Commissioning the Periphery

I’m going to try this blogging thing again. It’s mostly for me, for processing of ideas, and admittedly, sometimes for stress management. But currently I’m revisiting my ruminations for a number of reasons sparked by the opportunity to go to the American Academy of Family Physicians’ National Conference of Special Constituencies (NCSC). The NCSC brings together AAFP members belonging to one of five “constituencies” that would not traditionally be well-represented in organizational leadership.
(Even in the most progressive medical organizations, established power structures have continued to keep white men predominating in leadership positions.) The five constituencies are: women, minorities, GLBT, IMG (International Medical Graduates), and new physicians. GLBT representatives can be those who identify as gay, lesbian, bisexual, or transgender, or those who are supportive allies representing GLBT individuals at their institutions.

 NCSC was, in some ways, a harsh re-introduction to the frustrations of trying to make decisions using large-group parliamentary procedure to formulate policy recommendations that may be completely unpalatable to the larger organizational leadership. I had just arrived at the conference straight from the Society of Teachers of Family Medicine annual meeting, where our Group on LGBT Health had generated numerous ideas we can act on immediately. The STFM structure creates committee-like groups that are even more flexible and responsive than traditional committees. They rise and fall on the involvement, interest, and organization of the members, but in return, they can generate ideas, projects, and real change in record time.

 I’ve been a co-chair of the LGBT Health group for two years and it’s been one of the most rewarding leadership positions I’ve ever had. Why? Because I have met amazing people working for similar causes who have come together to actually accomplish a number of projects and presentations. Our first networks have expanded to include others who are working with us even though they are not associated with STFM or even Family Medicine. The diversity of ideas and resources we get from being interprofessional and interdisciplinary gives me the buzz of excitement that comes with palpable potential to accomplish great things.

 The people who participate actively in NCSC are a different group –equally dedicated and passionate, but more focused on generating incremental change in how the AAFP itself functions. I have the upmost respect for this “long-term investment” approach. It’s the very policy I advocate in terms of health system economics and when I counsel patients about the benefits of preventive care. But I admit that I find it just as difficult as anyone else to put so much energy into formulating, writing, and debating resolutions only to know that very few will make an impact in the near future.

 The tediousness of this process reminded me of 2 things, however. One is that we continue to need even more voices. All sorts of issues arose among participants ranging from discussions about being “out” as LGBT, IMG, or just politically active, to whether the term “IMG” is appropriate to include in anti-discrimination statements (more on both of those later). The range of topics and controversies were a testament that diversity of opinion creates both frustration and ultimately some degree of truth. The second reminder was gratitude for our Family Medicine organizations. There is no other organized medicine academy that I know of that specifically sponsors and heartily supports the inclusion of potentially “unheard” voices through two major conferences (both the NCSC and a Student/Resident Conference.) 

Back at home, I’m doing unrelated training in Social Network Analysis and we are learning about “Core-Periphery” networks. Most organizations with any size and power have a core of densely connected influential people. Their ties are so strong the network actually creates an in-breeding quality that is necessary for stability, continuity, and legitimacy. Like any inbreeding, however, the core loses most of its capacity for innovation. The periphery is absolutely key for new ideas, adaptation to change, and progress. The trouble with the core is that by definition the people inside it have a hard time recognizing the importance of the periphery and the peripheral players consequently have a very difficult time interacting with the core.

 But our leadership at the American Academy of Family Physicians sees beyond the insular core. They can be frustratingly bureaucratic and yet are stunningly visionary in this way. Over time, many organizations fall apart for lack of having the vision to see the whole structure. In the meantime, many of the “peripheral” people also lack the resources to attend and participate in such meetings, so we depend on our state and local leaders to support us financially and logistically.

 In my case, the Kentucky Academy of Family Physicians and our administrator also have had the vision and drive to send delegates to NCSC and the Students and Residents conference. This support is costly, and the fact they see it as an important investment demonstrates the strength of the KAFP and produces a very appropriate motivation for us delegates to pay back this investment with increased involvement in the state and national organization. The hope is that one day the peripheral members become part of the core and change it over time. But one thing that shouldn’t change is the recognition that there is always a periphery ready to innovate the organization into an effective voice in a constantly changing world.