Letters

What makes a leader?

To the Editor:

In regard to Dr. Robert B. Taylor's article "Leadership Is a Learned Skill" [October 2003, page 43], I think you've missed the mark. As a certified physician executive (CPE), fellow of the American College of Physician Executives and consultant for the Stanford Graduate School of Business, I have dealt with medical and nonmedical leaders alike on a national basis. Holding an executive position does not make you a leader; it merely gives you an opportunity to exercise leadership activities. There is no question that training and practice are important in improving effectiveness, but virtually all of the real leaders I have encountered were such because of their personality and character. These people possess an innate set of characteristics that allows a group of their peers to consciously or unconsciously identify them as leaders. A good analogy to leadership is athletics. We can all learn and train to be more skillful, but the real athletes are naturals. Average folks simply can't function in that way. Now that the demand for organizational leaders exceeds the supply, we must do the best we can to find the naturals.

Jeffrey Brown, MD, CPE
Redwood City, Calif.

Author's response:

I appreciate Dr. Brown's reply, even though he disagrees with the premise that leadership skills can be taught and learned. There are attributes that give one a head start in the leadership derby - a commanding presence, powerful voice, personal wealth and a Harvard MBA. I wish we had many such gifted leaders. We could use them to lead committees, task forces and state chapters in medical organizations. Most of us don't have these characteristics; however, as we assume leadership roles, we can acquire needed abilities through study and practice. We may not become executives, but self-taught leaders serve our colleagues at many levels in organized medicine. So, while I don't totally disagree with Dr. Brown's comments, I no longer believe the "sword in the stone" myth that only the noble, pure, chosen one can be my leader.

Is that patient new?

To the Editor:

I recently read Emily Hill's "Understanding When to Use the New Patient E/M Codes" [September 2003, page 33]. I work for a physician with an established private practice, but he occasionally works in an urgent care clinic and bills under the clinic's tax identification number for patients he sees there. If he sees a patient at the clinic who then comes to the private practice, should our practice submit a new patient code or an established visit code?

Diane Szyperski
Essexville, Mich.

Author's response:

The CPT definition of a new patient is "one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years." The key word in the CPT definition is "or." If an individual physician provides professional services to a patient, in any location, within a three-year period, the evaluation and management (E/M) services are reported using established patient visit codes (99211-99215). The issues of specialty and group tax identification numbers apply only when the patient sees another physician in the same group.

Tips for coding 99214

To the Editor:

"How to Get All the 99214s You Deserve" by Emily Hill [October 2003, page 31] was accurate and illuminating. However, the coding guidelines for 99214 remain cumbersome and inefficient. In my experience, over 95 percent of visits to family physicians that could be coded 99214 fall into three easily identifiable scenarios. These scenarios should represent at least half of all visits in most family practices.

The first scenario is a patient with a new, significant problem; the second is a patient with three chronic problems; and the third is a patient with two chronic problems, one of which is worsening. Each scenario has at least three points on the number of diagnoses and management options and invariably meets the moderate-risk requirement, due to the complexity as well as the presence of medication management and/or invasive testing/therapy. This means that when presented with these three scenarios, one must perform either a detailed history or detailed exam (my auditors recommend 1995 guidelines, as noted in the article's footnote) to code the visit a 99214.

Published guidelines, including those used by our own board, exist for most diseases. These guidelines encourage us to be thorough for the acute and chronic medical problems found in the scenarios above. Therefore, performing a detailed history and/or physical when patients present with these problems is appropriate for good medical care with the byproduct that we can bill and collect for doing our jobs well.

Physicians think in terms of patients with problems, as opposed to bits of information on a coding audit form. These scenarios should be much easier for practicing physicians to remember, as well as much easier for our resident physicians to learn.

Phil Whitecar, MD
Beavercreek, Ohio

Changing the perception of family medicine

To the Editor:

I am fortunate to practice in an area very open to family medicine. I enjoy more respect and camaraderie from my non-family physician colleagues than other family physicians seem to experience in other parts of the country.

About four months ago, my practice took over a pediatric practice from a pediatrician who has been prominent in the area for more than 30 years. He had no qualms about turning the practice over to three family physicians, and, on the whole, the patients have been very accepting. Our trouble seems to arise when a patient asks one of us what the difference is between family medicine and pediatrics. When we say that we also see adults, most people think, "How can you possibly do both?" I hung the posters distributed by the AAFP as part of its public awareness campaign a few years ago in the waiting room, which helps. I'm also hopeful that the Future of Family Medicine project will help patients find their way to my practice.

My partners and I have third-year medical students doing their family medicine rotation with us. It is clear that the medical school faculty is not pushing family medicine. The students feel the rotation is not very important and consider their assignments busy work. I hope that the Future of Family Medicine project prompts a change in the academic setting: Family medicine should get the respect it deserves, and students should be encouraged to become family physicians.

Samantha Pozner, MD
Springfield, N.J.

Diagnosing and treating strep throat

To the Editor:

We read Dr. Mark Ebell's article "Making Decisions at the Point of Care: Sore Throat" [September 2003, page 68] with great interest. The article encourages the use of the strep score calculator developed by McIsaac.1 In the example cited, the patient's score is 5, meaning there is a 52-percent chance that he has streptococcal pharyngitis. The author notes that it would be reasonable to treat him for this, but another interpretation is that the likelihood of the patient having streptococcal infection is no better than chance alone. Accordingly, there is good reason to recommend a specific microbiologic test, such as a rapid diagnostic assay or a conventional throat culture, as a guide to therapeutic decisions. Some of the more sensitive rapid tests can provide an answer with an 80- to 85-percent certainty within 15 minutes. Given that group A streptococcus causes only about 20 percent of pharyngitis episodes in children and 10 percent in adults, this seems like a more prudent approach, especially given concerns about the overuse of antibiotics.

We also have concern about including antibiotics (azithromycin) other than first-line antibiotics in a patient flow sheet for management of pharyngitis. This implies that these are appropriate initial choices for management of pharyngitis due to group A streptococcus. Unless the patient is allergic to penicillin, either amoxicillin or penicillin remains the drug of choice for this condition.

These recommendations reflect the current guidelines endorsed by the Committee on Infectious Diseases of the American Academy of Pediatrics.2 It would be in the best interest of all children to establish consistent, high-quality practice recommendations from the AAP and the AAFP.

Ellen R. Wald, MD, FAAP Donald R. Fischer, MD, MBA
Pittsburgh

1. McIsaac WJ, Goel V, To T, Low DE. The validity of a sore throat score in family practice. Can Med Assoc J. 2000;163:811-815.

2. Group A streptococcal infections. In: Pickering LK, ed. Red Book: 2003 Report of the Committee on Infectious Diseases. 26th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2003:573-584.

We want to hear from you

Send your comments to fpmedit@aafp.org. Submission of a letter will be construed as granting AAFP permission to publish the letter in any of its publications in any form. We cannot respond to all letters we receive. Those chosen for publication will be edited for length and style.

Author's response:

As I state in the article, another option for high-risk patients other than empiric antibiotics is "to base treatment on the results of a rapid strep test, or to obtain a throat culture and call the patient in two days with the results. If the culture is negative, you could discontinue antibiotics, recognizing the potential for false-negative culture results when the pretest probability is sufficiently high."

Given the limited accuracy of rapid antigen tests, if a patient has a high risk of strep based on the McIsaac rule and a negative rapid antigen test, he or she still has approximately a 15-percent risk of streptococcal pharyngitis. I would argue that empiric therapy should be an option, particularly when other factors (recently diagnosed strep infection in the family, for example) increase the risk of strep even further. This recommendation is consistent with an evidence-based guideline that the Centers for Disease Control and Prevention has endorsed.1

Regarding the choice of antibiotics, the first option was "none needed" and three of the other four choices were first-line antibiotics available in generic form. I agree that these antibiotics should be used in most nonallergic patients. While in an ideal world erythromycin would be prescribed to children and adults who are penicillin-allergic, the higher risk of adverse gastrointestinal effects with erythromycin and the more convenient dosing of azithromycin has made azithromycin the preferred drug for many physicians with penicillin-allergic patients. The encounter form simply acknowledges that reality.

1. Cooper RJ, Hoffman JR, Bartlett JG, et al. Principles of appropriate antibiotic use for acute pharyngitis in adults: background. Ann Intern Med. 2001;134(6):509-517.

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