Letters

Guidelines and flowcharts

To the Editor:
As a family practice educator with an interest in clinical guidelines -- used both as teaching tools and in clinical settings -- I enjoyed the guidelines article ["Where to Look for Good Clinical Policies," February 1999]. I would suggest using graphic-based information, such as flowcharts, algorithms and process maps, to communicate guidelines. They help to prioritize questions, portray knowledge in a more orderly fashion and force users to confront the tough issues that guidelines can raise.

The World Wide Web, in particular, has reinforced the value of a graphically based, point-and-click approach to gaining knowledge. Clinical guidelines should incorporate this approach.

David Pepper, MD
Fresno, Calif.

Thriving on money

To the Editor:
The schedule shown in the April 1999 article "Reducing Delays and Waiting Times With Open-Office Scheduling" is so offensive that I must stop in my tracks to write.

I count 33 spaces into which to herd cattle. Don't these physicians have in-house patients, nursing-home patients, phone calls -- or kids to have breakfast with? Seeing patients every 15 minutes, essentially all day long, is lousy! It takes a few minutes to read the chart before entering a room and maybe a few minutes to dictate, and what about the "Oh, doctor, while I have you ... "! All this in the name of "productivity"? One would be racing through a potentially very frustrating day.

I am 53, and it is little wonder that those of us who are older are becoming more and more disenchanted with what we see and experience in all facets of a society that thrives on money.

Robert Lux, MD
Newport, N.H.

Physicians know best

To the Editor:
No one understands and manages a physician's office better than a physician. Physicians, like me, who have sold their practices to a hospital or a physician practice management company (PPMC) have seen their short-term profits, their years of autonomy and their smooth office operations disappear.

I thought a PPMC would improve my office management, be a stronger force in negotiations with managed care companies, and provide additional capital for growth and development. On the contrary, I saw my office operations deteriorate, and little capital was invested in medical equipment, computer systems or expansion into new areas of service.

When our group was bought by yet another PPMC, my office ran even less efficiently because the new staff lacked personal relationships with my patients and the computer system was not user-friendly. My practice had become an inefficient, disorganized entity over which I had very little control.

Fortunately, I was able to pursue a career in academic medicine (which had always been my goal) after being an employed physician for only 21 months. But I now realize I should have maintained the autonomy of my thriving solo practice before moving into teaching.

While changes in the health care system will come and go, physicians must remain the foundation upon which all medical care is based.

George D. Harris, MD
St. Petersburg, Fla.

NPs and MDs working together

To the Editor:
Reading the letters in the February 1999 issue, I was interested to see that all the letters from nurse practitioners were supportive of team collaborative practice and all but one from physicians were disparaging about nurse practitioners. Most nurse practitioners work in a collaborative team practice with physicians and want to continue to do so. I am disappointed that the physician community continues to erect barriers to nurse practitioner practice even though there has been no attempt to change the requirement for collaboration. The states that have independent practice were legislated that way from the beginning.

I was disappointed with AAFP President Lanny Copeland's response in FPM. I have not seen any data that support his position that "using nurse practitioners as the first point of contact with previously undiagnosed patients is actually more expensive due to their extensive use of subspecialty referrals." These strong, negative, polarizing statements hinder our ability to work together.

Most nurse practitioners and physicians who work together have mutual respect for each other's strengths. Why can't we, as organizations representing our disciplines, get along as well as we can individually in practice? There are millions of Americans without health care. Working together, we can be part of the solution.

Mary Knudtson, MSN
President, American College of Nurse Practitioners
Irvine, Calif.

Copyright © 1999 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.