Mental and behavioral health are part of our general health and should be treated as such. Not a day goes by where I don’t talk about mental health with my patients. Society’s stigma around mental health is a problem, but I think we’re progressing toward greater awareness and dialogue.
By Limor Weinstein, MA., MHC., FAED, Psychotherapist, & Co-founder of Bespoke Wellness Partners
As a part of my interview series with leaders in healthcare, I had the pleasure to interview Dr. John Cullen, the President of the American Academy of Family Physicians (AAFP) and a family doctor with more than 25 years’ experience. He brings a unique perspective both as President of the AAFP, where he has a view of the major challenges, trends and innovations in American family medicine, and as a family doctor in a rural community, where he sees the daily challenges faced by rural Americans in accessing quality health care.
Thank you so much for doing this with us! Can you tell us a story about what brought you to this specific career path?
I was captivated by everything I studied in medical school — surgery, emergency medicine, pediatrics, obstetrics and so on. I learned that family medicine is the only specialty that can provide all these services, especially in rural settings. It’s amazing to be able to care for a woman as she decides she wants to have a family, throughout the pregnancy, at birth and after, then to care for her children. It blows my mind to watch the family grow up. I’m caring for my second generation now, and it’s really gratifying.
Can you share the most interesting story that happened to you since you began leading your company?
Every day as a family doctor is interesting, but I’ll tell you about two of the most interesting experiences I’ve ever had.
My son and I had just finished skiing, still wearing our boots, when we were passed by a car that slid off the icy highway, down a snowy bank and into a river. We rushed to the submerged car to find a mother and her nine-month-old trapped inside. My son kicked in the back window with his ski boots and the mother immediately handed the baby to us, then we helped her out. It was a scary situation, but my instincts and emergency training kicked in. As soon as they were free, I was checking for hypothermia and injury. Both the mother and baby are doing well today. Talk about not only being in the right place at the right time, but also feeling grateful that I had the training and experience to help!
My practice is in a beautiful but remote community called Valdez, Alaska. My partners and I are the only physicians within 300 miles. If there’s a chance that a mother may have complications while giving birth then we deliver in Anchorage, Alaska’s biggest city, which is about 5.5 hours from Valdez. It was winter when one of my patients was 31 weeks pregnant with twins. On Friday, I saw her and everything was fine. We discussed the plan for her to go to Anchorage on Monday and wait to deliver her babies. But in a twist of events, our community was hit by a terrible snowstorm and the babies were coming early. On Saturday she was already dilated to 7 cm and one of the baby’s umbilical cord was coming through the Cervix. We were all hands on deck that evening with 3 family physicians, a medical student and our nursing staff. I was able to delay the Cesarean section until a NICU team arrived from Anchorage to help. The mom and kids are still doing great!
Can you share a story about the funniest mistake you made when you were first starting? Can you tell us what lesson you learned from that?
When I first moved to Alaska and opened my practice, it was odd to see my patients outside of the office — whether at the grocery store or kindergarten graduation. I felt as if I knew everyone and their most intimate details. It took a while to get used to, but now it’s one of the most endearing parts about serving a rural community.
However, there are some places I just can’t go anymore. My wife and I love to dance, so we would go to the bar for date night. But I’d bump into patients that would tell me and show me things I didn’t want to see in that context! I would say, “Look, we can talk about this, but you need to come to the office to show me!”
What do you think makes your company stand out? Can you share a story?
Our clinic is high-functioning and tightly knit with our community. We mirror our patient generations with generations of physicians — clinic providers include experienced physicians, young physicians and students. Also, we have a mission to serve our community with the highest sense of altruism and care. We’ll hear that someone’s grandmother isn’t doing well and take the time to give her a call. Family medicine treats the whole patient by understanding the intersection of each individual’s physical, mental, familial and environmental health.
What advice would you give to other health care leaders to help their team to thrive?
Pioneer the team’s mission, deliver excellent customer service, represent the generations throughout your staff, and provide proactive, preventive care that prioritizes long-term patient wellness.
Ok, thank you for that. Let’s jump to the main focus of our interview. According to this study cited by Newsweek, the United States health care system is ranked as the worst among high income nations. This seems shocking. Can you share with us 3–5 reasons why you think the United States is ranked so poorly?
- The U.S. has a fragmented health care system: Unlike other industrialized nations, the U.S. health care system doesn’t prioritize comprehensive primary care. Health care is uncoordinated and fragmented and emphasizes intervention rather than prevention and comprehensive health management
- The U.S. emphasizes “sick care” instead of health care as a human right: We spend our money on the outcomes of unmanaged illness rather than early prevention and intervention.
- U.S. maternal and infant mortality rates are on the rise: Unfortunately, there are multiple reasons for this problem. One reason is the increase of obstetrical desserts where there is little prenatal care and long distances to delivery units.
You are a “health care insider”. If you had the power to make a change, can you share 5 changes that need to be made to improve the overall U.S. health care system? Please share a story or example for each.
- Increase spend on primary care: Great investment in primary care leads to lower health care costs and better health outcomes. Health care leaders must emphasize an increase in U.S. health care spend on primary care from 4–6% to the 15–25% that most high-functioning (and lower cost) health systems are spending on primary care.
- Stop focusing on “sick care:” Health care leaders must shift the nation’s “sick care” approach to care that is preventative and comprehensive.
For example, I had a patient with an external ear infection, which is easily treated with a topical antibiotic. Because of her high deductible health plan, she avoided treatment until her infection became severe. By the time she came into my office for care, I had to hospitalize her for 4 days with IV antibiotics! What would have cost her $120 to see me and get medication wound up costing her many, many thousands of dollars.
- Stop the bleeding in rural areas: Some rural communities have a higher maternal mortality rate than those of Third World countries, yet they are continuing to close hospitals. Health care leaders must invest in the health care of rural communities and provide cost-effective access.
- Increase family doctors as a specialty: More family physicians are needed to increase access to comprehensive, preventative health care, especially in shortage areas and hospital settings. To grow this pipeline, health care leaders can support the increase of family medicine residency spots for medical students.
- Use technology to improve access and reduce cost: Health care leaders can improve access and reduce costs by investing in and utilizing telemedicine, artificial intelligence (AI) and electronic health records (EHR).
Telemedicine is not just a tool for patients — in fact, research has shown that patient usage doesn’t reduce cost. The real power (and cost savings) comes when it is utilized by the primary care doctor in partnership with the patient to access specialists. For example, telemedicine can be used in rural hospitals to provide access to specialty care, like oncology, enabling the primary care provider to deliver the necessary treatment in their own office with the guidance of the oncologist.
OK, it’s very nice to suggest changes, but what concrete steps would have to be done to actually manifest these changes? What can a) individuals, b) corporations, c) communities and d) leaders do to help?
There’s a handful of things we can all expect, promote and fight for:
- Promote mandatory primary care spending: I’ve asked each AAFP state chapter to pursue mandatory primary care spending through legislation.
- Health insurance plans should allow primary care visits without a deductible, or at least a limited number without a deductible. Primary care should be considered more like a utility than a service.
- Support family medicine residency: The AAFP and other family medicine organizations are committed to boosting U.S. medical school graduate matches to family medicine by 25% by 2030.
As a mental health professional myself, I’m particularly interested in the interplay between the general health care system and the mental health system. Right now we have two parallel tracks mental/behavioral health and general health. What are your thoughts about this status quo? What would you suggest to improve this?
So much of what I see in my daily practice correlates with a patient’s mental health. Mental and behavioral health are part of our general health and should be treated as such. Not a day goes by where I don’t talk about mental health with my patients. Society’s stigma around mental health is a problem but I think we’re progressing toward greater awareness and dialogue.
How would you define an “excellent health care provider”?
I tell medical students that there are four karmic levels of health care. The lowest level is legal adherence — basically trying not to get sued — and is a terrible way to practice medicine. It’s expensive for the patient and demoralizing for the physician. The second level is business — keep your doors open and employees paid. But approaching medicine as a business is the root of many problems. Medicine is much more than a business, it’s a calling. The third level is the professional level — treating each patient to the best of your ability because that is the right thing to do. The highest karmic level is the grocery store level. I know I will see the patient in the grocery store after the visit and this really motivates us to do our best every day. This is how our practice has always tried to operate. If you focus on the higher level and do right by the patient, the other levels take care of themselves.
Can you please give us your favorite “life lesson quote”? Can you share how that was relevant to you in your life?
“Climb the mountains and get their good tidings. Nature’s peace will flow into you as sunshine flows into trees. The winds will blow their own freshness into you, and the storms their energy, while cares will drop away from you like the leaves of Autumn.” — John Muir, The Mountains of California
Nature has always played an important role in my life. I love exploring the great outdoors. I met my wife in a wilderness class. Ultimately, my passion for nature influenced the decision to move to Alaska.
Are you working on any exciting new projects now? How do you think that will help people?
Always. The AAFP is working on several projects to improve population health:
- We set up a task force for maternal and infant mortality, focusing on minority and rural communities. Right now, we don’t have the data to fully understand the problem, but we urgently need to solve this as more rural hospitals and OB departments are closing. We’re working with the National Rural Health Association and the American College of Obstetricians and Gynecologists on this project.
- We created an X prize for a better EHR that is self-documenting and has AI embedded. The parameters were designed by family physicians in collaboration with the Center for Medicare and Medicaid Innovation and the Centers for Medicare & Medicaid Services.
- Now in its third year, the AAFP created the Center for Diversity and Health Equity to address implicit bias and social determinants of health in order to be successful in promoting good health outcomes for individuals and populations.
What are your favorite books, podcasts, or resources that inspire you to be a better health care leader? Can you explain why you like them?
I enjoy all of Jim Collins’ books, especially “Great by Choice.” Collins shares so many great lessons about servant leadership, the problems with hubris, assembling a team, the importance of focus and core values.
“Moral Tribes” by Joshua Greene. A neuropsychologist, Dr. Greene studies the science of moral decision making. I’m intrigued by his concept about how empathy and altruistic behavior diminishes with numbers and distance.
“The Body Keeps the Score” by Vanderkolk about post traumatic stress disorder.
“The Myth of Mirror Neurons” by Gregory Hickock, which is relevant to burnout and patient care.
You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger.
A friend of mine had a patient on Kodiak Island that was hunting when a bear came out of the brush, knocked him over and stood there with her paw on his chest pinning him to the ground. The bear didn’t hurt him, but he wasn’t about to move either. She stood over him until her three cubs walked past, then lifted her paw and walked after them. In our current health care system, family physicians must be that mamma grizzly bear. We are the ones protecting our patients.
We must fight for comprehensive primary care. Furthermore, primary care with empathy, patient-physician relationships and technological innovation.
How can our readers follow you on social media?
Follow me on Twitter, @AAFPPrez
Thank you so much for these insights! This was so inspiring!