Letters

Rolls-Royces and family medicine

To the Editor:

WE WANT TO HEAR FROM YOU

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The "shortage" of family physicians described in your article "Encouraging News About Family Physician Recruitment" [April 2005] got me thinking about the shortage of Rolls-Royce dealerships in my county (we don't have any). I'm sure a survey would suggest that 99.3 percent of people would want a Rolls if it were available. However, when asked what they'd be willing to pay, most would respond, "$25,000 or less." When told the actual price of the Rolls, the demand would drop to 0.001 percent.

Busy family physicians struggling to keep their practices afloat can relate to this. Of course, in our line of work, high prices result from high overhead, which results from the mandates of third parties. Not that it matters to consumers; they just know health care is expensive. They'll wait until they have a problem they can't ignore and then go to a specialist.

I believe four things must be done to save family medicine:

Stuart Andrews, MD
Bellingham, Wash.

Tests, tests and more tests

To the Editor:

After reading Dr. Kent Jeffery's comments [see "High praise for maintenance of certification," Letters, May 2005], I now agree that more testing is better. Why not take a test every day? Better yet, why not take a test after every patient visit? We could all divorce our spouses, shun our kids, avoid vacation and make family medicine a priesthood-like calling. We can then focus our entire lives on taking tests to prove what medical school, residency, CME the old certification process and experience obviously have not.

Andrew Minigutti, MD
Dallas

"Welcome to Medicare" visits

To the Editor:

In "How to Conduct a 'Welcome to Medicare' Visit" [April 2005], Dr. Randall Card writes: "This should be an extremely focused physical exam. Height, weight, blood pressure, and visual acuity are the only required components. No specific vision tests are mandated, but using the Snellen chart is appropriate."

The family physicians I work with interpreted this as, "We only have to perform these vital signs during the initial preventive physical exam (IPPE), and no additional examination is necessary."

According to the Centers for Medicare & Medicaid Services Medicare Claims Processing Manual, [see http://www.cms.hhs.gov/manuals/104_claims/clm104c18.pdf, Section 80], the exam should include "measurement of the individual's height, weight, blood pressure, a visual acuity screen, and other factors as deemed appropriate by the physician or qualified non-physician provider, based on the individual's medical and social history and current clinical standards."

Unless I have been living in a vacuum, current clinical standards for preventive physical exams require more than just vital signs. If the patient's medical, family and social histories warrant it, examination of additional organ systems may be necessary.

Joy Newby, LPN, CPC
Indianapolis

Author's response:

Ms. Newby raises a great point. One of the main challenges of the IPPE is that it tries to be nonprescriptive in a prescriptive fashion, which makes it confusing. While physicians always have the option of performing an extensive physical exam, we need to remember the IPPE's primary goal is to increase the number of patients who receive Medicare's covered preventive services. Clinicians will always need to use their judgment in assessing the patients' needs and determining what the exam ought to include.

The time required to educate and counsel patients about the risks and benefits of vaccines, screenings and other tests is extensive, and reimbursement for the visit is equal to that of a level 3 new-patient office visit. For these reasons, our office is telling physicians to minimize the time spent performing the physical exam and maximize the time devoted to educating and counseling.

Randall O. Card, MD, FAAFP
Marquette, Mich.

Update

We have updated the knee injury encounter form [see "A Tool for Evaluating Patients With Knee Injury," March 2005; http://www.aafp.org/fpm/20050300/67atoo.html] to improve its usefulness. Because the pivot shift and McMurray tests may be difficult to perform on patients with a great deal of pain and swelling, the form now reminds physicians that the exam is limited and they should reexamine the patient in a certain number of days. Also, the form now includes additional prompts reminding physicians to evaluate the patient's strength, range of motion and neurovascular status, which are important factors for medical and medicolegal reasons.

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