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FP Report
May 2000 • Volume 6 • Number 5

AAFP asks Congress to protect patient rights
'Who do you want caring for your family -- an accountant or a physician?'

stethoscope or calculator
Stethoscope or calculator: That's the choice family physicians pose to Congress at a news conference on Capitol Hill. The banner proclaims, "It's time to protect patients!"

Forty-three family physicians defended patient rights last month on Capitol Hill. The FPs urged a House-Senate conference committee to save key elements in conflicting managed care bills.

"Here's what we'll show the managed care conferees," said AAFP President Bruce Bagley, M.D., of Albany, N.Y., as he brandished a calculator and a stethoscope at an April 10 news conference. "We'll ask the conferees, 'Who do you want caring for your family -- an accountant or a physician?'"

The family physicians and 10 others -- including medical students and representatives of AAFP chapters and the Organizations of Academic Family Medicine -- "hit the Hill" April 10-11. They delivered calculators and stethoscopes to the 33 members of the managed care conference committee. The FPs and others also met with their own lawmakers to seek a law supporting:

Rep. Dennis Moore, D-Kan., who represents the district where the AAFP headquarters is located, told reporters, "These physicians want to be able to do the right thing for their patients, and this Congress must make sure the law allows them to do so."

Christine Petty, M.D., of Rockford, Ill., said managed care has reduced health care costs. "Man-aged care is not all bad," she said. "For some, HMOs provide care they otherwise couldn't afford."

However, Petty and other FPs described hoops they have not always been able to jump through to get patients' care covered -- hoops that could be wiped out by strong legislation.

Mary Frank, M.D., of Rohnert Park, Calif., chair of the AAFP Commission on Legislation and Governmental Affairs, wrapped up the news conference. "My state has one of the largest managed care systems in the nation. Every day I am forced to choose whether to use a stethoscope or a calculator to treat my patients," she said. "I am a physician. I use my stethoscope."

On the front line
Bioterrorism: FPs may be first to sound the alarm

BY CINDY McCANSE
Arlington, Va.

It's the first nice day of spring, and you're beginning to regret having agreed to fill in at the local free health clinic for one of your partners.

Walking into one of the exam rooms, you're greeted by dry, wracking coughs. The patient, a 43-year-old male loading dock worker, complains of two days of fatigue accompanied by joint pain (flu), muscle aches (flu) and mild chest discomfort (and more flu). Several co-workers, he reports, have missed work this week with "some kind of bug."

His body temp is 101.8 degrees and nothing remarkable turns up on a routine physical exam.

So, if it walks like a duck and quacks like a duck -- it's a duck, right?

Ebola virus
Transmission electron micrograph of Ebola virus


Anthrax
Histopathology of human large intestine in fatal anthrax case

The answer is: not always.

According to some experts, primary care physicians may well be the vanguard of defense in a battle many of them are ill prepared to recognize, let alone fight. The possibility of a nuclear, chemical or biological terrorist attack on U.S. soil cannot be discounted, and practicing physicians must be equipped to respond appropriately.

Assistant Secretary of Defense for Health Affairs Sue Bailey, D.O., recently addressed differences in responses to nuclear, chemical and biological events. She spoke to medical military personnel, public health officials, emergency response personnel and practicing physicians at the Department of Defense Medical Initiatives Conference and Exhibition, "Weapons of Mass Destruction 2000," April 2-6.

The U.S. response to a nuclear attack -- decades in the making and fine-tuned during the Cold War -- would, of course, rely heavily on U.S. armed forces working with national and regional emergency response agencies. First responders to such an event would come from these entities.

In a chemical attack, Bailey noted, police and fire department personnel would be first on the scene. "But if it's a biological event," she told physicians, "the first responders aren't going to be people in uniform or those with the red lights on -- they're going to be you."

Scott Deitchman, M.D., M.P.H., from the National Institute for Occupational Safety and Health of the CDC in Atlanta, agreed.

In a plenary address to more than 600 attendees, Deitchman said community physicians are the key to recognizing a biological emergency. That recognition, he added, is going to require an astute physician with a high index of suspicion.

"I know that I for one wasn't taught about smallpox in medical school, other than that it was extinct, and I certainly wasn't told how to differentiate it from chickenpox," he said. "We need to bring physicians up to speed in how to make those diagnoses."

Look for zebras

The CDC has compiled a list of potential bioterrorism agents that reads like it's straight out of a B movie. Bacillus anthracis (anthrax), Yersinia pestis (plague), botulinum toxin, variola major virus (smallpox) and the Ebola virus strains are among those that top the list.

The initial clinical picture for many of these conditions mimics that of flu. No specific symptoms in the patient described above indicate he should be tested for d'Espine's sign or undergo chest radiography to look for a widened mediastinum -- a feature associated with inhalation anthrax. Yet, given his constellation of symptoms, this highly lethal disease is within the realm of possibility. Should anthrax be included in the differential diagnosis?

The answer is: maybe.

The Association for Professionals in Infection Control and Epidemi-ology Bioterrorism Task Force has identified several features that should increase physicians' suspicion of a bioterrorist attack:

The devil's in the details

For physicians, the problem only begins with making the diagnosis.

Sue Baily, D.O., assistant secretary of defense for health affairs
"The first responders aren't going to be people in uniform or those with the red lights on -- they're going to be you."

In conference breakout sessions sponsored by the AMA, physicians discussed other critical issues, starting with treatment and prophylaxis.

The CDC is charged with storing and issuing pharmaceutical agents needed during biological incidents through its National Pharmaceutical Stockpile Program, but these supplies must be distributed at the community level. Collaboration among physicians and public health officials will be needed to ensure efficient dispersal of these assets and accurate patient tracking.

Other treatment challenges include prescribing drugs for off-label indications and managing the needs of special patient populations. Adequate communication and cooperation among health care facilities and responsible public information dissemination will also be imperative.

But none of these issues will be addressed if physicians don't first believe there's a threat.

As Jeffrey Thomasson, M.D., a St. Louis radiologist, observed at a breakout session, "There's a sense of, if not apathy, at least disbelief. It's like believing in the tooth fairy to think that this could happen."

Unfortunately -- to hear Bailey and others tell it -- it's not a matter of if, only when.

Want to learn more?

A mini-course on bioterrorism will be offered Sept. 22 at the AAFP Scientific Assembly in Dallas. "The Family Physician -- On the Front Line Against Bioterrorism" will be facilitated by Col. Dale Carroll, M.D., M.P.H., of Fort Sam Houston, Texas. This course has been reviewed and is acceptable for 1.5 Prescribed credit hours by the AAFP.

You can also tune in to a live, interactive satellite broadcast Sept. 26-28. "Biological Warfare and Terrorism: Medical Issues and Response," sponsored by the U.S. Army Medical Research Institute of Infectious Diseases, will air 12:30-4:30 p.m. EDT each day. To register, visit http://www.biomedtraining.org or contact Rick Stevens at (301) 619-4880.

Bibliographic resources include:

Institute of Medicine and National Research Council. Chemical and Biological Terrorism: Research and Development to Improve Civilian Medical Response. Washington, D.C.: National Academy Press, 1999.

Franz, D.R.; Jahrling, P.B.; Friedlander, A.M.; et al. "Clinical Recognition and Management of Patients Exposed to Biological Warfare Agents." Journal of the American Medical Association 1997; 278: 399-411.

Henderson, D.A. "Bioterrorism as a Public Health Threat." Emerging Infectious Diseases 1998; 4: 488-92.

Vaccinate against smallpox? Preposterous! But will a vaccine be there if you need it?

BY CINDY McCANSE

It's no secret that we live in dangerous times. Responding to mounting concerns about worldwide terrorist threats, U.S. officials are seeking ways to protect American citizens from biological terrorism.

Smallpox lesions
Smallpox lesions cover the face of the young boy in this archival photo.

To this end, the NIH is currently funding a phase II clinical trial to gauge the immunogenicity of diluted doses of existing smallpox vaccine. This spring, the Center for Vaccine Development at Saint Louis University School of Medicine, the sole study site, began seeking participants.

Variola major, the virus that causes smallpox, is considered a potential bioterrorism agent. The highly contagious disease was declared eradicated in May 1980, thanks to a global vaccination program spearheaded by the World Health Organization. Only two known stocks of the virus remain: one at the State Research Center of Virology and Biotechnology in Koltsovo, Russia, and the other at the CDC in Atlanta.

But some experts fear that hostile parties may also have caches of the virus.

Manufacturing of the smallpox vaccine, Dryvax, ceased in 1983. About 15.4 million doses of vaccine remain in the United States, many of which may be unusable. The CDC controls distribution of the vaccine, which is now given only to laboratory workers at risk of occupational exposure to smallpox and to at-risk U.S. military personnel.

"The reason for doing this study is to see if we can increase the available number of doses in the event of a bioterrorist attack or biowarfare," said lead investigator Sharon Frey, M.D., associate professor of infectious diseases and immunology at SLU. "Being able to successfully dilute the vaccine would potentially increase the available stock by 10- to 100-fold."

Of 60 participants to be recruited for the double-blinded, randomized study, one-third will receive the full dose of vaccine, one-third will receive a 10 percent dilution and the remaining one-third will receive a 1 percent dilution.

Meanwhile, the U.S. Army Medical Research Institute of Infectious Diseases and the Joint Vaccine Acquisition Program, both at Fort Detrick, Md., are working to develop a tissue culture-derived smallpox vaccine. Clinical trials have already begun, and it is possible that the vaccine could be licensed by 2003.

"They're working on developing newer forms of vaccine product," said Frey. "What we're doing is really an interim step, waiting for a better product to come along."

Study promotes affirmative action
Minority generalists often care for low-income Americans

BY JANE STOEVER

Minority physicians in primary care often serve low-income patients -- whether or not the patients are members of minority groups.

It's a matter of choice. And roots. Minority physicians often opt to practice in areas with low-income populations.

Michael Ramos, MD
Michael Ramos, M.D., enjoys a well-baby visit with proud mom Angelia Simmons and daughter Roxanne.

"A lot of us, growing up, didn't have anything anyway, money-wise," says family physician Michael Ramos, M.D., of Pueblo, Colo. About 55 percent of his patients are Hispanic, about 40 percent are Anglo and a few are African-Americans. About half of his patients are on Medicaid, and 5-10 percent are uninsured.

"I do a lot of OB, see a lot of kids," says Ramos. "I like it."

Many of his patients work at a steel mill or in stores. "Everybody's pretty much the working poor here," says Ramos.

North of Denver, family physician Diego Osuna, M.D., practices in a community health center in Commerce City, Colo., an industrial area. The center serves local residents and migrant farm workers. About 25 percent of the center's patients are on Medicaid, and some 70 percent are uninsured.

"We're filling a great need," says Osuna.

The practice locations of Ramos and Osuna reflect findings from a study completed recently by the AAFP Center for Policy Studies in Family Practice and Primary Care in Washington, D.C.

The study, which surveyed all Colorado physicians, found that Hispanic primary care physicians practiced in areas with more poor people than the areas where Anglo primary care physicians worked (see chart).

"These findings argue for a special provision to admit ethnic minorities to undergraduate and graduate medical education programs," says the study report.

In conclusion, the report says, "We now have decades of experience with the failure of nonminority physicians to serve underrepresented minorities in rural and urban areas. These data suggest that attention to -- not avoidance of -- affirmative action may offer a better chance to serve the underserved in the future."

The AAFP has no policy on affirmative action in medical education.

Osuna says recruitment of prospective physicians likely to serve the uninsured is an important response but is only one response to the growing numbers of the uninsured. He adds, "As a society, we need to look at all the ways we can address the problem of unequal access to health care."

Percentages of population by ethnic composition
and poverty status in ZIP code areas where
Colorado primary care physicians practice

Population Served by
Anglo
physicians		 Served by
Hispanic
physicians
Hispanics 12.0% 22.1%
Below poverty level 12.6% 16.9%
Anglos 9.7% 11.7%
Hispanics 20.2% 24.7%

The study's principal investigator, Edward Fryer Jr., Ph.D., says that while the study was limited to Colorado, the large number of survey respondents (5,992), including a sizable minority group (135 Hispanic physicians), suggests the results may apply to other states. In addition, more African-American than Anglo physicians in the study practiced in low-income areas, but there were too few African-American physician respondents (only 64) for them to be considered statistically significant in the study.

Family medicine was popular among Hispanics in the study: 56.3 percent of the Hispanic generalists were family physicians, and 30.3 percent of all Hispanics in the study were family physicians. The Colorado Area Health Education Center Program in Denver initiated the study, which was completed by the AAFP policy center last year.

For more information, call Fryer at the policy center, (877) 349-0461.

mental health

May is Mental Health Month, a time to re-emphasize mental health screenings and patient education about mental health issues. The observance is sponsored by the National Mental Health Association, one of the cooperating partners for the Academy's Annual Clinical Focus, Mental Health 2000.


Too many kids on Ritalin?

The number of young children on Ritalin, Prozac and other psychotropic drugs is skyrocketing.

Some parents come to physicians and say they want their kids on Ritalin before the children have even been evaluated, AAFP Board Chair Lanny Copeland, M.D., said at a White House meeting and press event March 20. The parents have often talked with teachers who said they thought the child would benefit from the medicine, he added.

attention
While many youngsters benefit from psychotropic drugs, others may simply need attention and an outlet for their enthusiasm.

"It would be like somebody coming in at the age of 30 and saying, 'I have chest pains, I'd like to have coronary artery bypass surgery,'" said Copeland, who practices in Albany, Ga. He also said psychotropic drugs are an important part of the treatment of children with serious behavioral problems.

The March 21 New York Times and National Public Radio reported Copeland's comments.

The meeting kicked off an initiative that will feature a fall conference on the diagnosis and treatment of children with mental and emotional disorders. One goal: to build parent-teacher-physician teamwork in meeting children's needs, with or without psychotropics.

"We are not here to bash the use of these drugs," said Hillary Rodham Clinton, who chaired the March 20 meeting. "They have literally been a godsend for countless adults and young people with behavioral and emotional problems." But she warned that some youngsters on the drugs "have problems that are symptoms of nothing more than childhood or adolescence."

Clinton mentioned that between 1991 and 1995, the number of preschoolers on Ritalin increased by 150 percent, and the use of antidepressants for children under 5 increased more than 200 percent.

Clinton called attention to "Trends in the Prescribing of Psychotropic Medications to Preschoolers" in the Feb. 23 Journal of the American Medical Association.

The article notes, "There were large increases for all study medications (except the neuroleptics) and considerable variation according to gender, age, geographic region and health care system. These findings are remarkable in light of the limited knowledge base that underlies psychotropic medication use in very young children. The vast majority of psychotropic medications prescribed for preschoolers are being used off-label."

Go to http://jama.ama-assn.org/issues/v283n8/rfull/joc91250.html for the article.


Panic disorder gives fear the upper hand

BY SHARON DICKINSON DENT
Scottsdale, Ariz.

Greg Brotzman, MD
Greg Brotzman, MD

Just about everyone has had a panic attack at least once. But if the attacks continue and the fear of an attack is debilitating on its own, the problem becomes more serious, according to Greg Brotzman, M.D., associate professor at the Medical College of Wisconsin's family and community medicine department and a speaker at AAFP's CME course on women's health April 5-8.

Patients don't always present with the classic palpitations and shortness of breath, Brotzman said. "You might do a workup on the gastrointestinal tract, and then the patient starts having coronary artery disease symptoms, so you check that out. Next thing you know, he's having stroke symptoms," he said. "You can end up chasing your tail for some time before you take a step back and see what's going on."

The incidence of panic disorder in the general population is about 4 percent, rising to 15-20 percent for people with an immediate family member suffering from the disorder. Although about 40 percent of people with panic disorder don't seek help, those who do are more likely to visit a primary care office or emergency room than a mental health facility. Brotzman said 35 percent will go to their family physician.

Criteria for diagnosing a panic attack call for the patient to have at least four of the following symptoms: palpitations, pounding heart or accelerated heart rate; sweating; trembling or shaking; sensation of shortness of breath; feeling of choking; chest pain or discomfort; nausea or abdominal stress; feeling dizzy, unsteady, lightheaded or faint; derealization or depersonalization; fear of losing control or going crazy; fear of dying; paresthesias; and chills or hot flashes.

Panic disorder is diagnosed when a patient has recurrent attacks and a one-month history of anticipatory anxiety (fear of having an attack in a place from which the patient can't escape) and/or behavior change related to panic attacks. "This may not be something you can address in one visit," Brotzman said, noting it's essential to take a thorough history to identify other diseases and previous depression, substance abuse or psychiatric disorders.

When coding for panic attacks, specify whether the diagnosis includes agoraphobia and whether it occurs within the context of other anxiety disorders, such as social phobia or post-traumatic stress disorder.

"One thing you've got to keep in mind is that these people are in despair," said Brotzman. "Just having panic attack/panic disorder puts you at a greater risk of suicide, so we have to address that."

Treatment is multifaceted and based on patient education, behavior modification, psychotherapy, support groups and medications. Research shows that the greatest improvement in symptoms occurs with exposure therapy (gradually exposing the patient to the feared situation, if one is identified), especially when used in combination with medication such as serotonin-specific reuptake inhibitors, tricyclic antidepressants or benzodiazepines, Brotzman said.

Patients should be treated for at least 12 months and experience no panic attacks for at least three months before discontinuing medication. Brotzman warned that panic attacks and panic disorder can be chronic, so relapses are common.


Focus on mental health in May with these tools

As part of AAFP's Annual Clinical Focus, Mental Health 2000, all AAFP members will receive free patient education handouts this month on anxiety and panic disorder, attention-deficit hyperactivity disorder, dementia, depression, depression in older adults, emotional health, substance abuse and understanding your teen's emotional health. For more information on Mental Health 2000 or related issues, visit http://www.aafp.org/acf. You can join a discussion list, read about ACF elements or link to other online mental health resources.

The stigma of mental illness can keep people from seeking help because of fear of discrimination. You can fight the stigma with a free new kit developed by the Department of Health and Human Services' Center for Mental Health Services. It includes a poster, a fact sheet, brochures, a bookmark and an order form for additional materials. To order, visit http://www.mentalhealth.org/stigma or call (800) 789-2647.

depression in women
Wayne Blount, M.D., left, listens as Kathy Cronkite answers an audience question following their presentations on depression at AAFP's CME course on women's health.

BY SHARON DICKINSON DENT
Scottsdale, Ariz.

A patient's perspective

Since early adolescence, Kathy Cronkite has experienced extended episodes of overwhelming emotional pain. She found daily problems insurmountable, experimented with drugs to numb the agony and toyed with the idea of suicide, all while struggling to maintain a facade of normalcy.

Cronkite, a member of a National Institute of Mental Health advisory council and daughter of journalist Walter Cronkite, was the keynote speaker at AAFP's Primary Care in Women's Health CME course April 5-8, where she offered a patient's perspective on the battle with depression.

"My parents didn't know, my teachers didn't know, I didn't know that the problems that were disrupting my education and destroying my personal relationships had a name," said Cronkite.

That's typical, she said, noting that many people suffering from depression don't seek help because they don't realize "that the misery they're living in is a treatable illness."

The symptoms of depression -- low energy and fatigue, apathy, cognitive disturbances, lack of motivation, self-blame and hopelessness -- also stand in the way of getting treatment, she said.

Kathy Cronkite
"My parents didn't know, my teachers didn't know, I didn't know that the problems that were disrupting my education and destroying my personal relationships had a name."

Cronkite said she saw almost a dozen therapists before her depression was diagnosed by a pastoral care counselor during marital therapy. She denied it at first, thinking she couldn't have depression because she wasn't sad all the time. The therapist said, "I see an ongoing sense of hopelessness," and Cronkite knew he was right. "It was the first time in my life that someone had put into words what I was feeling," she said.

A psychiatrist confirmed the diagnosis and worked with her to choose a course of treatment that included medication and talk therapy, but Cronkite grappled with the stigma surrounding medication for mental illness. "I come from a family of Midwest stoics for whom taking an aspirin when you have a headache is a sign of weakness," she said. "The idea of taking medication, particularly something that alters your mind, was scary."

She did fill the prescription and soon felt the ebb of depression's excruciating symptoms. But she still felt ashamed about her condition. She hid her diagnosis from others, concerned that friends and professional peers wouldn't understand. She kept it a secret from her extended family for about six months, coming forward only when she realized the genetic predisposition to depression could affect other family members.

In 1990, U.S. News & World Report published a story about journalist Mike Wallace -- a longtime family friend of the Cronkites -- and his struggle with depression. "In that instant, my sense of shame lifted," Cronkite said. "I thought, if he -- who has so much more to lose than I do -- can talk about it in public, what am I afraid of?"

She chronicled her struggles and those of many celebrities with depression in her book, On the Edge of Darkness. She also became an advocate and educator on the topic of depression, serving on the NIMH's National Advisory Mental Health Council Behavioral Science Workgroup to help develop its new report, Translating Behavioral Science Into Action. You can download the report at http://www.nimh.nih.gov/tbsia/tbsiatoc.cfm. Or call (301) 443-4513 for a printed copy of the report, available in June.

Cronkite encouraged FPs to dispel four key myths about depression:

"You have to be depressed about something." Cronkite pointed out that even when everything seemed to be wonderful in her life, she couldn't find the joy in it when she was suffering from depression.

"Childhood is a happy-go-lucky time." Studies have shown that young children and even infants can experience the symptoms of depression, she said.

"All teens are a mess; it's those hormones." Cronkite said parents and doctors should be concerned if a teen-ager is moody, irritable, angry and antisocial.

"Of course the elderly are depressed. Look how much they have to be depressed about." The issues of aging may make older people feel sad at times, but that's different from depression, Cronkite emphasized. Elderly patients with depression can live happy, fulfilling lives if their illness is appropriately diagnosed and treated, she said.

The ability to enjoy the small things in life -- warm sunshine, blooming flowers, a baby's smile -- is like a gift each day, Cronkite said. But she expressed frustration that so many people afflicted with depression go untreated. "There is no longer any reason to separate mental and physical illnesses," she said. "There's one kind of chemical change in the brain, and we say they have Parkinson's, and we offer treatment and support for the family. There's another kind of chemical change in the brain, and we call them crazy, and we tell them to pull themselves up by their bootstraps."

A physician's perspective

A woman has a 10 percent chance of suffering from depression in any given year and a 20 percent chance in her lifetime. "So if depression isn't one of the top diagnoses in your practice, then you're missing a lot of it," said Wayne Blount, M.D., at AAFP's Primary Care in Women's Health CME course April 5-8.

Blount, family medicine department chair at the University of Tennessee in Memphis, said only about 25 percent of women with depression are getting adequate treatment.

The key to diagnosing depression, he said, starts with having a high index of suspicion. "Watch for the high utilizer," Blount said. Other symptoms that should raise an eyebrow include: fatigue ("The number one reason people go to the family physician's office is fatigue, and the number one cause of fatigue is depression," he said.), headaches that don't go away or keep coming back, sleep complaints, somatic complaints, weight/
appetite disturbances, atypical neurological problems, chronic pain, coronary artery disease and chest pain without coronary artery disease.

Such symptoms suggest screening is in order, said Blunt.

Once you have results from the screening, use the criteria for diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. The DSM-IV says a patient has depression if she has either anhedonia or loss of interest for most of the day nearly daily for at least two weeks, and at least five of the following symptoms:

"If you think your patient is depressed, it is incumbent upon you to ask about suicidal thoughts," Blount said. Ask the patient whether she ever thinks about dying or killing herself, whether she thinks about how she would die, whether she has determined a way to kill herself and whether she could resist the urge to do so.

Treatment for depression is a combination of behavioral counseling and pharmacotherapy, Blount said. "Studies show that behavioral therapy may work alone for mild depression, but medications are needed for moderate and serious depression." That's because patients with more serious depression may not experience the insight and breakthroughs necessary for recovery without the assistance of drugs, he said.

If you do the counseling, Blount suggests using a strategy such as BATHE from the book The 15-Minute Hour by Joseph Lieberman, M.D.:

Background -- What is going on in your life?

Affect -- How are you feeling about that?

Trouble -- What troubles you the most?

Handling -- How are you handling that?

Empathy -- That must be very difficult.

In up to 75 percent of patients with depression, initial medical treatment fails. In that case, keep experimenting with medicines and dosages until you find what works, Blount said. Once you find a drug that seems effective, the patient should take it for at least six months, even if she feels better sooner, he said.

Evidence-based medicine has shown that there are three treatment phases with depression, said Blount. In the acute phase (six to 12 weeks), you should aim for total symptom remission. In the continuation phase (four to nine months), aim to prevent relapse. And in the maintenance phase (more than a year), you want to prevent recurrence.

The six-month success rate is only 65 percent, but aggressive treatment with frequent follow-up improves compliance, remission rates and quality-of-life scores, said Blount. "The more follow-up you do with them, the more you talk with them, the better the outcomes," he said.

Letters to the Editor

Too many antibiotics

To the editor:

I would like to continue the dialogue on antibiotic misuse and overuse initiated by Dr. John Hickner in a March FP Report story and continued by Dr. Steve Kriebel in a letter in April.

I sympathize with Dr. Kreibel, who complains of "being bullied in the literature for doing too much of one thing and not enough of something else." However, I detect skepticism about the results of randomized trials. Randomized trials sometimes seem to contradict our experiences with patients. That doesn't mean the studies are wrong. More likely, it is a reflection of our limitations as observers and as processors of information. Think about it -- do you really know what happened to the last 20 patients that you treated for bronchitis? I bet some got antibiotics, and some didn't. Do you know how they were all doing one week later and whether the antibiotic-treated patients got better faster?

In Iceland, community physicians prescribed a lot of macrolide antibiotics in the early 1980s. Resistance rates of common community-based infections to macrolides increased. A campaign to reduce inappropriate use of macrolides in the outpatient setting reversed that trend and significantly decreased those rates of resistance. We should support campaigns that reduce inappropriate use of antibiotics in our country, not jump to the defense of outmoded prescribing practices.

Mark Ebell, M.D., M.S.
East Lansing, Mich.

To the editor:

Your recent article on the over-prescribing of antibiotics by primary care physicians gave me an idea. Instead of the academics of our profession bashing the community-based doctors for their practices, why don't they come up with a more objective method, a "virometer," so to speak, to determine whether some commonly seen infections are really bacterial?

"We didn't study all the sciences to become fortune-tellers"

I can test cardiac patients with an electrocardiogram and enzymes, a diabetic with a blood sugar or someone who is injured with X-rays. But while my patients trust me, it's harder to convince someone that Johnny's green nasal drainage for two weeks or Susie's injected tympanic membrane doesn't need more than just symptomatic treatment.

On the other hand, I've rarely had patients with sore throats who've had a negative strep test or people with urinary symptoms who've had a negative dip stick complain about not being treated with antibiotics. Those of us on the front lines need more tools, not just criticism. We didn't study all the sciences during medical school to become fortune-tellers.

Bruce Greenberg, M.D.
King City, Calif.

To the editor:

I am distressed that a letter (by Steve Kriebel, M.D.) in the April FP Report cites "I have seen no studies" as evidence that it's OK to use antibiotics in upper respiratory infections. One reference is sufficient to refute such an argument: an article by H. Seppala et al. on macrolide antibiotics in the August 1997 New England Journal of Medicine.

Unfortunately, Dr. Steve Kriebel does not cite his "several studies" which show that URIs have statistically significant improved outcomes, so I cannot discuss the quality or clinical significance of those studies.

Perhaps Dr. Kriebel has been practicing long enough to remember that we used to use ampicillin to treat uncomplicated gonorrhea. This is no longer considered adequate therapy. Much of the reason is due to the importation of penicillinase-producing Neisseria from Thailand during the Vietnam War. Thailand allowed (and, I believe, still does allow) over-the-counter use of antibiotics. I once visited a Bangkok pharmacy seeking a decongestant for a URI, and the pharmacist tried to sell me erythromycin as the preferred treatment.

I agree that antibiotic use in hospitals is an important source of bacterial resistance. This can be partially alleviated by measures designed to reduce nosocomial transmission.

Richard Lamson, M.D.
Baltimore

 

Match results

To the editor:

The April FP Report article regarding the decline in family practice matching quotes our AAFP president, Dr. Bruce Bagley, as stating, "The health of the public will be hurt -- this trend must be reversed." To imply such a devastating effect from this decline is perhaps not only a bit grandiose but also demonstrates an element of denial as to the state of our specialty.

Could the decline have anything to do with relinquishing hospital privileges to hospitalists or relinquishing direct patient care to a variety of midlevel practitioners, or perhaps relinquishing other medical-political privileging issues within hospitals and universities? Or is the new fad of Med/Pedi residencies really a ruse to avoid the conflict our specialty often feels with obstetrics? Or are the insurance companies making the business of medicine so hostile that the romance of medicine has evaporated, directly affecting our lifestyles, especially considering the debt burden students incur? Perhaps the bull market in family practice really is over. It may actually now be time to plan for a bear market by diversifying our specialty adequately to help it remain a viable, valuable option for career planning as well as for acquiring patient confidence.

Jerry Behal, M.D.
McAllen, Texas

To the editor:

I would like to comment on AAFP President Bruce Bagley's statement in the April FP Report that "family practice involves a high degree of commitment." He seems to be implying that family practice requires a higher degree of commitment to patient care and that this is discouraging medical students such as myself from applying for family practice residencies.

I disagree with Dr. Bagley. In my experience, family practitioners frequently had a great deal more family time than, for instance, internists or surgeons, not only in residency programs but in private and academic practice settings as well.

I think the move away from primary care by medical school graduates has more to do with the increasing complexity of care and the reality that a physician cannot stay current in internal medicine, pediatrics, obstetrics/gynecology and psychiatry. Subsequently, the quality of care suffers.

Ward Naviaux
Seattle

We want letters

Write us using the FP Report addresses. Please keep your letters to a maximum of 200 words; all letters are subject to editing.


Advantages abound in locum tenens work

BY SHERI PORTER

Locum tenens work, long a niche for doctors edging toward retirement, is snatching doctors fresh from residency or in the prime of their careers.

What's the draw? Try a break from managed care, time to explore options, medical mission opportunities and a family-friendly schedule.

Robert Thompson, DO, MS
Harsh conditions at the South Pole don't keep family physician Robert Thompson, D.O., M.S., from enjoying his locum tenens stay.

Robert Thompson, D.O., M.S., 41, of Harrisburg, Pa., has spent the past several years as a full-time, independent locum tenens practitioner. "Never say never, but it would take a very special offer to pull me away from my current practice and lifestyle," he says.

Last October, Thompson landed at the Amundsen-Scott South Pole research station to replace an ailing female physician. He's the only doctor available to scientists and support staff for a year.

Thompson's post-residency fellowship in family practice and obstetrics/gynecology plus extensive emergency medicine experience give him excellent qualifications as he builds a résumé of more than 40 locum tenens jobs.

He has developed a five-page practice profile form to help him evaluate prospective assignments, and he always weighs in with predecessors on prospective jobs.

"I am following a business plan I made in residency to do independent locum tenens work, which I saw as the last bastion of physician autonomy in the burgeoning managed health care environment," Thompson says.

Networking with other physicians helps independent locum tenens physicians track good jobs. That's how Patricia Witte, M.D., 31, of Madison, Wis., snagged her first assignments after residency. She's served in two Alaskan towns and two urgent care clinics in the more familiar terrain of Wisconsin.

"I'm only planning on doing locum tenens for about five years, and then I would like to settle down," Witte says. In short, she's checking out people and places and enjoying the travel and flexibility along the way.

Witte suggests setting up a home base "because you can't fit everything you own in a suitcase." She advises meeting with an accountant to avoid tax surprises.

Look before you leap into locum tenens

  • Ask yourself, "Am I flexible and adaptable?"
  • Consider starting out with a reputable placement service.
  • Network for leads.
  • Negotiate your contract.
  • Contact your predecessor.
  • Set up a home base to stash your stuff.
  • Consult an accountant.

Further down the career spectrum is Robert Bradley, M.D., 53, of Windsor, Colo. After 21 years in a small family practice, he was ready for a six-month break. An earlier taste of short-term mission work and an interest in native cultures lured him to Morningside Island, an aboriginal reserve off North Queensland, Australia.

"You do it for adventure, for relief, for cultural experience, travel -- just as a break from routine," Bradley says.

A representative from Global Medical Staffing Ltd., which offers international placements, contacted Bradley about the assignment. GMS President Bob Stringham says 50 percent of requests he receives are for family physicians because of their broad medical base.

The advantages of locum tenens assignments go far beyond exploring exotic places. Gary Morsch, M.D., 48, of Olathe, Kan., was exhausted juggling his busy family practice and his humanitarian aid organization, Heart to Heart International. Several years ago, he left his practice to set up and participate in a locum tenens hybrid called Physicians Who Care Inc.

Morsch recruits physicians to work part-time, long-term schedules. Doctors work in groups of four to fill shortages in rural communities in Kansas, Missouri and Nebraska. Each team member works one week a month in the assigned community and commits to a one-year term.

Physicians Who Care gives the traditional locum tenens model a twist, achieving two things: Physi-cians free up three weeks a month for their families and volunteer work, and underserved communities welcome continuity of care.

AAFP president testifies
'We are disappointed' about Title VII proposal

Bruce Bagley, MD and Rep. John Porter
Bruce Bagley, M.D., left, confers with Rep. John Porter after testifying to the subcommittee Porter chairs.

AAFP President Bruce Bagley, M.D., met with a House subcommittee recently to discuss appropriations for 2001. In three words, he summed up AAFP's reaction to President Bill Clinton's plan to eliminate funds for family practice training: "We are disappointed."

The budget Clinton proposed would zero out Title VII, Section 747 funding of family medicine, dentistry, physician assistant, internal medicine and pediatrics training programs.

"Section 747 is crucial to training the physicians that America needs most; it is the engine that powers the growth of this nation's supply of family physicians," said Bagley.

The chair of the subcommittee, Rep. John Porter, R-Ill., said he was "dismayed" by the zero budget proposal.

Bagley, who practices in Albany, N.Y., thanked the subcommittee for its longtime support. Last year, the administration also wanted to zero out funding for family practice training, but -- with the committee's backing -- the specialty received about $49.5 million for 2000. That compares with $50.5 million for 1999.

"Without your help, funding levels would be much lower than they are right now, and the actual existence of family medicine training programs would be threatened," Bagley told the House Appropriations Subcommittee on Labor, Health and Human Services, and Education.

Bagley asked for $87 million for the specialty in Title VII funds for 2001; $300 million for the Agency for Healthcare Research and Quality (compared with the current $204 million) and continued support for rural health programs, including the National Health Service Corps.

The testimony Bagley presented is online at http://www.aafp.org/fedgov/x984.xml.

Inside the Beltway

Add your voice!
Academy pressures Congress to let FDA regulate tobacco industry

The Supreme Court ruled March 21 that Congress has not given the FDA authority to regulate tobacco products. Six days later, the Academy pushed Congress to "make it so."

"Only through quick action (by Congress) can we avoid abandonment of tough FDA regulations that, since 1995, have helped keep tobacco products out of the hands of kids," said AAFP Board Chair Lanny Copeland, M.D., of Albany, Ga., in a March 27 letter to each member of Congress.

FDA regulations that may be in jeopardy include requiring photo identification of young people to prevent cigarette sales to minors and restricting the placement of vending machines to adult-only areas.

"It is most unfortunate that the court has ruled against the FDA regulating tobacco," said Copeland in a recent press release. "I see far too many families hurt by the ill effects of smoking: children suffering from respiratory illnesses because of exposure to second-hand smoke, mothers struggling with emphysema, young fathers dying from cancer."

The Academy has posted a sample letter at Speak Out on the AAFP Web site so you can easily e-mail your lawmakers about tobacco control legislation. By mid-April, more than 100 AAFP members had used the sample letter to share their views with Congress.

To open the letter, go to http://capitol.aafp.org/elecmail.html and follow the directions. First-time users of Speak Out may wish to access http://www.aafp.org/gov, click on "directions for first-time users" and print them out as a guide.

You'll notice sample letters on other topics about which you may want to contact Congress: managed care legislation, the Quality Health Care Coalition Act (which would allow physicians to collectively bargain with health plans about patient care issues), the Pain Relief Promotion Act and federal funding for family practice training programs.

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

Two features of the AAFP Web site focus on rural care and electronic medical records. Access http://www.aafp.org/rural for a health resource clearinghouse, listserv and bulletin board for rural family physicians. E-mail srehm@aafp.org to join the EMR e-mail discussion list, a way to share your comments on the design and use of EMR.

Monograph Collection

Scheduled to recertify this summer? Here's a review tool just updated with 1999 materials: the CD-ROM "AAFP Home Study Self-Assessment®: The Monograph Collection." The CD-ROM includes monographs published in 1994-99 and the 1998-99 audiotapes (#R273, $175, with annual updates for $95).

2000 Scientific Assembly

Proven value: Watch your mail later this month for the registration brochure for the specialty's premier CME meeting, the AAFP Scientific Assembly Sept. 20-24 in Dallas. To have the best choice of courses and lower costs, register by June 28.

Proven value: Obtain the degree of AAFP Fellow, a distinction shared by more than 28,000 of your colleagues. Fellows are recognized for their public service, publishing, research, volunteer teaching, academic training, CME, medical practice and service to the specialty. Apply by Aug. 1 to have your name listed in the program for the Sept. 22 Fellowship Convocation at the Scientific Assembly in Dallas (application and eligibility requirements, #R401, free).

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

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