April 2000 -- FP Report

April 2000 • Volume 6 • Number 4

Decrease is bad news for Americans
Primary care match results down overall

BY CINDY McCANSE

Family practice lost ground in the National Resident Matching Program for the third year in a row, according to data the NRMP released March 16. Perhaps more disturbing is that for the first time in recent history, both the total number of residency positions filled with U.S. seniors and the fill rate for U.S. seniors were down for all primary care categories: family practice, pediatrics-primary, internal medicine-primary and combined IM/pediatrics.These figures could herald a downturn in primary care residencies.

The 2000 fill rate for family practice residency programs was 81.2 percent -- 2,603 positions filled out of 3,206 offered. The 1999 fill rate was 82.6 percent. The specialty filled 94 fewer total positions in 2000 compared with 1999, and U.S. seniors filled 191 fewer positions.

Two of the other primary care categories -- pediatrics-primary and internal medicine-primary -- also had declines in total numbers of positions filled this year. For combined internal medicine/pediatrics programs, although the total number of positions filled actually increased by 10, nine fewer positions were filled with U.S. seniors.

The three-year downward trend in family practice programs comes on the heels of seven solid years of increasing match numbers: From 1991 through 1997, the number of filled family practice positions steadily rose, including four consecutive years of record-breaking numbers of positions filled (1993 through 1996).

According to AAFP President Bruce Bagley, M.D., of Albany, N.Y., the drops among primary care categories in 2000 bode ill for Americans.

"Primary care physicians keep America healthy by offering high-quality, up-to-date health care that focuses on prevention," he said. "If the number of medical school graduates choosing primary care careers continues to decline, there won't be enough primary care physicians to treat our growing population. Obviously, the health of the public will be hurt.

"We are issuing a call to all those who are concerned about ensuring a healthy America -- this trend must be reversed."

A number of factors have contributed to the decline, Bagley said, not the least of which is students' concern about incurring substantial medical school debt. Despite the current rise in salaries for primary care physicians, the rate of increase is quickly outstripped by educational indebtedness.

Lifestyle is another factor Bagley cited. "Family practice involves a high degree of commitment to patients," he said. "Development of the close doctor-patient relationship that is the hallmark of family practice requires time and skill, but yields immeasurable rewards."

Perry Pugno, M.D., M.P.H., director of the AAFP Division of Medical Education, holds a similar view. "Family physicians care about the public. We belong to a values-driven specialty," he said. "We need to be sure that those values and the rewards of family practice are being conveyed to medical students.

"But we must also ensure that we are educating our patients about the specialty of family practice in the same way that we tell them to get their immunizations or teach them about prevention. We need to educate them to become proactive about legislative issues affecting family practice."

Family physicians, policy center to research patient safety

The Academy is planning the nation's first study on patient safety in family physicians' offices.

"Right now, there are no studies on medical errors or patient safety in U.S. ambulatory care," says James Galliher, Ph.D.

"We know medical and administrative errors jeopardize patient safety in hospitals," says Galliher, research affairs manager in the AAFP Scientific Activities Division. "We also know the government will mandate ambulatory care studies. This project puts us ahead of the curve."

A pilot study will be conducted by 50 family physicians in AAFP's new National Network for Family Practice and Primary Care Research. Participants will report and describe 10 errors they observe in their practices; tell whether patients are involved in the errors; say what might have prevented the errors; and note characteristics such as the patients' and physicians' age, gender and ethnicity.

No patient names will be recorded, and physician names will not be part of the study data.

The AAFP Center for Policy Studies in Family Practice and Primary Care in Washington, D.C., will analyze the data by late this year.

"This pilot study is the beginning of a whole program of research on patient safety in primary care," says Susan Dovey, M.P.H., policy center analyst and principal investigator for the study. The research project dovetails with the Institute of Medicine report calling for studies of medical errors.

Repercussions of IOM study could make care safer

BY JANE STOEVER

Fallout from an Institute of Medicine report could make health care less hazardous to everyone's health.

In November, the IOM issued To Err Is Human: Building a Safer Health System, the first of five IOM studies on health care. Preventable errors in U.S. hospitals kill from 44,000 to 98,000 patients a year, said the IOM. It called for the errors to be cut by 50 percent within five years.

Policy-makers sat up and took notice. Congressional panels studied the report, and President Bill Clinton proposed $20 million for a patient safety center.

Safer primary care
Ambulatory settings as well as hospitals are fair game for safety enhancements, says IOM member Joseph Scherger, M.D., M.P.H., who helped write the report. Scherger, a former AAFP director, is associate dean of the University of California medical school in Irvine.

The report, which deals mostly with hospital care, recommends information systems to override the possibility of human errors. "When we check in our luggage at the airport, it's not human beings who write down the flight number. It's done electronically," says Scherger. "We also need safe prescribing systems, to make sure patients get the right medicines, the right dosages."

Scherger targets procedures and the injection of powerful medications as danger zones.

"Very often, ambulatory settings are ill prepared to deal with emergencies, such as someone having a strong allergic reaction or decreased breathing," he says. "In my experience in many family practice offices, usually no one has turned on the oxygen tank in a long time to see whether it works. We aren't ready to respond quickly."

Eighteen states already require confidential reports on serious errors. The IOM would expand that to all states.

When a jet crashes, the airline must report the accident, investigators search for the cause, and inspectors check out similar planes to prevent more tragedies. "What happens when a bad thing happens in a medical environment?" asks Scherger. "Is there an immediate response? Do we share information? Are other health care sites checking to make sure they don't have the same thing happen?

"We're still very much a cottage industry, loosely run, locally controlled. More safety will mean more standards."

AAFP supports spirit of report

On March 16, the AAFP Board of Directors voted to support the spirit of the Institute of Medicine report on medical errors. The Board committed the Academy to studying steps to enhance safety in family physicians' practices.

AHRQ's role
The patient safety center suggested by IOM will be part of the Agency for Healthcare Research and Quality (formerly the Agency for Health Care Policy and Research).

"We may find ways to help physicians and their staffs educate patients better and prevent errors," says AHRQ Director John Eisenberg, M.D. "We'll consider things like using computer systems to flag lab results that aren't normal and to alert physicians."

States will collect data on errors in a way that prevents identification of individual doctors and patients. "Health systems will be identified," says Eisenberg, "because we need system solutions."

He adds, "We hope we can help physicians understand where there are opportunities for errors and what they can do to avoid them. We understand resources are limited, staffing is limited. So we need to find efficient ways of identifying errors and then avoiding them."

AFP at 50 years: still the same winning philosophy

The April 1 American Family Physician marks the publication's 50th anniversary. In 1950, members of the (then) American Academy of General Practice, as well as others in the medical, publishing and advertising communities, greeted the debut issue of AFP's predecessor, GP, with much ballyhoo.

This cartoon accompanied "The Doctor's Bag -- What Should Be in It," from the April 1950 GP.

Hailed by one reader as "the finest-looking medical journal in the world," GP eschewed the stodgy image common among medical journals in favor of a fresh, innovative approach. Mac Cahal, J.D., the Academy's chief executive officer and managing publisher of the fledgling publication, characterized it as a "medical magazine" rather than a journal. The idea, he wrote in an early issue, was to ensure that GP would not be doomed to languish in "dusty libraries," serving only as a "repository of 'contributions to the literature.'" Rather, GP was designed to serve as a resource tool for the practicing physician.

To that end, GP featured short, practical clinical articles replete with illustrations. Other components covered topics ranging from news of the Academy to disease-state management to governmental regulations. In short, GP had it all.

But for one early GP reader, it was the clinical articles that drew and held his interest.

"I saved a lot of them because they were pertinent and practical," said Stanley J. Siwek, M.D., of Harrison, N.J. "And I filed them accordingly, so that I could refer to them at another time."

He stored his copies of GP and, later, AFP in a playhouse in the back yard, spending hour upon hour out there clipping articles of interest. Once, he became so absorbed that he forgot the beer he'd brought out with him. When he finally picked up the can, he found a slug crawling into it. Pretty compelling reading, surely.

Today, in AAFP readership surveys, AFP is ranked as the favorite journal six times more often than any other. This continued success can be attributed to its hands-on philosophy.

In 1950, content was driven largely by reader input. It's a formula that still works today, according to current AFP editor and Stanley Siwek's son, Jay Siwek, M.D., of Washington, D.C.: "That's been my goal -- to make it a reader-friendly, practical reference for FPs. I like to think of the practicing docs out there -- what is the information they need to better diagnose and treat patients? -- and think of that as the guiding principle of what we publish."

Public Advisory Board holds lively first meeting

Washington, D.C.

Lively discussion regarding errors in medicine, the empowered patient, universal health care coverage and pharmaceutical costs marked the first meeting of the AAFP Public Advisory Board Feb. 15-16.

The board consists of 15 people outside the specialty who have agreed to provide their insights and perspectives to the Academy's deliberations on public policy and patient concerns. Nine of the 15 were able to attend the February meeting: James Bentley, Ph.D., American Hospital Association; Daniel Callahan, Ph.D., Hastings Center; Jane Delgado, Ph.D., National Alliance for Hispanic Health; David Hennage, Ph.D., American Nurses Association; Audrey Forbes Manley, M.D., Spelman College; Lee Newcomer, M.D., United Healthcare; Ed O'Neil, Ph.D., Center for Health Professions; John Seffrin, Ph.D., American Cancer Society; and Karen Williams, National Pharmaceutical Council.

The Public Advisory Board met with the AAFP Executive Committee. "All involved seemed to feel this was a productive and enlightening first session," said AAFP EVP Robert Graham, M.D. He added, "We believe our Public Advisory Board is the first one any national medical society has established."

Can students add value to your practice?

BY JANE STOEVER
Washington D.C.

Are you worried about Mrs. Wilson's recurrent back pain but figure she'll call you when it gets bad enough?

Do you need to read the latest research on urinary tract infections to identify the most cost-effective length of treatment?

Have you put off starting a preventive home care program for your chronic heart failure patients?

Would you like to arrange group sessions for your diabetic or stop-smoking patients?

Do you wonder whether the home health aide is giving you the whole picture?

Patient Sheila Brown-Cooper, top photo, talks with Gene Kallenberg, M.D., right, about an ad for new arthritis medicines. "Look them up," Kallenberg tells medical student Zachary Ibrahim. Lower photo: Kallenberg and Ibrahim hear regular "thub-dubs" from Harry Rosenberg, occasionally troubled by rapid heartbeats.

If you're saying yes, you're not alone.

Gene Kallenberg, M.D., chair of the family practice division at George Washington University, and his colleagues asked primary care preceptors, including FPs, to list things they wish they had more time to do. Their endless "to do" lists are reflected in the questions above.

Kallenberg asked the preceptors, "What if you had help from a highly intelligent, college-trained person who wants to grow up to be like you?"

Enter the medical student. With two caveats: The medical school needs to teach students more pragmatic skills early on, and the school needs a longitudinal curriculum so preceptors can come to know and trust the students' abilities.

At GWU, first- and second-year students work as apprentices to their primary care preceptors one half-day every other week. Each student chooses a patient to follow, one expected to need regular care.

"I always come into the clinic when my patient comes in," says Andrew Fenton, a first-year GWU medical student. When his patient was admitted to the emergency room for shortness of breath, Fenton took the patient records and lab reports to the ER, stayed with the patient awhile and visited him each day he was hospitalized.

GWU plans to inform preceptors about the students' abilities. "In the near future, we should be able to tell preceptors the students will know how to counsel patients on smoking cessation, how to help the preceptors find information on the Web and how to make home visits," says Kallenberg.

Since the mid-1990s, studies have shown that medical students take 30-45 minutes of a physician's time per half day. On the day they precept, physicians stay at work longer to get caught up and tend to eat lunch with students instead of having down time. Students reportedly cost physicians one or two patients per half day -- but at least one study said preceptors' weekly productivity exceeded that of other physicians.

Kallenberg and Thomas Schwenk, M.D., chair of the family practice department at the University of Michigan in Ann Arbor, listed ways preceptors might make the most of students while teaching them. Kallenberg and Schwenk propose that students be trained to carry out activities including those mentioned above, plus:

find and organize patient education materials,

investigate practice populations and community demographics,

conduct patient satisfaction surveys,

review patient charts to assess care of various types of patients,

give in-service training to your staff,

conduct patient-based literature searches,

perform sports preparticipation and other screening exams, and

make and document follow-up phone calls.

Kallenberg and his colleagues polled preceptors across the country last year to see whether they would be more willing than they currently were to have students in their practices if the students had some of the skills noted in this story. About 47 percent said yes, about 6 percent said no, and about 47 percent said it wouldn't make any difference. "We concluded having the students learn pragmatic skills early on would augment our efforts to attract physicians to answer the call to teach," says Kallenberg.

If you're interested in precepting the next generation of family physicians, contact the family practice department at the nearest medical school. You may be impressed at the ways even new medical students can add to your practice while they're learning to be physicians.

Don't rule out ART of manipulative medicine

BY SHARON DENT
Las Vegas

Martin Offenberger, M.D., left, of La Habra, Calif., practices osteopathic manipulation techniques with Charles MacDougall, M.D., of Plano, Texas, at AAFP's course on the musculoskeletal system.

Allopathically trained physicians often dismiss manipulative medicine as an unproven alternative therapy, but research is beginning to show it can help patients regain range of motion and overall health.

"For example, manipulation in the acute setting has been shown to be an effective modality in low back pain," said Dennis Cardone, D.O., assistant professor and director of a sports medicine fellowship in the family practice department at the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick. Cardone presented sessions on manipulative medicine techniques at the Office Procedures and Management of the Musculoskeletal System CME course Feb. 21-25.

He referred to the November 1999 New England Journal of Medicine, which featured results from a large study of patients with low back pain, comparing the use of traditional treatments alone with the use of those treatments augmented with osteopathic manipulation. The study found that manipulation decreased the need for pain medication and physical therapy.

Even some of the most basic, easy-to-learn techniques can have a dramatic impact on patient health, said Cardone. "It's not a panacea, it's not a cure-all, but when mixed in with the other modalities, it's effective," he said. "And it's definitely been shown that a physician's touch -- laying on of hands -- has healing powers unto itself."

Participants practicing the techniques on each other at the CME course frequently expressed surprise at the improvements they felt in their own bodies. "I heard people say that they never felt so relaxed, the muscles never felt so relaxed, they definitely felt an increase in their range of motion and the popping sensation wasn't as scary as they thought it might be," said Cardone.

He shared three fundamental osteopathic philosophies with attendees:

The body doesn't function as a collection of separate parts but as an integral unit.

An abnormality in the structure of any body part can lead to abnormal function, either at that body part or at some other location in the body. Therapeutic manipulation may be used to correct mechanical disorders of the body.

There are somatic components to disease that not only are manifestations of disease but also can contribute to ongoing physical problems.

Manipulation is indicated in patients with a somatic dysfunction -- a problem somewhere in the musculoskeletal system usually causing muscle pain or motion restriction, Cardone said. Specific criteria determine whether a patient has a somatic dysfunction. Just remember the ART of diagnosis:

Asymmetry -- Palpation of a joint with somatic dysfunction reveals that the bone involved is asymmetric with respect to its normal position and to the position of bones contiguous to it.

Restriction of motion -- A joint is restricted or meets an abnormal barrier in one or more planes of motion. Motion in the opposite direction is normal or free.

Tissue texture changes -- The soft tissues around the joint (skin, fascia or muscle) undergo palpable changes. Acute and chronic somatic dysfunctions present different tissue texture changes (see chart below).

If you suspect a somatic dysfunction, said Cardone, consider referring the patient to an osteopathic physician who practices manipulative medicine (not all D.O.s do it). Or better yet, learn how to do it yourself. Cardone emphasized that the techniques don't need to take much time: "A very focused treatment on a specific area takes just five minutes."

Where can you get training in manipulative medicine? The AAFP will offer clinical seminars and procedures workshops at the Scientific Assembly Sept. 20-24 in Dallas. Assembly information will be mailed to all members in May. Or attend next year's musculoskeletal system CME course; look for details in a fall mailing.

Check for types of tissue changes

Characteristic Acute Chronic

Temperature Increased Slight increase, decrease

Texture Boggy, more rough Thin, smooth

Moisture Increased Dry

Tension Increased, rigid Slight increase, stringy

Tenderness Greatest Present but not so severe

Edema Yes No

Erythema test
(run fingers down
either side of the
spine with some
pressure) Redness lasts Redness fades quickly or
blanching occurs

Official call is issued for Congress of Delegates

Pursuant to Chapter IX of the AAFP Bylaws, notice is hereby given of the 53rd annual meeting of the Congress of Delegates.

The Congress, to be held at the Wyndham Anatole in Dallas, will open at 7:30 a.m. Monday, Sept. 18, and conclude about noon Wednesday, Sept. 20.

AAFP members are encouraged to participate in the Sept. 18-19 reference committee hearings, where issues are debated before being considered by the full Congress.

Proposed amendments to the AAFP Bylaws must be submitted by June 12 to be considered by the 2000 Congress of Delegates. Proposed amendments should be signed by five or more AAFP active members.

Proposed resolutions for the Congress to consider should be submitted by Aug. 19 by constituent chapters.

Both the proposed resolutions and amendments should be sent to the AAFP executive vice president at the American Academy of Family Physicians, 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672, or faxed to the EVP at (913) 906-6093.

Robert Graham, M.D.,
AAFP Executive Vice President and
Secretary to the Congress of Delegates

Befuddled by a FOOSH?
Mechanism of injury could solve puzzle

BY SHARON DENT
Las Vegas

Chances are you recently treated someone who suffered a FOOSH -- a fall on an outstretched hand. But did you know that taking a good FOOSH history can practically make the diagnosis for you?

Alice Epperson, M.D., left, of San Antonio and Shayla Kasel, M.D., of Simi Valley, Calif., practice the steps in a wrist exam at an AAFP CME conference.

"In medical school, we were taught that 'fall on an outstretched hand' was all we needed to know, but the position of the hand determines where the mechanical and vector forces were transferred up the arm," said Joseph Moore, M.D., of Quantico, Va., who chaired the AAFP's Office Procedures and Management of the Musculoskele-tal System CME course Feb. 21-25.

Ask the patient to describe the fall in detail. "Tell them to show you how it was done," Moore said at the course. "Did they fall forward and skin their hands up, or did they fall back and jam their hands and shoulders into the ground?"

The answers can help you make a differential diagnosis:

I fell forward and landed on my outstretched hand. The force from the fall typically transmits to the distal radius. "Nine times out of 10, they'll get a distal radial fracture," said Moore.

If an X-ray confirms that diagnosis, do a closed reduction to correct any dorsal or volar angulation. Then cast the arm in that position, immobilizing the elbow and the wrist. Do a follow-up X-ray in plaster in a week, switching to a short-arm cast in about three weeks, Moore said. A healthy adult likely will heal within four to six weeks.

Children often experience a "buckle fracture," in which the bone is partially collapsed. In that situation, a short-arm cast for about three weeks usually does the trick, Moore said.

I fell forward on my hand, and I think I sprained my wrist. Don't assume pain means sprain. Always look for a scaphoid fracture, said Moore. "If you suspect a scaphoid fracture and there's nothing on X-ray, you typically put them in a short-arm thumb spica cast for two weeks, and then you re-X-ray out of plaster," he said. "If you're still suspicious and the X-ray still doesn't show anything, do a bone scan. The exam for scaphoid is that classic 'snuff box' tenderness; feel the distal pole of the scaphoid in the crease of the wrist."

About 70 percent of scaphoid fractures occur at the waist, said Moore. "However, pay particular attention to the less common but more severe fractures at the proximal pole," he added.

When should you refer the patient to an orthopedic surgeon? If you can answer yes to any of these questions, then a referral is warranted:

Was there a delay in presentation?

Is the fracture in the proximal third of the scaphoid?

Are the fragments displaced?

If a nondisplaced waist or distal pole scaphoid fracture is confirmed, put the patient in a long-arm thumb spica cast and X-ray in plaster that day and again in a week, said Moore. After three more weeks, remove the cast for an X-ray but replace it for another four to six weeks, possibly switching to a short-arm spica cast for the duration of the treatment.

"The biggest thing is that you've got to prepare the patient psychologically to be in a cast for 12 to 16 weeks," Moore said.

My daughter fell out of a swing and landed on her hand with her arm outstretched behind her. "Typically, those forces will be transmitted up through the radius to the elbow, so they'll have fractures at about the distal humerus," said Moore. "They are typically treated in a long-arm cast from three to six weeks." Consult with an orthopedic surgeon if fragments are displaced.

Keep an eye on growth plates in your younger patients, he said. "Watch for the medial epicondylar and supracondylar fractures when they fall on a backstretched hand."

I fell down the stairs and landed on my outstretched hand with my elbow locked. A child reporting this type of fall is likely to have suffered a supracondylar fracture, Moore said. Consider a referral if you're not comfortable treating these tricky fractures.

If this patient is an adult, the diagnosis typically is radial head fracture. How can you be sure? "Look for the fat pad sign," Moore said. "Fat resides in the capsule of the joint, and when there's a fracture -- even if it isn't evident on X-ray -- the fat pad will float up out of its bed because of blood in the joint. A billowed anterior fat pad is positive, and any visualization of the posterior fat pad is pathologic."

Radial head fractures in adults should be treated in a sling for comfort for four to seven days. Then the patient can remove the sling and begin extending the elbow and supinating and pronating the hand to regain mobility. "Over four to six weeks, they'll gradually get better," Moore said. A referral is in order if the fragment is displaced or depressed or involves more than a third of the articular surface, he said.

Head for Azerbaijan with Physicians With Heart

Robert Zemke, M.D., of Yarmouthport, Mass., confirms the delivery of medicine in Samarkand, Uzbekistan, in 1999.

If international family medicine intrigues you, consider joining the Physicians With Heart airlift to Azerbaijan this October.

Family physicians will help deliver donated medicine and supplies to the former Soviet republic of Azerbaijan, which borders the Caspian Sea. During the trip, family physicians will introduce Azerbaijani health professionals to a new concept: family practice.

The delegates on the trip will also bring aid to an orphanage for handicapped children, whose needs include powdered milk, soap, jackets, toys and clothing.

The partners in this eighth annual airlift to former Soviet republics are the Academy, the AAFP Foundation, and Heart to Heart International, a humanitarian aid organization based in Olathe, Kan.

Particulars. The trip Oct. 6-15 will cost about $3,500 per person. To participate in the airlift, contact Heart to Heart at (405) 787-5200.

Physical challenges. Candidates for the trip should be able, for example, to walk long distances, climb stairs, lift luggage, eat indigenous foods, sustain a demanding schedule and possibly fly on propeller planes.

Donations. If you'd like to help fund the airlift's medical supplies and the donations to the orphanage, call (800) 274-2237, Ext. 4452, and ask about contributing to the AAFP Foundation International Fund.

Getting FPs to small-town America
Rural training tracks rise to the occasion

BY SHERI PORTER
Omaha

Good ideas survive. So it's no surprise that "one-plus-two" residency training has enjoyed stellar growth in the past decade.

Today, the nation has about 30 accredited rural training track programs, an increase of more than 60 percent since the rural training track concept popped onto the scene in the late 1970s. Most RTT models feature the "one-plus-two" format -- one year in a university hospital setting, followed by two years in an outlying location.

Above: Resident Terry Becker, M.D., chats with Patricia Neville after her yearly physical in Ravenna, Neb. Left: The clinic in Doniphan, Neb., stands out -- the building sits smack at the edge of a cornfield.

The idea is to grab residents who relish the thought of life in rural America -- and get them in that setting as quickly as possible.

"If we train residents in Omaha, it becomes difficult to get them out to a rural practice. We need to train people in rural areas," says James Stageman, M.D., director of the family practice residency at the University of Nebraska Medical Center in Omaha.

"The perfect applicant is someone who is from rural Nebraska," he adds, because residents with roots in small communities are often anxious to return to that setting.

A dire need for physicians in underserved areas is fueling the growing trend of RTTs. Stageman says the University of Nebraska program has a mandate to train and place rural physicians.

The residency program convinced two residents to pioneer its first rural site in Grand Island in 1992. Eight years later, the program lists 19 graduates with six more expected in July -- and all but four of them will have stayed in-state.

Nebraska claims the largest RTT model, with 24 slots. Residents spend their first year in Omaha. The last two years give them experience in one of four community hospital sites stretched out across Interstate 80: Grand Island, Kearney, North Platte and Scottsbluff, just short of the Wyoming border. In hub-and-spoke style, each hospital also helps fund a clinic in a small neighboring community.

Todd Woollen, M.D, second-year resident, fills one slot at St. Francis Medical Center in Grand Island. He sees his own private patients in Doniphan. Woollen grew up in Alma, Neb., population 1,200, and he likes the feel of this small community. "I'm treated like a physician," he explains. "Here, you grow into your role as a physician more rapidly. I can't imagine a better way to train."

Residents in the rural sites give an overall positive assessment of their "one-plus-two" training.

They agree that the university setting provides more didactics, ample access to subspecialists (who are in short supply in small communities), plenty of patients, a diversity of cases and the latest in technology.

Terry Becker, M.D.:
"If you're not self-motivated, you shouldn't be here."

But the residents have been happy to leave the traffic of Omaha behind. They have enjoyed slipping into their local communities and building relationships with doctors and patients. Hospital staff in Kearney and Grand Island are described as willing teachers -- who view working with residents as a refreshing change of pace.

Second-year resident Mark Becker, M.D., sees his private patients in the Ravenna clinic. "Your responsibility level for the initial decision making increases in a rural setting," Becker says. While he recalls stimulating interaction with the large pool of residents in Omaha, he doesn't miss the competition for training opportunities.

At Kearney's Good Samaritan Health Systems, Becker says he is first in line for hands-on experience -- whether it's maternity care or care of children. There's no pecking order here.

The RTT model is not for everyone. Third-year resident Terry Becker, M.D. (not related to Mark), grew up in Kearney and will join a practice there this summer. He advises students to take a hard look at themselves. "If you're not self-motivated, you shouldn't be here," Becker says. Rigid university hospital schedules are absent in rural Nebraska.

There's also the danger of culture shock. Most residents in the Omaha program hail from non-urban Nebraska. But when it comes to relocating, spouses' feelings count, too. Nobody understands that better than Richard Fruehling, M.D., associate director of the RTT in Grand Island. Fruehling and his wife host a social evening once a month, usually at their home. They invite residents, spouses and often children. The evenings are designed to promote camaraderie within the group, says Fruehling, and "to remind them there's more in life than medicine."

The success of the RTT program in Nebraska is directly tied to one of the first rural models, accredited in 1986 at the family medicine residency in Spokane, Wash. "Not only were they pioneers, but they were willing to share their experiences with others who were trying to develop programs," says Michael Sitorius, M.D., chair of the University of Nebraska family medicine department.

The concept of rural-based residency training has grown widely, says Robert Maudlin, Pharm.D., assistant director of the Spokane program. "We learned if you want graduates to practice in rural areas, immersion in rural life and mentorship by rural faculty gives them a head start."

Grants help residents attend Conference on Patient Education

Family practice residents can get financial help for attending the 22nd annual Conference on Patient Education Nov. 16-19 in Albuquerque, N.M.

The application deadline for the Resident Scholarships and Grants Program is July 15. For more information, visit www.aafp.org/pec. Or contact the AAFP Health Education Department by e-mail at pec@aafp.org or by phone at (800) 274-2237, Ext. 5532.

You can also receive a faxed application by calling AAFP Express at (800) AAFP EXP [223-7397] and supplying your AAFP ID number. Ask for item #7003.

National Conference mixes learning, caring, fun

If a conference designed by residents and students for residents and students sounds good to you, you're in luck.

You can register now for the National Conference of Family Practice Residents and Medical Students Aug. 2-6 in Kansas City, Mo. If you're looking for a residency or a job as a new FP, you may find your future at this meeting.

Kathy Kobbermann, M.D., left, of Appleton, Wis., and Megan Stormo, a medical student from Rochester, N.Y., practice suturing skills at the 1999 National Conference.

The keynoter will be family physician Nancy Dickey, M.D., of College Station, Texas, the 1998-99 AMA president.

Several elements will reflect the meeting's theme, "Caring for the Underserved."

FP brothers John Clarke, M.D., of Laurelton, N.Y., and Matthew Clarke, M.D., of Rosedale, N.Y., will present the annual Stephen Jackson, M.D., Memorial Lecture. The Clarkes conducted studies that showed how important music is to inner-city adolescents and then produced a rap CD called "Asthma Stuff" to increase teens' medication compliance.

FP Donald Weaver, M.D., director of the National Health Service Corps and an assistant surgeon general, will also speak.

Community service opportunities will include a blood drive, work at the Kansas City Community Kitchen and a pop tab round-up to benefit the Ronald McDonald House.

Educational opportunities include workshops on clinical skills, leadership development and career planning, as well as procedural skills courses.

See the launch of AAFP's student Web site -- a special area will be set up in the AAFP Resource Center to showcase this new source of information and assistance.

During the business sessions, you'll get a chance to develop resolutions that may influence Academy policy.

For nighttime fun, come to a party at Science City in Kansas City's newly renovated Union Station and the traditional picnic and square dance at Crown Center Square.

There are three ways to register: online at www.aafp.org/conference, by fax at (913) 906-6083, or by mail to National Conference c/o AAFP, 11400 Tomahawk Creek Parkway, Leawood, KS 66211. Questions can be directed to conference@aafp.org or to (800) 274-2237, Ext. 6726.

Grassroots advocacy efforts

To the editor:

The special section, "Grassroots Advocacy," in the March FP Report was terrific. I especially appreciate the report on what the Colorado AFP is working on. I will quote and circulate this in my efforts to obtain prenatal care coverage in Oregon.

Just one comment and one correction: (1) It is not only undocumented immigrants (i.e., those who have come here or stayed here without authorization) who are ineligible for Medicaid because of their immigration status. Even authorized ("legal" or documented) immigrant women, if they arrived after August 1996, when the Welfare Reform Act was passed, are ineligible. Thus, for any state to provide for their prenatal care requires state-only Medicaid funds (no federal share), just as for undocumented women. (2) It would be wonderful if the efforts of Drs. Carolyn Shepherd and Virgilio Licona and their colleagues succeed. However, it wouldn't make Colorado the first state to provide this coverage. California has done so for many years, as has Washington. Georgia and Texas have also made some of this coverage possible, though I don't know if the latter two states have been able to sustain it lately.

Tina Castañares, M.D.
White Salmon, Ore.

To the editor:

I read with interest the item in the March 2000 FP Report, "Gun Safety Finds Niche in Wisconsin, Hunter Haven."

I was pleased to read about the proactive preventive education stance portrayed in the article. Firearm safety is best obtained through education programs that seek to prevent accidents that occur out of ignorance or curiosity. Violence is glorified in today's mass media to the point that children's video games are scored by body counts. Is it any wonder that we see this violence spilling out onto our streets?

If the mass media is the only education this nation's children receive, this epidemic of violence will continue to spread. To counter this tendency, the AAFP should support mandatory firearm safety education in the school system. The National Rifle Association maintains an outstanding program for children, "Eddie Eagle," available on request.

There are political interest groups that oppose any firearm safety education for our children, arguing there is no such thing as firearm safety. A preventive firearm safety education program that succesfully reduces accidents would show the weakness of their stance.

Darryl Riegel, M.D.
Lompoc, Calif.

Antibiotic overuse

To the editor:

Concerning the March FP Report article, "Deadly Risks of Antibiotic Overuse Warrant Widespread Education," I have a few comments. We poor FPs are constantly bullied in the literature for doing too much of one thing and not enough of something else. The reason we often don't do as the prospective double-blind trials recommend is that, in the real world, we can't exclude patients from our daily experiments in life.

Specifically, the antibiotic resistance issue became a reform campaign based on little evidence. I have seen no studies showing that antibiotic use in outpatient-acquired infections in community practice leads to antibiotic resistance. On the other hand, several studies have shown statistically significant improved outcomes for treatment of even upper respiratory infections with antibiotics. In the United States, at least we restrict antibiotics to prescription only, unlike many other countries. Plus, I think antibiotic overuse in terminal patients in tertiary care institutions is by far the main cause of resistance.

Steve Kriebel, M.D.
Forks, Wash.

Doctors Ought to Care

To the editor:

The FP Report (December 1999) faced a daunting task in trying to compress the history of AAFP's efforts to curb tobacco into 1,500 words. I appreciate the allusion to difficulties I experienced in 1977 in trying to ignite the interest of AAFP leadership in confronting the tobacco industry, as well as references to Doctors Ought to Care.

However, the statement that "pressure (on the AAFP) to take a stand on tobacco also came from an ongoing grassroots movement among constituent chapters ... with FPs across the country crying out about tobacco's destructive impact on health" is misleading. The pressure was orchestrated entirely by DOC board members who were involved in the Academy at local, state and national levels. Beginning in 1978 and for the better part of a decade during the National Conference of Family Practice Residents in Kansas City, Mo., the DOC board met for the purpose of hashing out anti-smoking strategies.

With regard to Tar Wars, the current AAFP-endorsed tobacco use prevention program, both its concept and organization were wholly derived from DOC.

I am disappointed that the name of my colleague Dr. Rick Richards, a past member of the Congress of Delegates and a past DOC president, was omitted from the article. Between 1979 and 1998, Dr. Richards was invited to speak on tobacco at every NCFPR. He single-handedly attracted more students and residents to the fight against tobacco than any other AAFP member.

Alan Blum, M.D.
Tuscaloosa, Ala.

AAFP Candidates

The California AFP announces the candidacy of Mary Frank, M.D., of Rohnert Park for AAFP director.

The South Carolina AFP announces the candidacy of Boyce Tollison, M.D., of Easley for AAFP director.

Congress addresses NHSC, other health issues; court rules on Medicare suit

Here are some federal issues that may affect the specialty:

NHSC. The National Health Service Corps is up for its 10-year reauthorization. Senators and representatives haven't paid much attention to the corps in 10 years and probably don't recall its importance.

That's where you come in.

If you were in the corps or work with the underserved, tell your lawmakers how NHSC does or could improve care for their constituents. Let your lawmakers know NHSC is a training ground for professionals who often continue their careers in service to minority and disadvantaged populations.

Note: The Bureau for Primary Care estimates a current need for 20,000 primary care clinicians nationwide, skilled in medicine, dentistry and mental health. In 1999, the corps had 2,349 clinicians serving in underserved areas -- meaning the current corps is equipped to meet only 12 percent of the health care access needs of the nation.

Managed care bills. House and Senate conferees, at press time, were debating provisions in widely divergent bills from the two chambers. The Academy supports the strong provisions in the House bill, the Bipartisan Consensus Managed Care Improvement Act, instead of the limited provisions passed by the Senate as the Patients' Bill of Rights.

Appropriations. The Academy is lobbying members of Congress to increase funding for immunizations, Title VII family practice training programs, rural health programs, and the Agency for Healthcare Research and Quality (formerly the Agency for Health Care Policy and Research).

IHS. The Academy has joined Friends of Indian Health, a coalition that supports reauthorization of and funding for the Indian Health Service.

Supreme Court ruling. The Supreme Court decided Feb. 29 that challenges to Medicare Part A regulations must complete Medicare's lengthy review process before culminating in lawsuits.

In a 5-4 decision, the court sided with the Department of Health and Human Services and against a nursing home association that sued HHS over its regulations. The Academy had signed an amicus brief supporting the association.

Here's the rub: The court's decision restricts the role of associations, including medical societies, in suing on behalf of their members.

Order from AAFP at (800) 944-0000 unless otherwise noted.

Learn about diabetes at your computer. The CD-ROM "Management and Prevention of the Complications of Diabetes" pulls together many products and programs from AAFP's 1999 Annual Clinical Focus. For a free CD-ROM (#R587), order by June 1.

Proven value: Visit www.aafp.org, AAFP's Web site, updated daily. Use the site to report your CME and take CME quizzes from AAFP publications. The site's newest feature, Speak Out, at http://capitol.aafp.org/ lets you e-mail Congress, find out what's happening in Congress each day, and access information about legislation and your lawmakers.

Proven value: The 1999-2000 AAFP Reference Manual presents more than 34 clinical statements, 75 health issue policies and many operational policies. First copy free, other copies $10 (#R613).

FP Report is published by the AAFP News Department.
Copyright © 2000 by American Academy of Family Physicians.

FP Report | Headlines | AAFP Home | Search