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Retaining Optimism in the Face of Adversity

From the Division of Medical Education, American Academy of Family Physicians, Leawood, KS

Correspondence: Corresponding author: Perry A. Pugno, MD, MPH, CPE, Director, Division of Medical Education, American Academy of Family Physicians, 11400 Tomahawk Creek Parkway, Leawood, Kansas 66211-2672 (E-mail: ppugno{at}aafp.org)

Nicholas J. Pisacano was an optimistic man. Considered to be the founding father of the discipline of Family Medicine, Dr. Pisacano had already spent years working toward his goal when, in April 1963, he proposed the establishment of a certifying board to the American Academy of General Practice. That proposal was soundly rejected. But Dr. Pisacano's optimism remained firm, and 6 years later the American Board of Family Practice was established ... and a new specialty was born.

We have all experienced significant successes as well as disappointments and failures. All great leaders have experienced multiple failures, but the challenge I wish to address is how to go about surviving those disappointments and retaining the optimism needed to move forward and accomplish great things. It is my personal perspective that you will never become great until you have failed enough to get some perspective of what's really important in your life. As Winston Churchill said, "Success is not final; failure is not fatal. It is the courage to continue that counts."

So change is inevitable, but change for the sake of change is simply not productive. Change can provide an opportunity to help us grow and avoid stagnation. It provides an opportunity for improvement, and disappointment is often simply the failure to control or manage change. We lose our optimism when we have a disappointment because we lose confidence in our ability to control and manage the unexpected. We have all heard the "ain't it awful" comments of today.

• "Family doctors are underpaid." But so are pediatricians, psychiatrists, police, firefighters, and elementary school teachers, all important contributors to today's society.
  
• "We're drowning in bureaucracy." Similar feelings have been documented as being common among the ancient Romans.
  
• "Young people lack motivation." Isn't that what Grandpa said about Dad?
  
• "The world is changing too fast." This was a common concern at the turn of the century (1900).
  

So, perhaps Billy Joel was right when he said, "The good old days weren't always good, and tomorrow ain't as bad as it seems."

In today's society, one diagnosis of concern is "metathesiaphobia," or the fear of change. This is characterized by the fear that the best has passed us by and anxiety about an uncertain future. We tend to reminisce about "the good old days" and our pessimism results in a paralysis of inaction.

How do we get past that? I believe in the ABCs: Actions Bring Consequences and Determine Emotions. In other words, acting positive will make you feel positive. This is the power of attitude because our lives are not determined by what happens to us but by how we react to what happens. We are affected not so much by what life brings to us but by the attitudes we bring to life. A positive attitude brings forth a sequence of positive thoughts, events, and eventually outcomes. Hence, I offer Pugno's Pearls for a Positive Perspective:

1. Behave in an optimistic manner and you will indeed feel optimistic.
   
2. Avoid negative people. They are energy vampires and will "suck" energy from you.
   
3. Learn something positive (and useful) from every failure.
   
4. Take a good hard look at an avocado. God has a sense of humor, so it is okay to laugh at yourself once in a while.
   
5. Try to always do what's right, not just what's expedient. That way, even if you fail, at least you were on the "high road."
   
6. Always tell the truth. It's much easier than remembering to lie consistently.
   
7. Remember that success favors the well prepared. As John Gardner, former secretary of Health, Education, and Welfare, was noted to have said, "Life is filled with golden opportunities, carefully disguised as irresolvable problems."
   

Fear of change has not, however, characterized the specialty of family medicine. In fact, family medicine has been out front in leading change that has intimately affected organized medicine throughout its history. We were the first specialty to require recertification. And again, we were among the first to define the process of Maintenance of Certification and invented the concept of evidence-based continuing medical education. We had the courage to take a hard look at ourselves through the Future of Family Medicine project, and we led the definition and implementation of the patient-centered medical home. In fact, comfort with the uncertainty inherent in a change environment is what family medicine does very well. The reward for "staying the course" has been a changing tide that now seems to be in our favor.

Today in family medicine, we have great cause for optimism. Let us consider the following:

• As family physicians we retain the privilege of becoming an integral part of our patients’ lives and to help make their lives a little better every day. Who else has a better job than that?
  
• The tide of student interest in family medicine careers is beginning to turn. Activity among family medicine interest groups is at an all-time high, and a recent survey of those groups reported that 44% of students see increasing interest in family medicine among their classmates.
  
• Residency Program Solutions (formerly known as the Residency Assistance Program) has expanded the number of consultants available, generated an expansive menu of new products and services, and now even has the capacity to provide change management consultation services to the nation's family medicine residencies.
  
• Merritt Hawkins, the nation's largest physician recruitment firm, reported in 2008 that family medicine is the number 1 recruited specialty over the last 2 years, with 27% of family physicians receiving in excess of 6 job opportunities per week.
  
• The 2008 National Resident Match Program (NRMP) reported the best overall residency fill percentage for family medicine on record, with an increase in US seniors reversing a 7-year trend and the first increase in positions offered in the past 10 years.
  
• The 2008 Military Match saw family medicine selected as the number 1 specialty of choice.
  
• The P4 Project (Preparing the Personal Physician for Practice), family medicine's 5-year demonstration project in residency innovation, is entering its third year of success with multiple learning collaboratives, and self-directed and shared learning groups having been created. However, the most important outcome of this project has already occurred, namely stimulating innovative approaches to resident education throughout the nation's more than 450 family medicine programs.
  
• TransforMED, the American Academy of Family Physician's (AAFP) newest initiative in practice enhancement and support, has successfully completed its national demonstration project and transformed the learnings from that investigation into products to support family medicine practices.
  
• Opportunities for clinical services and payment reform are beginning to emerge. The Medical Payment Advisory Committee of the federal government is beginning to recommend support for primary care by increasing reimbursement for cognitive services and providing fiscal support for continuity management. In addition, the Government Accountability Office in February 2008 presented its report to Congress and quoted extensively from the AAFP's 2006 workforce policy document.
  
• The 2008 Association of American Medical Colleges Workforce Research Conference presented multiple clear demonstrations of family medicine as the "solution" to the mal-distribution of health-care services, the aging of America, and the decline in generalism among the nation's internists.
  
• A consistent message is beginning to emerge from the reports of federal advisory committees, including the Council on Graduate Medical Education and the Health Resources and Services Administration Advisory Committee, all recommending increased support for primary care. This theme has been replicated by multiple members of Congress, who are preparing bills supportive of primary care and the patient-centered medical home.
  
• More and more family physicians are being found in key leadership positions, including the new dean at Florida State University, senior staff at the Agency for Health Care, Research and Quality, and the new executive director for the Council of Medical Specialty Societies.
  
• The patient-centered medical home is gaining increasing public visibility. The principles of the patient-centered medical home, originally put forth and endorsed by the AAFP, the American College of Physicians, the American Academy of Pediatrics, and the American Osteopathic Association, have since been embraced by key constituencies, including the American Medical Student Association, the Association of American Medical Colleges, and the Patient-Centered Primary Care Collaborative, representing more than 100 organizations and business entities and demonstrating the rapidly growing support from industry for this concept.
  

Indeed, the discipline of family medicine must be doing something right. By holding fast to the principle of integrity, family medicine has demonstrated the courage to face adversity and continues to choose right over wrong, ethics over convenience, and truth over popularity. As I read recently on a popular business poster, "There is never a wrong time to do the right thing," and family medicine is doing the right thing for America. Instead of talking about "the future of family medicine," I believe that we can legitimately say "the future is family medicine."

	Notes

Top Notes

 
This article was externally peer reviewed.

Funding: none.

Prior presentation: This paper is based on the 2008 Nicholas J. Pisacano Memorial Lecture delivered in June 2008 at the AAFP Program Directors Workshop in Overland Park, Kansas.

Conflict of interest: none declared.

Received for publication August 4, 2008. Revision received September 16, 2008. Accepted for publication September 22, 2008.

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