health and selected me to fill that position. And in doing so they felt it was appropriate that that person not be representing one of the organizations, so I stepped away from being the AAFP’s representative. Another person was appointed to that and the board grew from twelve to thirteen. So that’s the path to get to the current position I have, which is currently board chair and president.\n\nWhat knowledge and skills then do you think have prepared you for this leadership role?\n\nI think that the leadership opportunities that come from serving on the AAFP board, and especially as an officer in the president-elect, president board chair succession, bring a lot of skills. A lot of media skills. My position in the FMA health project was intended to be the public voice, so in my role I do a fair bit of media and moderating of panels and things like that. And it’s a skill that I was able to hone in my time as AAFP leadership. My own sort of personality is to be fairly organized and to be strategic in thinking. And so as I was talking about the path to medical school, logically thinking, you know, what were the easiest degree requirements that met the medical school requirements. I think I’ve got a logical, analytic mind that way. I handle complexity well. But at the same time, I’m a good listener, a good synthesizer. I occasionally come up with really good ideas. But more often I hear somebody else have an idea that maybe they just don’t even know is a good idea. And if it is, I can sort of synthesize and build on those. So I think that’s a strength that I build, that I bring. Obviously, this FMA Health is a project of significant financial scope and both within my masters degree there was some sort of finance and budgeting and project management skills in my leadership position with my medical group in Spokane. I was one of the executive team leading what was then our $250 million a year enterprise. I’ve done some work through ACPE, American College of Physician Executives. They changed their name, I forget what it is right now. But I’ve done some of their course work around business and finance. So I bring some organizational skills. I’m not an educator, I’m not a researcher, but organizational skills to lead people in projects I think was an important piece. And the other thing I really gained is in my leadership time in AAFP and participation in the working party, I have good personal relationships with many of the people who are now actively involved either as board members or on the tactic teams and amongst the leaders of the eight organizations, you know, their staff leadership, are all people that I know and have working relationships with. And I think that really has been a strength to bring to that position.\n\nAnd, indeed, Family Medicine for America’s Health involves multiple organizations not only in terms of the organization of the effort itself but who you all will be dealing with in these years ahead. And we will come back a little bit later to some questions that sort of compare FMA Health to the Future of Family Medicine project. So, what, in your view, is the value and purpose of FMA Health?\n\nSo, as it was conceived, the FMA Health project was very much intended to build on the foundational work of the original Future of Family Medicine project. Not at all to recreate that but to look back and see what work had been accomplished in the subsequent ten years, what had changed in the landscape and how did sort of need to redirect going forward. So it’s important, in my opinion, not just to the specialty but, really, to the health of the American people. You know, we, as family physicians, I think too often discount the importance of the care we provide to patients in improving the health of not just those people but families and communities in the whole country. And, you know, we’ve seen an erosion in the primary care foundation of our healthcare system. You know, we’re not producing enough primary care physicians to keep up with demand. And we need to change that if we want to have a healthy population completely separate from a healthy and viable specialty. But the specialty of family medicine is unique positioned to serve that role in primary care to have those outcomes. And if there was one sentence that sort of described the value and purpose of FMA Health is to achieve the Triple Aim of this concept of improving healthcare delivery as far as its safety and efficacy of quality. Also, to improve the health of the population but also to constrain the spiraling costs of healthcare. We’ve somewhat expanded that a little bit to include what’s often called the quadruple aim, which is to address concerns about the professional satisfaction of, honestly, not just family physicians but all members of the healthcare team. The practice of medicine is stressful. Our system is undergoing significant changes that bring on a lot more stress and we really need to address that. So it’s a big component of the project as well.\n\nCan you talk a little bit about the Triple Aim and how that relates nationally to the activity and direction of FMA Health?\n\nCertainly. So the concept of the Triple Aim came from the Institute of Healthcare Improvement, Don Berwick and his shop, and was really put into motion during his tenure as interim CMS administrator. And part of the value in aligning the work of FMA Health with the Triple Aim is the Triple Aim itself, at least within the health policy world and the key stakeholders, other than patients, the key stakeholders within the healthcare system understand the Triple Aim and its importance. In many ways, I view it as a tectonic movement within the healthcare system. And the more that we align our efforts with that, I think we will be acknowledged for contributing to that. And I would argue without a strong primary care system you can’t possibly achieve the Triple Aim. So we were also fortunate, at the media launch event, to have Dr. Berwick as one of our speakers sort of acknowledging the significance of the Triple Aim into our project and to the health care of the country. \n\nWould you say the Triple Aim is widely recognized within the nation, at this point, by people making decisions about health resources and so forth?\n\nI think within government and key stakeholders like large employers, health payers, large healthcare systems, certainly I think it’s well-known there. I think in the lay public, not nearly so much. But in the key decision-makers, and my hope is that eventually patients will be more key decision-makers and influencers in a grassroots sort of manner that impacts the healthcare system that they depend on. But currently I think that awareness is not really there.\n\nAnd then you mentioned that there’s a fourth component now that’s been added?\n\nYeah, this idea of professional satisfaction. You know, we’ve seen in surveys of physicians over the last several years an increase in the number of physicians reporting burnout. The professional satisfaction is low, they’re frustrated by their work. Particularly the work that doesn’t contribute to patient care, we’ve seen so many changes in healthcare that involve adding work to physicians that they don’t necessarily see as within their scope or valuable to the care they deliver. Things like coding system changes, like ICD10, the meaningful use transition to electronic health records, challenges with the payment system are all things that are real frustrating for physicians and we need to try to address that as best we can.\n\nAnd at the same time, has there been an erosion of the scope of practice?\n\nAs a family physician? Yes. I think there’s been a change, in my observation, and from what I’ve read and heard. And some of the best data comes from the American Board of Family Medicine’s diplomate survey when people are recertifying and describe what component they include in their practice. There certainly has been a shift over time, fewer people doing hospital care, fewer people doing obstetrical care. Interestingly, fewer family physicians providing care to children. And some of that, I think, has been voluntary. Some of it’s been brought on by the system. But in the view of FMA Health, maintaining full scope training for family physicians is critically important. And then family physicians can choose which areas of practice they’re going to include as they go forward from their training based on the needs of their community but that their training should involve all of those areas.\n\nSo attention to a fairly wide range of issues that impact the profession’s satisfaction with what they’re doing?\n\nI’m sorry, I didn’t catch that piece of your discussion. You’re thinking of the scope as it relates to professional satisfaction? \n\nYes, I was trying to link those two. \n\nI do think that it can be a component of dissatisfier if people are finding from their hospital or from their medical group or at the influence of health plans that they’re not able to do those things that they’re appropriately trained and have the experience and the desire to deliver for their patients. And I do think that there’s a component of that in this reduction in scope of practice. But some of it is just people are choosing to do less. You know, sometimes the obstetrical thing is a liability insurance issue or it may be a lifestyle choice about less on-call and after hours demands. So I think there are a number of forces involved.\n\nAre family physicians being called upon to do new things in terms of present and looking forward to the years ahead that maybe are influenced by FMA Health? Because I’ve noticed some discussion of integration of public health or mental healthcare, for example.\n\nYeah, I would put that all broadly in the context of evolving and disseminating the Medical Home Model for delivery. And so, certainly, to have the impact it needs to have in actually improving health broadly, the Patient-Centered Medical Home model really needs to integrate into the community through public health efforts. And family physicians are aware probably more than any other specialty of the direct correlation between people’s mental and their physical health. So we are very much highlighting those, if they have ongoing evolutions in the Patient-Center Medical Home model, and at the same time highlighting that current payment model doesn’t necessarily fund adequately to be successful in those areas. The other piece that I would point out that really is an evolution is the concept of population health and using both strategies and technology so that thus far, and this has been part of the Patient-Centered Medical Home model from the beginning, that our care of patients isn’t isolated just to when they come in for visits in our office but that’s extended in between visits as well.\n\nCould you just say a little bit more about population health in terms of defining it?\n\nFrom my standpoint, and I’m no expert in this, I look at is as sort of an evolution from the Wagner Chronic Disease model where you would sort of have registries of patients with different chronic illnesses and to reach out to them periodically if they were overdue for services or reach out to them with educational materials. You know, in many ways population health is expanding that to be everyone. You know, to reach out to people with prevention and wellness messages. You know, it’s fall, it’s time for your flu shot even if you don’t have a chronic illness. In our young and healthy, influenza immunization is recommended for everyone. Perhaps reaching out to them with fitness and nutrition messages, things about smoking cessation. Things that are broadly related to health but not necessarily always just healthcare delivery.\n\nAnd so, in some cases, as you’re dealing with one aspect, say tobacco, with people who smoke, you’re also dealing with the impact on people around that individual in the same household or in work spots and so forth?\n\nAbsolutely. In the broadest sense, it’s thing like environmental health, water safety, communicable diseases. You know, all those things that have been traditional pieces of public health. The Institute of Health recently put out a report about the importance of integrating public health and primary care, which certainly is not surprising, because those of us in family medicine and primary care has been – yet, sadly, those are probably the most underfunded components of our healthcare system.\n\nThat perhaps opens the door then to the question of, in your opinion what’s going on with healthcare in America right now and what do you think needs to be done? And then we’ll logically want to move into how, again, Family Medicine for America’s Health is going to address that.\n\nIt’s hard with these sorts of questions to separate the personal opinion from my representative role for FMA Health, but I think they’re largely overlapping. You know, the data of the healthcare system in the U.S., I wish I could remember who to attribute this quote to. My understanding was it was, at the time, a CMS administrator. But the quote was something about healthcare system in the United States, it’s not about health, it’s not caring and it’s not a system. We have really disintegrated care that’s often not coordinated well in a primary care and specialty care. It involves not enough prevention and wellness and good chronic illness management that is the key skill set for family physicians in that area, but instead involves way too much in the way of late illness care, salvage therapy for things that should have been prevented. So the goal of FMA Health is to, through various areas around workforce and practices -- and supported by appropriate payment models to build and advocate for a primary care foundation for a healthcare system that addresses those decisions. You know, we hear these statistics all the time about how much we spend per capita compared to other first world countries and yet indicators of health for our people are typically at the low end of participants in those surveys.\n\nSo how does Family Medicine for America’s health go about addressing these issues?\n\nThere are a number of areas in which we are involved. I mentioned the burnout piece. And for a lot of physicians, they identify their engagement with their electronic health record as part of that frustration. Our technology tactic team is working to engage the technology community with a physician voice from family physicians about how those systems can be made more user-friendly, more usable, actually contribute better to the healthcare delivery of patients rather than intrusion in that delivery. One of our charges, and particularly for our practice team, is about how do we go about do we build on the work so far on the Patient-Centered Medical Home. You know, we know a number of members really haven’t embraced the model and they have concerns about it – and many of those concerns can be well-founded. But we want to build on the success thus far and evolve that model to address any evidence of shortcomings. But, again, to expand it to include the integration of the public health and mental health and population health as well. What we believe needs to happen is a fundamental shift in how primary care services are paid for. So with the current fee for service system, you get paid for what you do. And if that’s fixing a hip or putting in a stent or removing somebody’s appendix, a fee for service, a payment for work done I think makes sense. But what family physicians do, our work is continuous and the unit of work is a month or a year of care for people. It’s not just a visit base, if we’re going to have this model extended between visits. So we are charged by the family medical organizations with advocating for a comprehensive payment model where the bulk of payment is on a per member per month basis for delivering primary care services, whether those are face-to-face or virtual or population management. But that the bulk of it be a per member per month payment. And the practice knows who their patients are, they’re engaged with them and that they’re off the fee for service hamster wheel of having to see X number of patients simply to pay the bills of the practice. One other feature is you mentioned adequate workforce. So we have a real focus through our workforce group on having a well-trained workforce. And the goal is framed broadly because it involves both recruiting enough people to the specialty, having adequate residency training capacity at content and then having a professional lifestyle that makes people stay in practice. Because one of the areas where we’re losing our workforce is early retirement to people that are burned out. Another area is our engagement group. We understand that this type of fundamental change in the healthcare system can’t be accomplished by family medicine alone and we look to our other colleagues that work in the Medical Home model. So not just other physician specialties, but other clinicians, is to get our charge to collaborate with them as far as bringing those changes forward.\n\nI have a feeling that we’ll circle back again a little bit to what are the problems as we learn more about Family Medicine for America’s Health. But I wonder if we could sort of compare the effort for FMA Health with the Future of Family Medicine project because there’s clearly a lot of differences in terms of the means of execution and expansion of the players involved in this effort. Even the creation of the post that you are holding, for example. Could you talk a little bit about the organization?\n\nSure. First, as a disclaimer, I wasn’t directly involved in the original Future of Family Medicine project, so my knowledge of it is based on what I’ve read and what was reviewed in the preparation for the current project. But in many ways it’s quite different in a number of ways. I think the specialty and the healthcare systems are in a different place at the beginning of this project. At the time of the original Future of Family Medicine project, I think there was concern about the actual viability of the specialty, and that was included in its report. I think at this point the view is not so much about the viability but the direction of the specialty. You know, what’s going to be the role of family medicine and how do we engage and change efforts that get us to the goals that we’re pursuing. The original Future of Family Medicine project, to my knowledge, did not have a large public facing communication strategy. And so as we looked to create the current FMA Health project, there were really two main areas that we identified that the original project had not desired success as was hoped. One is change in the payment system. And I just talked a bit about that. The other was expanding the public awareness of family medicine and its importance, again, not just to them individually but to their family and community and to the country as far as having a high quality healthcare system. So the current project includes a significant communication outreach targeted both to the public and to key stakeholders about those issues. On the strategic side of the project, in the original Future of Family Medicine project a strategic plan was created and individual tactic areas of work were divided up amongst, at that time, the seven participating organizations and they would report back to each other periodically. But, for the most part, the work was conducted by individual organizations according to the plan. It was felt, in the creation of this project, that it would be more integrated and successful to have the conduct of the project handled by a single entity and that led to the creation of FMA Health as an organization created by the now eight sponsors with representation from their boards but to then take over the day-to-day management of the project.\n\nSo there’s been a creation of an ongoing leadership activity and then, also, the hiring of organizations to assist in this work?\n\nYes. So the working party itself initially engaged strategic and communication consultants in the research that led to the creation of the project. So the communication work was funded by AAFP and the strategic engagement work was funded by American Board of Family Medicine. And those consultants gathered information, worked with the participants in the working party and the steering committee for the project and it led to the generation of the project plan. At the time that the project plan was completed and it was elected to move forward, it was felt by the organizations and by the then FMA Health board that the best way to proceed with implementation was to continue a subsequent engagement with both the communication and strategic consultants that had been engaged in the creation of the plan.\n\nWhat do you think were the learnings, if any, from engaging these two organizations who I presume weren’t in the health fields necessarily previously? Did they bring any insights or questions they were asking, raise new discussions in any way?\n\nYeah, so let me take both of them separately. The strategic consultants actually had done a lot of work with other professional organizations including different specialty organizations. So not in the area of sort of healthcare delivery necessarily, although they had done work with strategic planning for integrated delivery systems. But it was more intra-professional organizations. And then they did a lot of work outside of healthcare as well, with some of it being transferable sort of knowledge and some of it not. But they did particularly bring expertise in integrating the work of multiple organizations such as the working party in a collective effort, so they have that expertise. The communication consultants came from a large, a multi-national communication group that has done some messaging around health issues like … I shouldn’t speak because I’m not sure which ones. But around public awareness campaigns about health issues. Not specifically about family medicine or even different medical care things, but more, I think, things that would sort of fall more in the public health or personal health choice type of category. Their work including some public opinion research, the communication folks, about, again, what was the view of family medicine as a baseline, if we were going to launch into this communication effort. And, unfortunately, you often had to explain to the survey participants what family medicine was. But once they understood that it was family care across generations, care across venues of care, once they understood more clearly what family physicians were, they highly valued them. I mean in a public opinion survey type of thing, we were up there with groups like the American Red Cross. So there was an amazing sort of respect for the work of family physicians that we need to build on people understanding that sort of collective skill set that they want and that, in fact, is embodied in what family medicine and family physicians do.\n\nIn looking at Family Medicine for America’s Health and looking back at the Future of Family Medicine, this is a slightly larger group participating. Can you talk a little bit about the addition of an eighth organization?\n\nYeah. So there was a time a time during my AAFP leadership where largely for budget reasons there hadn’t been as much engagement with some other professional organizations. And one of those was the American College of Osteopathic Family Physicians or ACOFP. As AAFP came out of some budget challenges, we began participating with them. At the time I was AAFP president, I might have been the first person in several years to have gone to their meeting. But it became very clear that their concerns and their values were much aligned with ours. And subsequent presidents after me went to their annual meeting, had the same experience. So that led to both an outreach to ACOFP to participate, but also outreach from ACOFP. ACOFP, as they heard about this effort, they’re, like, we would like to be involved. So it was really a connection built from both sides and added them as a participant not just in the FMA Health project but an ongoing participant in the working party meetings.\n\nAnd another difference perhaps between FMA Health and the Future of Family Medicine project seems to be the use of tactic teams that cross organizations greatly. Can you talk a bit about that?\n\nThe original strategic plan included the creation of six tactic teams in areas that include research, workforce, practice, payment, engagement and technology. So those six. Recognizing that some of the tactics that we were given would cross over. So, say, you know, something about using electronic health records might be both technology and practice. But the idea was to convene small groups that were representative of the different organizations but also representative of different regions of the country, different sizes of the practice. And we were looking for diversity in gender and race and every other aspect that we could, recognizing that we have thirty participants in the tactic teams with five for each of the six, that we couldn’t get all the diversity that we might have liked. But that was the idea, to build those skill sets in the representation to address the work in those tactic areas.\n\nAnd what do the teams go about doing? \n\nThe teams meet twice a year in person to discuss the work that’s been assigned to them by the project plan and how they see being successful working with that. And then they also are building support networks of people who have particular knowledge and expertise and provide input to the work of the tactic team. But they don’t necessarily have to participate in all the meetings or come to the in-person meetings. And so it’s creating, in some ways, sort of a volunteer force pulling from all of those folks that have something to contribute into the work. What’s evolved, in my opinion, is the recognition that that can’t get all of our work done with just volunteer time. And as much as, in some ways, FMA Health was stood up independently to begin with, it’s become very clear that to be successful in our work that it’s not going to be autonomously done by FMA Health but very much in collaboration and coordination with sponsor organizations that have often very deep resources as far as expertise and personnel in areas that are the work of FMA Health.\n\nAny examples come to mind?\n\nProbably the best one currently would be in the technology area. So there’s a technology tactic team that has, obviously, a broad charge. You know, how do we fix the technology that’s involved in delivering healthcare? And it was recognition that the AAFP has been engaged in that since the very beginning as the original Future of Family Medicine project moved towards electronic health record and had built expertise in its now E-healthcare Alliance so that rather than stand up some type of separate primary care technology center, that instead the tactic team and the other eight organizations would engage with the ongoing work of the AAFP as it relates to the technology piece. So the technology team continues its work in other areas but in work that really is in the scope of AAFP’s E-Health Alliance, having them do that work and simply being aware of it and integrating it to their work and that of the other tactic teams.\n\nSo there’s the advantage of more organizations and individuals being able to participate but maximizing the use of existing relationships and resources?\n\nYeah, exactly. I look at it as in the original Future of Family Medicine project all the work was allocated out to different organizations and done somewhat separately. In some peoples’ minds originally the FMA Health might have been to consolidate all of that into one place and instead it’s more sort of a both model. Some of the work being done directly within FMA Health but FMA Health in a lot of ways serving as an integrator and coordinator with some of the work being done within the individual sponsor organizations.\n\nThe name of the effort is Family Medicine for America’s Health but you’ve referenced it in materials that I’ve had access to, the fact that there is communication either at the individual level through focus groups or organizationally with other parts of primary care – because primary care pops up in a lot of the materials as well. Can you talk a little bit about how that’s moving forward with the PAs versus the primary care physicians within other organizations, etc.?\n\nIt’s sort of an interesting multi-component answer. So I would say you’re absolutely right. Even in the formation of the project plan there was discussion of should be this Primary Care for America’s Health or Family Medicine and sort of strong opinions, as you would imagine, on both sides. We have colleagues who feel like we were diluting the family medicine message if we talked about primary care and then other people who are much more focused on sort of the collaborative strategy that includes our primary care colleagues and other specialties. In the generation of the project itself, for me, I think, led to it being Family Medicine for America’s Health, is that it was challenging enough to bring eight separate family medicine organizations together around a strategic plan. If we were to go out more broadly and involve other physician primary care specialties and non-physician clinicians, that we would have spent a lot of time trying to create the project rather than do the work. And so the strategy that was taken was to have it be Family Medicine for America’s Health but to be inclusive where appropriate in our work. So in promoting the evolution of the Patient-Centered Medical Home, that obviously involves any of the team members in the medical home model. So we have some participants of our tactic teams that are not family physicians. We have a nurse, we have a physician’s assistant, we have a non-physician researcher. But more we plan to get that influence as these support networks that I mentioned around the core tactic teams, as those are built out, to get those voices represented. And then one of the areas of work for our engagement team is at the organizational level engaging other professional organizations in these discussions. So it’s sort of at multiple levels.\n\nHave you had any feedback from any of the other organizations? Is there any fear, any excitement?\n\nI would say there might be a little bit of both. At the time of the media launch in October of 2014, I had a chance to meet with some leaders, staff leadership mostly, that were D.C.-based, some other organizations just to let them know about our project. I did have a chance, also, to address a meeting at the Council of Medical Specialty Society about our project. I do think that there are both folks that see this as a self-promotion for family medicine but I also believe that there are people who see this as advocating for the necessary change in our healthcare system. So I haven’t come across any sort of truly oppositional efforts of other folks, but certainly I think there are some varied opinions.\n\nWithin the family, can you talk a little bit about chapter involvement, that is chapters of the American Academy of Family Physicians? Or any sub-units of any of the other organizations? \n\nThat’s a really good question Herb. So there’s a couple of pieces to that. One is we tried to be, again, very inclusive. So the AAFP obviously has the most extensive chapter system but the ACOFP does as well. So we have a number of materials that are related to our communication effort called Health Is Primary. And we make those materials available to the chapters to disseminate and have information for them to discuss the project with their membership. We’ve given a presentation at the annual leadership conference of the AAFP to chapters as elective leaders within the AAFP about the effort and what’s going on. The initial year of our communication effort involved our city tour which was to go out to communities and have a panel discussion about the various aspects of family medicine and its value to the healthcare system to an audience where we sought to have key people there. So health plans and employers and patient advocates. So those were constructed in collaboration with the chapter local to whatever venue was having that city tour. So those occurred in Seattle, Raleigh, Chicago, Denver and Detroit. So those big chapters were engaged with us. I mean they were not a chapter event, but obviously they had the most expertise about their local area that could facilitate the success of our city tour event. And so we worked with the chapters, and continue to do so, about gathering those stories, those bright spots of where family medicine has meaningfully addressed different aspect of healthcare and look to share those stories.\n\nSomething that happened in the fall of 2015 was a new partnership, a new activity with CVS Health. Can you talk a little bit about that and any reactions that you all have heard?\n\nIn the construction of our project we were very ambitious about what we wanted to accomplish particularly in the communication but also in the strategic effort. And our plan involved expenditures in excess of what the commitments from the eight sponsoring organizations, so there’s a funding piece to my answer. But there is the idea that even though money has been invested for the communication strategy, when you’re looking at a national communication strategy it becomes very expensive if you’re using paid media, advertising. So our communication strategy in the Health is Primary campaign rely heavily on social media, earned media like interviews, public service announcement type of placements. We just had one of our ads in Fortune Magazine, just in the last couple of weeks, a several hundred thousand dollars ad placement that was free for us as a public service placement. So an important part of the role with the CVS piece is they have 7,000 stores and pharmacies and the relationship we have them is co-promoting this concept of health is primary and that primary care delivery is critical to people’s health and it needs to be high-quality and coordinated. Any time you’re looking at a potential sponsor, you’re always looking at what’s the downside or questions that might happen. Obviously not all family physicians embrace the concept of a retail care delivery. The thing that swayed both the sponsoring organizations and the FMA Health board is, in some ways, in important ways, CVS Health is unique amongst retail clinic providers with its Minute Clinics. And by that I mean they embrace the Medical Home Model. They are on public record including a media event, publicly saying that they don’t want to be the primary care provider. They want to be the medical neighborhood extension of patients medical home. If they see patients that don’t have a usual source of care, they seek to connect them to a medical home. And that’s the message that resonates with the message that we have for patients, so that’s why we feel comfortable proceeding with this strategic relationship with them.\n\nThey, also, within an organization within pharmacy, gave up tobacco within recent years.\n\nYeah, exactly. We had a media event in November and we highlighted (I’m glad you brought it up) for the issue of tobacco. Obviously, we talked about the importance of public health measures in family medicine and primary care and tobacco cessation and avoidance is a critically important one. And CVS has taken a unique position amongst pharmacies in removing sales of tobacco products from their stores and actively collaborating with partners that they have in different communities where they are an extension of the medical home and the medical neighborhood model and they provide smoking cessation services. And so they really are a key ally in the tobacco cessation efforts. At that meeting event we had Andrew Sussman, who is the key person over the Minute Clinics for CVS. And also had Regina Benjamin, former Surgeon General and family physician who is obviously a strong anti-tobacco advocate. Also had Rich Wender, who is the chief cancer control officer for the American Cancer Society, also a family physician. So that event, in collaboration with CVS, allowed us to talk about a number of things about tobacco cessation, about the Medical Home model in the neighborhood. But also highlighted these different roles that family physicians have because we had people from the American Cancer Society and a former Surgeon General whose specialty is family medicine.\n\nWe’ll be needing to pause for a moment to turn the tape over. But let me ask about public health outreach. Have you had any contact with such groups as the American Public Health Association or the Centers for Disease Control and Prevention?\n\nTo my knowledge, not with the Centers for Disease Control and Prevention. We’ve had some sort of preliminary discussions with the Public Health Association, but nothing has come to any particular fruition at this point. You know, we are just starting the second year of a five year project. A lot of our first year was sort of getting organized with these tactic teams and prioritizing our work. So this is the year we’re really looking to accelerate that work including those source of engagements.\n\nSide 2: Dr. Stream, what other thoughts do you have as we look at the future for Family Medicine for America’s Health and our current healthcare system?\n\nI think it’s useful for folks who are going to follow after this project to sort of understand the timeline type of issues. I would like to think that we’re going to accomplish all of our goals completely within the five years of our project, but that’s a little bit facing things like achieve the Triple Aim and reduce healthcare disparities. I think it’s impractical to think all of that will happen. I want people to understand that both the communication effort and the strategic effort are intended to be very metric-driven. This is not a feel good project. We are following a metrics related to the communication effort about peoples’ understanding that family medicine and primary care, it’s importance to them, their own engagement in their own health. And so as the project proceeds, we’ll be tracking those metrics. And I think it will be useful to see how much of that endures beyond the duration of our project. And in this three year communication effort, can we make an impact on peoples’ understanding of family medicine and what family physicians do. On the strategic side, the timeline is even longer. We are looking at metrics related to individual tasks or things related to research and related to workforce and training and technology. And yet the impact of many of those may not be seen until after the project and so we are looking to identify metrics to our success where it’s ongoing data perhaps gathered by others. So, for example, the American Board of Family Medicine’s diplomate survey every time people recertify. Now there’s important information about their scope of practice. And we’re looking to potentially have additional questions added to that, that can provide some of the follow-up information relative to the work of the project. I would envision at some point, I wouldn’t guess a time, but ten years seems like sort of a round number … At some point I envision there will be another effort like this because the challenges in our healthcare system are deep and are going to go on for a while. And I hope that information we’re leaving behind in these archives as well as academic papers that will be published and other enduring work will serve as a good resource to people that follow up with this. The other thing that will happen is that at various points along the way, I mentioned earlier the idea of some of this technology work had already been handed off to the AAFP E-health Information Center. But other work will be handed off at different points along the line perhaps that is better suited to one of the family organizations rather than primarily with FMA Health. But obviously at the time that the project winds down, currently estimated to be a five year project, any undone work needs to be handed off to somebody to be completed. So those who are going to fill leadership positions in these eight sponsor organizations can look to see where some of that work might come to them to carry on.\n\nHow much agreement and how much disagreement has there been in general across these  various issues at the board level?\n\nIt’s interesting, in the creation of our board we have very specific discussions about what decisions would take super majority to make sure we didn’t sort off-track with some minority opinion. But I’m not sure I recall any discussions by our board that didn’t lead to unanimity. We’re not at all averse to different opinions, but the board itself has been really good. I’ve been impressed, in serving as their chair, that they’re not at all hesitant to bring up disparate points of view with great respect for one another’s point of view being presented. But at the end, once all voices have been heard, we seem to come to a pretty clear consensus for a course of action. So I would say it’s a lot of diverse opinion represented but with the charge to the board members of thinking what’s in the best interest of the project. Regardless of what other positions they might hold in organizational or other professional roles, in their role as a board for FMA Health they all do a great job of identifying what’s in the best efforts of the project.\n\nWhat does that say, do you think, about the specialty?\n\nI think we’re a congenial group as family physicians. I think it also speaks to – a lot of this collaborative discussion happened in the creation of the project plan, so I’m grateful to see there’s not a lot of conflict in the execution of the plan. There was a lot of discussion that happened in its generation. But your comment brings up an important time to make what I think is an important comment, and that is that I think that over the course of the specialty, our success in dealing with some of the challenges we’ve been talking about has been impaired by our own congeniality. You know, our sort of just nice personality as family physicians. So I’ve been quoted as saying we need to get over our family medicine nice. And that’s not to say that we need to be difficult or confrontational, but we can’t be shy about the fact that our healthcare system absolutely, from anybody’s perspective, needs a strong primary care system. And just because we, as family physicians, are the largest component of that primary care system doesn’t mean that it’s somehow self-serving for us to advocate for what our country needs. And we need to unabashedly stand up for family medicine on behalf of our patients.\n\nSort of a related question: Where do you see family medicine being within the larger healthcare systems that are in some parts of the United States or perhaps all of the United States now? Are family physicians playing key roles as decision-makers in large, integrated systems?\n\nIn my experience, they are in many places and perhaps not in others. One that sort of, it’s not a specific strategic outcome, but one of the things that we’re really looking to concrete it to is leadership development of family physicians both within the specialty but also in venues, as you mentioned, perhaps within their medical group or integrated delivery system. I know a lot of my colleagues, when somebody leaves clinical practice for an administrative position, no matter how important that position might be, sort of mourns them leaving clinical practice. But I have to say that I look at them as infiltrators. They take their family medicine values and their family medicine heart to that insurance company, that employer, that elected position, whatever it might. And the specialty has been around long enough now that we have members of our specialty in very key positions that can have an influence.\n\nAre there any other participants in Family Medicine for America’s Health that you feel should be interviewed?\n\nWell, I know we discussed offline it was the current board members. So there’s thirteen of us. The tactic team leaders of whom there are six, definitely that’s a good start. I do think that given the importance of … You were commenting on the quality of the work in our annual report, a lot of that is the work of our consultants – and they are incredibly committed. They’re not family physicians. They came to this project simply through a contractual relationship. But they have drunk the Kool-Aid and they believe in family medicine and that reflects in the quality of their work. So I think some of the key folks in the consultants, it would be worthwhile to interview. I do think that the executive leaders of the eight sponsoring organizations, since they created this project along with their volunteer leaders … Since the eight sponsor organizations have funded and given direction to this effort, I think that their perspectives would be worthwhile. That’s probably it. The next level to maybe think about would be the folks that I work with on a sort of day-to-day effort. One of the things that’s allowed us to be, in my opinion, successful fairly quickly is the organizational administrative support that we’ve gotten from our partner or our sponsor organizations. So most especially that’s the AAFP who we have an administrative services agreement with. They’re providing administrative support including financial and legal services at essentially no cost. Sarah Thomas is, in a lot of ways, our program administrator and I work directly with her. And Dale Culver, the AAFP CFO is our CFO, so as related to financial issues. The other is Heather Leith counsel. Mostly it’s under contract review and has to do with guiding the curation of the limited liability corporation that is the corporate structure for FMA Health - and I don’t know if that would be of interest or not. But those would be the folks at least to consider.\n\nDr. Stream, thank you ever so much. Last chance for any thoughts that have occurred to you in the course of this oral history recording that you would want to raise or share?\n\nJust that I feel incredibly lucky to be in the position I have. It’s just one of those things where you’re in the right place at the right time. I think there are any number of people that could have filled my role as well or better than I could. But having finished my AAFP period of service and therefore the participation in the working party in the generation of this project just gave me the unique opportunity to participate as a board member and then as the board chair and president. And I’m just incredibly grateful and I hope the future shows that we were successful in making a difference for the specialty and for the healthcare system in America.\n\nThank you.\n\n(End.)","format":"text/plain"},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162277/file/295066#t=0.0,3385.5615"}]}]},{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162277/file/295065","type":"Canvas","label":{"en":["Media File 2 of 2 - StreamGlen_02_Access.mp3"]},"duration":739.8567,"width":640,"height":360,"thumbnail":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/public/images/audio-default.png","type":"Image","format":"image/png"}],"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162277/file/295065/content/1","type":"AnnotationPage","items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162277/file/295065/content/2/annotation/1","type":"Annotation","motivation":"painting","body":{"id":"https://aviary-p-centerforthehistoryoffamilymedicine.s3.wasabisys.com/collection_resource_files/resource_files/000/295/065/original/StreamGlen_02_Access.mp3?1760559038","type":"Audio","format":"audio/mpeg","duration":739.8567,"width":640,"height":360},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162277/file/295065","metadata":[]}]}],"annotations":[]}]}