{"@context":"http://iiif.io/api/presentation/3/context.json","id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/iiif/tb0xp6x62q/manifest","type":"Manifest","label":{"en":["Dr. Jennifer Devoe"]},"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":["Date"]},"value":{"en":["2017-08-29 (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":["family medicine","family physician","American Academy of Family Physicians","Family Medicine for America's Health"]}},{"label":{"en":["Subject"]},"value":{"en":["Jennifer Devoe, MD, DPhil (personal name)"]}},{"label":{"en":["Language"]},"value":{"en":["English (primary)"]}}],"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: 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/162449/file/295878","type":"Canvas","label":{"en":["Media File 1 of 2 - DeVoeJennifer_01_Access.mp3"]},"duration":2593.9485,"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/162449/file/295878/content/1","type":"AnnotationPage","items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162449/file/295878/content/1/annotation/1","type":"Annotation","motivation":"painting","body":{"id":"https://aviary-p-centerforthehistoryoffamilymedicine.s3.wasabisys.com/collection_resource_files/resource_files/000/295/878/original/DeVoeJennifer_01_Access.mp3?1761146647","type":"Audio","format":"audio/mpeg","duration":2593.9485,"width":640,"height":360},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162449/file/295878","metadata":[]}]}],"annotations":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162449/file/295878/transcript/85510","type":"AnnotationPage","label":{"en":["Dr. Devoe interview transcript [Transcript]"]},"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162449/file/295878/transcript/85510/annotation/1","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"Tape 1, side 1\n\nDr. Young: This is side 1 of tape 1 of the oral history of Dr. Jennifer Devoe, a member of the board of Family Medicine for America’s Health. We’re recording this on September 29, 2017. I’m Dr. Herbert Young, a volunteer at the Center for the History of Family Medicine.\n\nDr. Devoe, do we have your permission to record this interview?\n\nDr. Devoe: Yes.\n\nDr. Young: Could you state your full name and degrees?\n\nDr. Devoe: It’s Jennifer Devoe and I have an MD, an MPhil, a DPhil, an MCR and I’m also a fellow of the AAFP.  \n\nDr. Young: And I understand your medical degree is from Harvard?\n\nDr. Devoe: Yes, it is.\n\nDr. Young: And can you tell us a little bit about the other degrees?\n\nDr. Devoe: My medical degree is from Harvard and I was there in 1993. Then after three years of medical school, wanted to pursue more training in comparative health policy and the history of medicine, so I traveled to Oxford University in Oxford, England where I obtained an MPhil and a DPhil in economic and social history. And I then completed my MD at Harvard and embarked on residency at Oregon Health and Science University in Portland, Oregon. Then after my residency, began a post-doctoral fellowship in health services research and realized I needed to take more biostatistics classes, so managed to, through my various course work, earn another masters in clinical research which is the MCR.\n\nDr. Young: And do I understand you also have had a K award?\n\nDr. Devoe: Yes. So I had a post-doctoral fellowship called an F32 from the US Agency for Health Care Research and Quality or ARQ. And then after two years on the fellowship from then, I obtained a KO8, which was a five year career development award from ARQ to continue my mentor training in health services research.\n\nDr. Young: What are your current positions?\n\nDr. Devoe: I currently am a professor and recently was named the John and Sherry Soltz (?) Endowed Professor in Family Medicine at Oregon Health and Science University and also serve as the department chair. I am a practicing family physician. Have taken care of the same panel of patients for over sixteen years. I also teach medical students, residents, fellows, senior faculty and am principle investigator on a number of federally funded research studies receiving funding from ARQ, the National Institutes of Health and the Patient-Centered Outcomes Research Institute. \n\nDr. Young: Do I understand that you have another affiliation as well?\n\nDr. Devoe: So my primary affiliation is in the Department of Family Medicine at OHSU. I also have a joint appointment in our Department of Medical Informatics and Clinical Epidemiology and I have an investigator appointment at the Kaiser-Permanente Center for Health Research and I serve as a senior research advisor at a non-profit community organization called OCHEN (?). \n\nDr. Young: Do I understand that involves many practices, this latter group?\n\nDr. Devoe: Yes, OCHEN (?) is an information network that serves over 400 primary care practices across the country providing them with information technology, data and analytics, practice facilitation, quality improvement coaching. And we built a 21st century practice-based research network within OCHEN (?) which has been able to leverage their integrated data systems and do a number of quote big data end quote studies with clinical data from the electronic health record and linking that data to insurance claims and community vital signs data within many of these communities that these health centers serve.\n\nDr. Young: A very extensive background and I’m sure more to come. \n\nDr. Devoe: I hope so.\n\nDr. Young: Could you talk a little bit about how you got involved in Family Medicine for America’s Health?\n\nDr. Devoe: Sure, that’s a good question. I got a call from Frank DeGrees (?), who at the time was the president of the North American Primary Care Research Group, and he said, you know, the organizations of family medicine, the Family of Family Medicine, is organizing – and at that point I think it was still the Future of Family Medicine 2.0 – and we’re building a core team that wants one representative from each of the seven family medicine organizations. Now, since that time we’ve added the eighth which is the Osteopathic Family Physicians, but at the time it was seven. And he said the NAPCRG executive committee and leadership would like to know if you would serve as our representative to the core team and then there will be two additional representatives serving on the steering committee. And I said sure, I’d love to serve in that role.\n\nDr. Young: Had you been active extensively in NAPCRG prior to the phone call?\n\nDr. Devoe: Yes. So I have been involved in NAPCRG since I was a graduate student and had the great pleasure of being one of the inaugural interns at the Robert Graham Center when Larry Green was directing the center. And as a Pisacano Scholar, I had the great opportunity to be an intern at the Graham Center and Larry said, oh, you’re a family physician doing research, you need to be connected to NAPCRG and, oh, by the way, NAPCRG needs to send a representative to Keystone 3 in Colorado, I think you should go. So I’ve been affiliated with NAPCRG since the late 1990’s and was one of their representatives to Keystone 3 and then became a fellow representative on the board when I was in fellowship. And I believe I’ve only missed on NAPCRG meeting over the last twenty years. Good heavens. A very devoted NAPCRG member and have met and been mentored by some of the giants in primary care research and really love the organization and its nurturing vibe and the people who are in NAPCRG, including Morris Woods, the founder.\n\nDr. Young: And do I remember, you’ve held officer posts as well?\n\nDr. Devoe: Yes. So as part of this journey with FMA Health and national leadership, I did get asked to serve as NAPCRG president and I’ve just about completed my three year presidency role where I was the incoming president and the president and this year I serve as the past-president and board chair. So I will be completing that three year service in November of this year.\n\nDr. Young: Are you going to miss all the meetings? And I don’t mean the NAPCRG meetings, but I mean the board meetings? \n\nDr. Devoe: I will definitely miss seeing colleagues and being engaged in NAPCRG leadership. I’m excited for new folks to have the opportunity to enjoy those meetings as well. I will, however, stay on with my connections to FMA Health as the representative to the board that was appointed by NAPCRG. So will still have some meetings ahead of me. \n\nDr. Young: I think the next question we’ve covered a little bit, but I’d like to hear more about what particular knowledge and skill sets you feel you’ve brought to this project.\n\nDr. Devoe: That’s a really great question. I think that, of course, as a researcher I’ve brought those skills. And having had experience through my graduate work and understanding health care systems in other countries and, also, the history of community health and family medicine and primary care, despite being one of the younger members of the team, I had that great knowledge from my study in history and also the great knowledge of different systems and understanding health care systems. And had been in the Pisacano Scholars group, had worked with the Graham Center, had done a number of things, had been at Keystone and was fairly well-connected with folks across family medicine as well. Our department being one of the largest departments with a very successful program has also helped me understand family medicine education and the academic world of family medicine at medical schools. So different experiences have hopefully helped me contribute and have a somewhat unique perspective.\n\nDr. Young: Are there any areas of research in particular that you think have been very important to this effort that you’ve been involved in?\n\nDr. Devoe: Yes, I think that while most of my work has focused on access to health insurance, some of my work is also focused on access to care and paying for care differently. So that’s both the research I’ve done, the papers I’ve published but also some of the knowledge I have about practice payment. Access to care has been helpful in forming some of the conversations and helping to stay up to date on some of the conversations as well.\n\nDr. Young: What do you see as the value, and for that matter, really, the purpose of FMA Health? And it’s helpful obviously that you had a perspective from some of the prior specialty-wide attempts to address some of these issues like Keystone.       \n\nDr. Devoe: I’ve really appreciated family medicine’s continued efforts to reflect on why we’re here, what role we play in the health system, what role we play in our patients and populations health and to dig deep within ourselves to understand what we’re doing well, what we could be doing better, and how we can expand on efforts to achieve what we all set out to achieve in the beginning of the discipline. And that now looks a lot like the quadruple aim, but, of course, that term wasn’t around in the 1960’s and before. But what can we do to help our country achieve the quadruple aim of better health care, better health, lower costs, improved health professional wellness. And also really focusing on the work of Barbara Starfield and others, how can we leverage the value that we bring as family physicians and primary care professionals in improving equities in the health of all people.\n\nDr. Young: Can you elaborate a little bit on what you see as being leveraging that issue?      \n\nDr. Devoe: I think that we’ve struggled with that both in the core team and in FMA Health and we’ve come up with these various domains and developed core teams and strategic planning. And I think there were really, in my mind, two things that we needed to do a better job of. And one of that, which I think we’ve focused a lot on, which is external communication. And that’s just helping folks that are not family physicians or perhaps don’t have a family physician understand what the heck a family physician is and what it is we do and how we potentially or really can add value. So that’s really kind of the external communication piece. And educating the public, educating policymakers, educating employers, educating payers, educating the community at large about who we are, why we’re here, what we aim to do, how we want to do it. And then I think the other challenge is as we’ve grown and as we’ve diversified and as we’ve increased our numbers, the internal communication and figuring out how can we collectively, together, as a very large group of family doctors, how can we understand what we do and coordinate what we do and speak with one voice despite all of our differences and the diversity of training and  different perspectives that we have. At the end of the day, most of us, if not all, I can’t speak for everyone – but most of us really chose this specialty because we care deeply about building long term relationships with patients and improving patient and population health. And that was, in my mind, one of the reasons why I wanted to become more involved in FMA Health. And the purpose of FMA Health another punctuated opportunity to reflect on who we are, where we’ve been and where we’re going and really set that compass in a direction that is going to improve health. \n\nDr. Young: As you look at the specialty now compared to perhaps when you first started down the road, what’s happened to the specialty that brings challenges in terms of those two communication targets, internal and external?\n\nDr. Devoe: I think it comes back to the internal and external again. I think externally the health care system has changed. The way that medical and health care services are reimbursed has certainly created a paradigm within which we have had to function. Right now we’re very much in the fee for service paradigm where we’ve had to figure out how to provide services and bill for those services and have had the external environment tell us that some of what we do is of less financial value than what other doctors in the system do. So that’s been a growing challenge in the external environment that many historians have documented over decades. And that’s part of what I think has created a challenge and also limited, in some ways, what family physicians do or are able to do. So there’s the external environment within the health care system and within how that larger system has defined who we are and what we can do or not do. And then, again, internally I think that there are new people entering the field that have different ideas about where they want to spend their energy and where they want to spend their time and how best they see improving health. And it’s interesting that I’ve seen a lot of the new generation circle back to the original founding generations to really start thinking about are we improving health, are we achieving health equity, are we addressing social behavior, behavioral economic environmental determinants of health, and how can we be doing a better job of that. That’s, again, sort of an interesting, I guess, back to the future, so-to-speak, where there’s a lot of new ideas but in my historian mindset I realize, well, those are just old ideas that have come around again into a new window of opportunity perhaps to moving forward. I think there’s also a lot of people in the research world in not my area of research but other colleagues that have begun to document, you know, fewer and fewer physicians are delivering babies and fewer and fewer family physicians are doing hospital care and taking care of children and really trying to understand some of the changes in scope of practice and breadth and depth of practice. And some of that is helpful in understanding this is an old paradigm, what people are doing or not doing. But I think there is more work to be done in understanding, well, if folks are not doing that, maybe they’re doing something else. And not necessarily saying that these changes are good or bad, but understanding more of the picture of where are people spending their energy and should we, as a discipline, be concerned about scope of practice, for instance, or other issues, when we don’t really have a great mechanism for fully measuring what people are doing and the impact that they’re having.\n\nDr. Young: So if I hear you correctly, it sounds like you’re saying we don’t really know with great accuracy exactly what family physicians are doing or not doing. There are certainly studies indicating that procedural skills or, as you say, providing maternity care has decreased. I mean that’s true for obstetricians, I understand, who aren’t starting their career delivering babies but going right into gynecology. Anyway, back to family medicine … And yet you’re saying, if I’m hearing correctly, they may be doing different things, new things, things done in a different way perhaps, how they’re dealing with team approaches to care or electronic health record utilization and that that’s something that needs to be further defined?\n\nDr. Devoe: I think so. And there’s a lot of innovation, again, around leveraging and utilizing technologies, team care, as well as partnering with other community organizations. There’s medical legal partnerships, there’s partnerships with social service organizations, there’s partnerships with innovative payers that are willing to pay very differently, there’s the integration of behavioral health into primary care. Although, again, some of these things are not new. I learned in much of my reading, this was all part of the plan for family medicine as a discipline and for primary care and certainly for federally qualified health centers in the early day, much of this was part of the vision. And for various reasons, that vision hasn’t been realized in many places, so revisiting how to be accountable for population of patients, how to do population health, how to adequately identify and address social determinants of health, how to do a community needs assessment. All these things we’ve talked about over the decades, but we have new tools potentially that can help us further that vision and achieve some of what we had set out to do in the beginning as family physicians.\n\nDr. Young: What, in your opinion, is the current state of health care and health care delivery in the United States? And it’s particularly interesting that you obviously also studied in England and so had perhaps more direct contact that many of us with other systems of care.\n\nDr. Devoe: Yeah. So this is a huge driving passion for me in going into family medicine, then also going into health policy research and now academic medicine is that the state of health care in America is, we are on life support, if you can even call it that. We have a non-system. We don’t have a system. There’s increasing amounts of data showing that we spend more money than double, triple the amount of money that any of our counterparts in the developed world, yet we have worsening health outcomes in multiple, different ways. So our population is getting sicker, they’re living shorter lives, in poorer health – which is actually the title of the IOI report that colleagues, family physicians will edit it. And then when you look at the work that Barbara Starfield published in her research, countries with strong primary care, the one potential fix – of course, I could be biased, but even before I became a family physician I started looking at this and thinking about this, countries with strong primary care have much better population health and they’re able to more adequately provide for the health care needs of their population than we are in the U.S. I think there’s also work that’s been done by Dr. Bradley at Yale and others showing that we spend the same amount on social services and health care as many of these other countries but we are spending the vast majority of that on health care versus social care, and so we’re really out of balance with services that can improve health. So that’s another area where the data would begin to point to solutions or shifting those funds upstream and addressing many of the social and economic behavioral health needs of our populations sooner before we then have the downstream costs associated with all those preventable conditions that are developed. And then you have that under-investment in social care and other things like education and job training and environmental protection. And then that, coupled with once these people do end up in the health care system, you have a very small number, inadequate workforce in primary care to really seek in to manage and provide the comprehensive care and integration and coordination that’s needed. And so most of those people end up in very costly, very inefficient, fragmented systems and get services that have little or no evidence to support that they’re going to be effective. So it’s work to be done to build a health care system, but also work to be done to more adequately address social determinants of health. And we have a public health system that’s also been on life support for a very long time. We have a lot of health care dollars paying for end of life, downstream costs that could be reinvested in the upstream area.\n\nDr. Young: So is it fair to ask if as part of, and I’m thinking more the external communication you were referring to earlier, that a realization of what you just said as being how it is in the United States as opposed to other nations, is that part of the education that has to occur with the external audiences in order to do the other aspects of Family Medicine for America’s Health that the core teams have been working on? \n\nDr. Devoe: I think so. And I think that is a coalition of voices that need to continue with that message. So there’s a number of folks that I think have done a nice job of messaging from the Robert Woods Johnson Foundation to Kaiser Family Fund Foundation to Commonwealth Foundation to some of our more enlightened policymakers and state leaders and national leaders and certainly patient groups as well. So there’s a whole cacophony of voices in that orchestra trying to play that same tune. And we are one voice and some of it is figuring out where do we need the physician’s voice to be and where can another voice actually deliver the message more effectively. Because I see us in this really interesting bridge of family doctors. We’re still part of the problem, right? We’re doctors in the health care system yet we tend to be aligned ideologically and often times more so with our colleagues in public health and certainly with community organizations than we might be with colleagues in heath care and medicine. And I guess me being in an academic health center, I think, in that term. So I am in the school of medicine, I’m in the department of family medicine, but I tend to have a lot more similarities with faculty in the school of public health and the school of nursing than some of my colleagues in the school of medicine.\n\nAnd so we I think can we an effective voice, but we also are physicians so we tend to also be perceived as being part of the problem and be perceived as being self-serving when we talk about how some of these monies need to shift and some of the different areas of the health care system need more emphasis and others need less.\n\nDr. Young: To what extent do you feel that Family Medicine for America’s Health is in tune with what you’ve just been saying?  \n\nDr. Devoe: I think a lot of the effort is certainly in tune with it. I think this was the thinking that inspired the leaders to launch Future of Family Medicine 2.0 which then became Family Medicine for America’s Health. I think it’s in much of the communications campaign that comes out in showing, hey, you know, there’s a lot of people talking about payments and government and insurance and no one is really talking about health, so we’re trying to bring health back into the conversation. So I think that’s been successful and part of the driving force. I think that a more challenging aspect of Family Medicine for America’s Health is really rolling up our sleeves and working within these core teams to figure out, okay, we know that we have a broken system. We know that there’s a lot of work to do. What can we do, with our very limited resources and primarily volunteer teams, to set up some strategies in these eight areas that will propel our discipline to make a bigger difference in the future?\n\nDr. Young: Did you work with one of the core teams in particular?\n\nDr. Devoe: No surprise, I’ve been the liaison to the research team.\n\nDr. Young: I would agree, not a surprise. Were the sorts of questions … Actually, why don’t you share where the transition is occurring, because I understand there had been a change sort of in the game plan within the project, and how that’s impacted the core teams?            \n\nDr. Devoe: It has been an interesting journey, I will say, to figure out … We’re all on the same page but everybody has slightly different ideas about how to get where we’re going. And I think that’s a lot of what’s happened in this project. I think there’s been an increasing focus, especially with the external environment changing as drastically as it has over the last few years, first going to MACRA where, as before, we have been attempting to repeal some other archaic financing and rules that the federal government had used to pay family physicians essentially less and less to do more and more. So there was a big shift towards MACRA. Then there was the Affordable Care Act which expanded coverage and began some very innovative work on practice transformation paying differently through alternative payment and some -- payment models. The CPCI Initiative out of the CMMI as well as the CPC Plus Initiative - sorry, I’m using a lot of acronyms. Those all really  propelled and changed the landscape. And then we had the election of President Trump and lots of efforts to try and repeal and replace everything that we had thought was going to be in place for a while. So it’s been a real tumultuous external environment, to say the least. And I think that has really had leaders scratching their heads and saying we thought this was going to be a five year endeavor, which turned out to be, I guess, more of a seven or eight year endeavor. But we feel like we have to keep making corrections midstream, so there was a lot, I think, disagreement among funders of the FMA Health initiative as to whether we would have more of an impact with more money going into the communications strategy and getting that external message out and spending more time in Washington, D.C. and spending more time with our state policymakers and some of our important stakeholders in educating them as opposed to do we really have the time, resources and teams in place to do some work around strategic planning and launch some strategic initiatives. So because of the tumultuous times and all the, I think really, feeling  a little bit scattered in where we needed to put our energies, funders decided that they did want to put more ultimately into the communications side of the FMA Health and take that away from the strategic planning side. So it was challenging for teams to figure out how do we get the same amount of work done or some of the same projects launched on a much shorter timeline with fewer resources. \n\nDr. Young: Perhaps this is a time to ask a question that has a little history to it as well. Future of Family Medicine came up with ten recommendations, as I remember it, and then various organizations were going to step forward and sort of take on one or more of those. Then looking back at it later, some people said, well, no, we needed a more vigorous way of assuring that the work started and would be continued. Can you speak a little bit of how the project is, what it’s learned from that and what it’s going to do?\n\nDr. Devoe: I think what was learned from that, as you mentioned, was there was Keystone 3 and Future of Family of Medicine’s landmark article published in The Annals of Family Medicine and these task forces created that developed these very eloquent reports with lots of recommendations. And then those were more or less taken up by the existing family medicine organizations and there was no over-arching body that held any kind of oversight or accountability for any of that work moving forward or any of those aspirations becoming reality. And I think we were fairly lucky in some ways that much of that work did end up moving initiatives forward. Of course, a lot of visionary folks that knew that technology was going to become a bigger factor and that we were going to have highly sophisticated electronic health records and more data than we knew what to do with and that we were going to need to move towards team-based care, that we were going to have to do population health in new and different ways, that we were going to have to integrate behavioral health into primary care. So it’s interesting as a historian. Again, I lived through that but as a student and resident, so I didn’t have the roles that I do in leadership now. But it would be interesting going back and asking the question - again, if that initiative had never happened and those task forces hadn’t put forth some of those documents and set forth that roadmap, would a lot of this stuff have happened anyway? I don’t know the answer to that. Maybe, maybe not. So did we change the course of history in having that initiative happen at the point in time it happened is an open question. I think a lot of people would say, well, it was very important, it really did help launch these new initiatives that helped us gain a better understanding of our future and where we needed to go and what was being asked of us and required of us to make a bigger impact. I think the same questions will be asked of FMA Health ten or twenty years from now, is if this initiative and organization hasn’t been formed and we haven’t had a board that was autonomous and independent from the other eight organizations that really did drive this  work, created these teams, took accountability for a number of initiatives getting launched and a roadmap getting developed, would things have developed differently if we hadn’t have had FMA Health at all. And certainly I’ll be curious to be looking back twenty years from now and hopefully can be looking back successfully as to whether it was an initiative that made a big difference.\n\nDr. Young: We hope to do another series of interviews more in the maybe five to seven year period. But to get back to the question of what is going to happen then as the core teams finish their formal work within Family Medicine for America’s Health and will there be an ongoing board level activity - or is that yet to be determined?      \n\nDr. Devoe: My understanding is that there will be four of the seven teams will be completing their formal work and continued meetings at the end of this year 2017. And there will be three teams continuing into next year, so payment, practice and health equity teams. And the board will continue to oversee their work as well as to move forward the work of the board -- study teams.     And I believe the calendar now has the board meeting into the middle of 2019 and then the board and the LLC, as far as I understand it, will be, I don’t quite know what the word is, will be done. \n\nDr. Young: So it’s not really clear, what sort of centralized, shared activity will occur after the current board is done with its work? Yet to be determined?\n\nDr. Devoe: As far as I know, there will be the work that each of the eight individual organizations continue to do. There have been a number of partnerships between organizations that have evolved through this process. So just thinking of research examples, the ADFM and NAPCRG           \n\nhave created and launched an initiative called Building Research Capacity. They’ve also been working on a bibliographic (?) analysis of departments of family medicine and their research activities. There have been efforts launched to create a map of all research activities across the eight organizations and several events and conferences identified where people will continue to meet and move forward research strategic initiatives. So there is going to be some collaboration amongst the eight groups. But a lot of the leadership and facilitation will happen through NAPCRG, so North American Primary Care Research Group. And in the case of some of the other core teams, there’s not one obvious organization that will provide a home for all of the initiatives, so there will be continued partnerships for many of the initiatives to, I think, strengthen the connection between some of the organizations, which is hopefully a lasting legacy of FMA Health. Again, I haven’t been in national leadership, but my understanding is prior to FMA Health many of our family medicine organizations were not connecting on any regular basis and were, in fact, duplicating some projects that one or the other didn’t know the other was doing. So it’s almost like the right hand didn’t know what the left hand was doing. So there has been, I think, a significant amount of communication and partnership. And the other thing I like to joke about is what better way to make all eight family medicine organizations work more effectively together and agree on something than to create a ninth organization that they can all criticize in various ways. So if nothing else, FMA Health has achieved the goal of bringing all the organizations together to critique and criticize much of what we’re doing and hope that we can deliver the world with limited resources and a very short timeline. \n\nDr. Young: In the research area it is interesting to sort of look back at what has happened in the past and building capacity has certainly been an issue, I think, long on NAPCRG’s list. I was, in fact, earlier today looking at the 2000 NAPCRG national meeting and some of the things that were on the agenda there and a document called “NAPCRG In 2000” which included a discussion of capacity building. It obviously is research. The American Academy of Family Physicians has gone in and out of several activities - as, among other things, budgets have been larger or smaller or various advocates have been in positions to advocate or not. So it is interesting, I’m sure, for you to look at the history of the specialty and also of the nature of the organizations that have come together and figure out what are the most effective ways of keeping certain activities going. And, again, especially at a time when such organizations as ARC (?) are under some threat. \n\nDr. Devoe: Again, I didn’t live through all these decades, but in talking to people and understanding a little more about research arriving on the national stage a little more permanently in this round of family medicine conversations, I think early on there were perhaps more critics thinking we don’t need to do research in family medicine because we are the discipline that’s taking care of the people and we can be educators and we can be full time doctors but we don’t need a body of research. And there were obviously some voices that were saying, yes, we do. But over time and what I’ve realized in this process is research was one of the strategic teams developed and there’s a growing realization among an increasing number of family doctors that we absolutely do need to have research. We need to have family medicine community laboratories. We need to have scientists that are family medicine researchers that are helping us understand our data better, create new knowledge, disseminate the knowledge and information such that we can improve our care and improve health and turn our data into knowledge and this knowledge into action. And that’s been, I think, a long, arduous journey and we’re certainly not anywhere near the finish line where we can say we’ve achieved victory, but we are making some progress in that internal communication amongst our own members that even if someone is not interested in doing research, they understand the importance of having in the structure within primary care and family medicine to do high quality research and the resources to do it. And that’s something NAPCRG’s realized all along and certainly the American Academy of Family Physicians has as well. They’ve had periods of time where they funded research centers and they’re currently housing and funding the Robert Graham Center and a number of other initiatives. So it’s important to have seen this evolution and have it continue. The challenge then becomes how do we advocate for changes in some of the current research institutions. How do we get a National Institute for Primary Care Research, for instance? Or how do we billionize ARC (?), which has been another initiative that family physicians have come together to lobby for. How do we at least keep ARC in existence and not have to spend all of our energy to help it survive? How do we convince new funding organizations like PCORI (?) that the work that we’re doing is valuable and needs to be in their funding portfolio.\n\nDr. Young: We’ll pause for a moment to turn over the tape.\n\nTape 1, side 2: Dr. Young: This is side 2 of tape 1 of the September 29, 2017 interview with Dr. Jennifer Devoe.\n\nDr. Devoe, you were talking about the research challenges.\n\nDr. Devoe: Yes, I think that the next big challenges as we come a long way in our discipline recognizing the central importance and value of research, then it’s turning our sights on how do we collectively advocate for the infrastructure, then the capacity that’s needed. And, again, giving the example of where I am, in an academic medical center, I see them speaking the language of we have a community laboratory and it requires a significant amount of resources to maintain the infrastructure which includes now the information technology data and expertise to analyze that    data as well as much of the engagement -- and relationships that we’ve built over time with community providers and others providing primary care across our communities because it helps people understand that there are needs for primary care laboratories that also require resources and that you can’t do this support for free. It’s a lot easier for a medical school to understand what’s needed for a basic science laboratory and they’re very happy to pour millions of dollars into equipping and maintaining those laboratories and so we’ve begun to think about how do we talk about the laboratory as a structure that’s needed for us to do high-end tech science. So those are the kinds of things that we’re working on figuring out both in academic settings but also in community settings and developing really unique partnerships with diverse groups of stakeholders that often times include state health policymakers and insurance companies and employers and health systems and people that are committed to understanding the value of primary care and understanding how to improve primary care. So that’s been really interesting and exciting but there’s a lot of work that still needs to be done in that area and funders to fund this work at the same level that they’re funding other work in, for instance, basic science or drug development or other areas where NIH has a huge amount of money invested.\n\nDr. Young: You mentioned the larger health care systems, large integrated systems. Are they understanding family medicine? Are they understanding the research issues as well within family medicine?\n\nDr. Devoe: That’s a good question. I think the enlightened health systems that are accountable for a population and improving the health of a population at an affordable cost are very much in tune with the value of primary care. So there are systems like Kaisers that have long known the value of primary care, have a very strong primary care workforce and honestly have built some of that infrastructure to continue to expand the evidence and support the scientists. There’s a lot of those with evidence-based practice and evidence-based policy that are really trying to better understand how we can use evidence and translate that evidence into practice and more people working in dissemination and implementation science to say, well, we found this was effective in one system, how can we effectively disseminate it to all systems and make sure that everyone is equipped with this new information and providing evidence-based care. So there’s a lot of family physicians and scientists working in that area. I think other folks that have recognized the importance of primary care are payers and employers, so we have a number of employers partnering with primary care physicians to create direct primary care practices or direct access to primary care. And then there’s insurance companies that are thinking differently about providing a product where more of the resources are going into primary care because they’re seeing that they’re going to be able to save money in avoiding those downstream costs with preventable diseases and hospitalizations. So there’s this interesting coalition of folks, yet we still haven’t seen a lot of changes even with this mounting scientific evidence. And many folks that you would think all being advocates of expanding primary care, I think there’s still the traditional paradigm and there’s still a lot of folks making a lot of money on the current model that are resisting change from the status quo. \n\nDr. Young: Do you think that the medical student now who is entering family medicine is driven by different issues than those who went into family medicine five, ten, twenty years ago?\n\nDr. Devoe: That’s a really good question. I do not study those factors, so I’m sure there is some great evidence of literature that I’m unfamiliar with. So anecdotally I would say some of the same factors drive medical student interest and choice in family medicine, the ability to do full spectrum care, the ability to maintain relationships with patients over time, the ability to work in a community and partnership to address some of these social, behavioral and economic determinants of health, the ability to be well-trained to go with the global health settings, to be well-trained to go into rural settings, to really develop these partnerships and relationships with patients in communities over time. So a lot of that I think is somewhat similar. This idea of taking care of the whole person and being very comprehensive in being able to treat any one of any age with any condition that walks in the door and feeling competent to do that. So certainly those interests, I’m guessing, have been fairly similar over the decades from the beginning. We don’t have this counterculture attitude as much, so there’s fewer people rebelling against the status quo because we are now kind of part of the status quo and we have a place in most medical schools and we’re part of the establishment as opposed to the counterculture in the way that we were in the beginning.\n\nDr. Young: I would be curious, where do medical students go now if they are part of the counterculture?\n\nDr. Devoe: A really good question. I think I’m seeing more of them not going to medical school and going to public health schools. \n\nDr. Young: That certainly would make sense.\n\nDr. Devoe: Yeah, I see a lot of them say, well, you’re not improving health, you’re providing medical care - I want to improve health. So there are new undergraduate degrees popping up all over the country in community health and public health that are some of the most popular degrees at the undergraduate level. I think there’s a large group of folks getting masters in public health. And then those folks that do want to go onto professional schools that might otherwise have gone to medical schools, they’re either going to become nurse practitioners and PAs because they feel like I can do just about as much doing this and have much less time and training and less debt. And/or they’re going into getting degrees in public health or other similar types of degrees or services.\n\nDr. Young: It’s interesting that my medical school is now a school of medicine and public health at the University of Wisconsin. \n\nLooking at the core teams and thinking back to what you said about how changes are occurring in practice and so forth, any thoughts on any of the redesign and the core team that has tried to say how do you make change in a practice, for example? Any thoughts on how that will continue?\n\nDr. Devoe: I think it’s still coming back to some of the challenges and opportunities that were identified in the Future of Family Medicine initiative fifteen years ago and that is we have to align our practice teams with our payment incentive and figure out how to have those well-aligned in order to drive the change, pay for the change, sustain the change. So there’s a lot of flurry. And I guess maybe now there’s even more data and systems available than there were fifteen years ago and I don’t know whether that’s helping or complicating the issue. \n\nDr. Young: Well, if practices are essentially being challenged to go about their work in different ways with more use of teams, better use of medical information, looking at community outreach that you mentioned earlier in terms of needing to make population improvements. Can you say that again, sorry? I’m trying to draw together a variety of the things that we touched on earlier in terms of the changes that are occurring or being urged to occur and what the Family Medicine for America’s Health has done looking at, okay, are there successful models of how you change your practice to be more team-oriented or for outreach into the community to increase your population success or use of medical records and so forth. Any thoughts on how that will continue as the project ends?\n\nDr. Devoe: I think there is certainly some really innovative programs being launched that will continue into the future. The payment and practice team has partnered on a number of them because, as I said, we learned from the Future of Family Medicine and continue to learn that you can’t change practice without changing payment and they go hand-in-hand. So the fact that they’re continuing to work together and develop new practice models, new payment models, calculators for practices to understand if their payment were to change, how that would impact their bottom line. What they can add, what they can subtract to be more savvy about their payment at the same time that they’re transforming their practice and bringing on new team members and integrating more technologies. There’s a lot of folks that are actively engaged and will continue to be actively engaged as technology evolves. And the technology team did a really nice job of saying, no, we really can’t think of technology in the current state, which is the electronic health record. We really need to think about the future state and move as quickly as possible to the next technology that’s beyond the electronic health record or better than or different than or build upon it. So that’s been I think one of the ways that the various teams have integrated their work. But again, practice is going to transform, enable, how do I apply technology, which is also then incentivized by payment. You’re going to need research to study many of these changes and understand how to study natural experiments, how to set up quasi experimental designs to know what you’re doing is really making a positive or a negative impact. Feed that information back quickly, understand the science behind once you find something that seems to be effective, how do you disseminate it. And then you bring in the workforce team that is thinking about, okay, how do we engage learners and help to expand the workforce by getting our learners excited and engaged in some of the transformation. So there’s I think a lot of synergy between many of the teams. The engagement team, obviously, how do we engage patients and other stakeholders more actively than perhaps we have in the past when we focused a lot more on the physician and not so much on some of the others on the team and extend over all the health equities really looking at how are we making an impact that’s strengthening what we do but then also achieving better equity. So there’s a lot of work that gets cross-cutting across the teams and cross-cutting across the organizations and it will be a challenge to continue some of it, I would anticipate.          \n\nDr. Young: Do you think there will be activities that fall outside of the usual seven or eight organizations that made up this project, each with areas that are why they exist as organizations and as politics can change, that can change directions as budgets change that can enhance or take away? Yes.\n\nDo you see relationships occurring, for instance, between departments of family medicine that might be consistent with the goals of Family Medicine for America’s Health say in the research arena but doesn’t formally involve NAPCRG or the department chairs or other national organizations?\n\nDr. Devoe: That’s a really good question. I think there’s a lot more collaborations, whether that’s facilitated by technology that’s enabled us to communicate minute by minute as opposed to what it was like in the pre-webinar days. So it’s hard for me to say that it’s more or less or any more beneficial or less beneficial than it would have been in the past, but I certainly see folks collaborating more easily and more often on research projects, practice innovation projects. I see some of our organizations doing a very nice job of facilitating that. I think the AAFP has a number of conferences and networks that bring people together across different stakeholder groups, across different state chapters, across different interest areas. I think some of the other organizations do a nice job of that as well. I think STFM has several conferences now where folks are able to disseminate information, learn from each other, and also online chat rooms and other various ways that they can share information resources and collaborate. So I think that’s happening perhaps more than it was in the past. And a lot of it’s organic, so it’s really hard to measure and know the extent to which it’s happening or whether it’s having benefit. Certainly enriching to many of us because I was thinking that that FMA Health board is very different from other boards where people kind of cycle on and off boards and they’re engaged for a period of time in activity and then they go on to something else. We’re all family physicians and we’re all committed to this for the long haul. So despite not serving on a board currently, I think that many of us will stay connected. We have a community of professionals that are deeply connected and have shared passion and have built these relationships, so I think that many of us will continue to serve in formal and informal ways throughout our careers. And one of the things I love about family medicine and certainly academic family medicine is I’ve seen a lot of people get connected to this amazing community of people beyond their hometown and beyond their home institution. And it’s very enriching certainly personally and also, I think, for the discipline to have so many of us connected over the miles and over the years.\n\nDr. Young: There’s one other part of this whole activity I would like to ask about – and that is patients. I’ve noticed that some of the organizations involved, including NAPCRG, have patients involved in their board discussions. There was a public representative, if I remember correctly, appointed to this board. YES. But at that practice level is there any emphasis on patients?\n\nDr. Devoe: There are a number of initiatives that have been spearheaded both by the FMA Health board and the engagement team to really build tools and assist practices for more actively engaging patients. Some practices have been doing it for decades, other practices are still wanting more information about how to do it, why to do it. So there certainly have been initiatives to help practices form patient engagement groups or patient advisory councils and that’s been a big push among the engagement team and other leaders. So in addition to wanting to get patients on boards (?), there’s been this push into practices – and I know the engagement team has spent a significant amount of time on that. I think that’s a little more challenging for us is to be able to measure it accurately. So I don’t know that we can necessarily say what percentage of family physician practices have patients engaged in advisory roles or leadership roles and how they’re doing that and what difference it’s made. But I know that’s something that people are really excited and eager to further develop. \n\nDr. Young: And I assume that also applies to not only how a practice operates in seeking input from patients but care of individual patients in terms of their education and understanding of what’s going on and …\n\nDr. Devoe: Yeah, and they’re influencing it in a positive way and feeling engaged and understanding it. I remember a moment where we were in that first year with the core team and the steering committee and we had these monthly meetings with the core team and had come up with the concept of Family Medicine for America’s Health and we were presenting it to the full steering committee for their approval and feedback. And I remember this moment where I was very passionate and I said it’s probably better for me not to get in front of a microphone ever again if there’s a patient that can deliver the same message about the importance of family medicine. And I want to be able to empower and train and engage those patients so that I don’t have to stand up here and deliver this message because it’s much more powerful coming from a patient. \n\nIndeed. And that’s the place that we need to get to in this external as well as internal communication that if it’s just family doctors talking about the importance of Family Medicine for America’s Health, we’ve failed. We have to have patients and communities talking about the importance of Family Medicine for America’s Health. \n\nDr. Young: And that does actually raise one other thing I meant to ask earlier: There’s been obviously different partners involved in Family Medicine for America’s Health. I know there was some outreach to other medical groups, to nursing and so forth. You’ve introduced though other types of involvement in academic departments within the medical school, for example, or the public health community and so forth. Any comments on work accomplished and work yet to be done in terms of outreach and cooperative activity with any of these other groups?\n\nDr. Devoe: There is a lot of work to be done in building these relationships and speaking with one voice across primary care and that’s one of the areas that this initiative has not moved the needle far enough on, in my opinion. And some of it has to do with this changing demographic of who’s going into primary care from some of our colleagues in medicine. There’s fewer and fewer general internists, fewer and fewer general pediatricians. Folks that want to be generalists tend to go into the hospitalist generalism realm as opposed to the primary care outpatient realm. So it’s, I think, been a challenge and an area where we should have put more emphasis and resources. And in addition to the medical specialties that are in the primary care camp, certainly the inter-professional, multi-disciplinary groups across nursing, behavioral health, pharmacy, et cetera, as well as the patient and consumer advocacy groups. So I think we’ve done a better job in engaging the patient and advocacy groups and also continuing to support and develop the Patient-Centered Primary Care collaborative which I think is an organization where much of this work can live on and we can have these multi-disciplinary partnerships across many disciplines and different stakeholder groups. So PCPCC I think is an important organization to watch and to hopefully, as you said, if there’s cross-cutting strategies and tactics that don’t fit nicely within one of the eight family medicine organizations then for us to work with PCPCC and others to take some of those initiatives and move them forward. \n\nDr. Young: Anything you’d like to say before we end the session?\n\nDr. Devoe: No, we covered a lot of ground. This was really fun to think about being at this one point in time and what we’re doing and think about it from the past and the future as well.\n\nDr. Young: Thank you so much, Dr. Devoe.\n\nDr. Devoe: Thank you.","format":"text/plain"},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162449/file/295878#t=0.0,2593.9485"}]}]},{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162449/file/295877","type":"Canvas","label":{"en":["Media File 2 of 2 - DeVoeJennifer_02_Access.mp3"]},"duration":1494.3555,"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/162449/file/295877/content/1","type":"AnnotationPage","items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162449/file/295877/content/2/annotation/1","type":"Annotation","motivation":"painting","body":{"id":"https://aviary-p-centerforthehistoryoffamilymedicine.s3.wasabisys.com/collection_resource_files/resource_files/000/295/877/original/DeVoeJennifer_02_Access.mp3?1761146645","type":"Audio","format":"audio/mpeg","duration":1494.3555,"width":640,"height":360},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162449/file/295877","metadata":[]}]}],"annotations":[]}]}