June 2000 -- FP Report

June 2000 • Volume 6 • Number 6

Outgoing Executive Vice President Robert Graham, M.D., left, and incoming EVP Douglas Henley, M.D., share a laugh during Henley's recent meeting with staff at AAFP headquarters.

I'm terribly excited to be here today. I'm energized. I'm challenged. And I'm as nervous as hell!"

So said family physician Douglas Henley, M.D., of Fayetteville, N.C., after his introduction as the Academy's new executive vice president-designate at the AAFP Annual Leadership Forum April 29 in Kansas City, Mo.

Henley, an AAFP past president who has been in private practice for 20 years, walked with his wife, Mary, to the stage amidst an enthusiastic standing ovation. "Six years ago, when I walked down the aisle of the Congress of Delegates as your president-elect, I thought that would be my peak emotional high," he said. "But no -- this just beats that hands down."

It's a time of great change and opportunity for medicine, Henley acknowledged, but change and opportunity are familiar turf for the specialty, which has always served as a counterculture to the medical establishment.

Grasp the opportunity for change, he urged. "How can we make the principles of family practice the center of a new health care system that's better than the one we have now?"

Henley will become EVP on Aug. 1. He will be the first practicing family physician and the first AAFP past president to serve in the position. The AAFP Board of Directors selected Henley to succeed Robert Graham, M.D., who announced last July his intent to leave the AAFP.

Soon after his introduction as EVP-designate, Henley sat down for an interview regarding his vision for the Academy's future. Highlights of the interview appear below.

Bio bits: Douglas Henley, M.D.

Medical school, family practice residency: University of North Carolina, Chapel Hill

Private practice 20 years in Hope Mills, N.C.

Diplomate, American Board of Family Practice

AAFP Fellow

Active in AAFP since medical school

AAFP president in 1995

Served two terms as AAFP Board chair

FP Report: What made you want to become AAFP's EVP?

Henley: My initial goal as a family physician was to come back to my underserved hometown to meet that need, which I did. But in addition, my 23 years as a volunteer in the Academy allowed me to advance the discipline and impact AAFP policies on the national and state level. Becoming the EVP seemed to be the natural next step -- and an opportunity to bring the perspective of 20 years of private practice to the EVP position.

FP Report: What's your vision for the AAFP? What does the Academy need to do in the next several years?

Henley: First and foremost, we have to remain an ethical medical professional organization, putting patients' interests first before our self-interests. If we don't, we lose our credibility and our ethics. Fortunately, what's good for our patients is usually good for us.

Beyond that, the Academy needs to maintain its strong public advocacy, for patients in regard to public health issues and universal coverage, and for our members in regard to what government does to them. I know what it's like to deal every day with bureaucratic red tape. We should do what we can to eliminate some of that.

AAFP has a very diverse membership. We need to better understand them, so we can prioritize what we do for them and enhance the value of AAFP membership. I think we do a good job, but it's a continuously changing health care environment. We need to be proactive.

FP Report: Isn't information technology another area for proactive thinking?

Henley: Definitely. We need to use advances in information technology to communicate with and provide services to our members and chapters. We need to use it to advocate on behalf of the discipline, our members and their patients. We do need to help members use it.

We must help members improve care with electronic medical records, quality improvement, performance measurement and evidence-based practice. These represent huge changes for most members, especially EMR, but ultimately the changes can make their lives easier and their care better.

CME is another area ripe for proactive thinking. We need to determine the best blend for providing CME, including the Internet. And we definitely need to provide CME on genetics and cultural competency. Genetic advances will profoundly change the way we practice. And the country's ethnic makeup will change dramatically in the next 10 to 15 years, while most members already in practice have not had training in how to interact with patients from different ethnic groups.

FP Report: How should the Academy respond to the three-year downward trend in the number of medical students matching in family practice residency positions?

Henley: We need to move beyond blaming the medical school establishment for the downturn. Can we also dare to look within and challenge ourselves? Are we doing something wrong? What is the quality of our residencies, our curriculum? We need to do this to continue recruiting the best and brightest to join us in this specialty we love.

FP Report: You sound optimistic about the future of the Academy and family practice.

Henley: I am optimistic! There are challenges, yes -- but the Academy has the resources, the people, the knowledge and the experience to help this specialty be as good as it can get. And I continue to firmly believe that family physicians, because of their broad training, always will be adaptable to changing times. If you maintain your focus on being a clinically competent physician with empathy and compassion for your patients, you will do well -- and I think FPs do that better than any other specialists.

Aetna, physician groups weigh in on settlement terms

BY SHERI PORTER

It's a done deal in Texas, but a recent settlement between the Texas attorney general and Aetna U.S. Healthcare has raised some eyebrows.

On April 11, Texas Attorney General John Cornyn announced a voluntary agreement with Aetna (http://www.oag.state.tx.us/notice/avc_fin1.pdf) that put to rest a 1998 lawsuit accusing the company of offering doctors financial incentives to limit patient care. Initially, the settlement was touted as a model for managed care reform across the country. But as physician groups and lawyers wade through the 50-page document, comments such as "ambiguous" and "full of loopholes" keep popping up.

For example, the May 8 issue of The National Law Journal points out that under the agreement, licensed medical professionals determine medically necessary care. But patients may be surprised to learn the provision includes Aetna physicians and medical directors in addition to their own doctors.

The article also objects to a provision that deals with the relaxation of Aetna's "all-products" requirement forcing physicians to participate in all of Aetna's health plans even if they want to participate in just one. This is good news for physicians in small practices, but large groups don't have that option.

Kim Ross, chief lobbyist for the Texas Medical Association, said his group has brought its concerns directly to the attorney general's office and to the leadership of Aetna via meetings and conference calls.

"There has been some progress in closing the gap between the language as we read it and the intent of the agreement," Ross said. "We think we can stand down after just a little bit more work with our attorney general."

John Kelly, M.D., Aetna's director of physician relations, said physicians should welcome the agreement because it offers financial protection and helps physicians and patients understand how the company conducts business.

"We chose to sit down with the attorney general to arrive at an agreement that goes way beyond the issues raised in the original complaint," Kelly said.

Some physicians, such as AAFP Director James Martin, M.D., of San Antonio, remain upbeat. Martin sees the settlement as a great start. "It will help me retain continuity of care with my patients, it gives my patients more information in making health care decisions, and the agreement provides avenues to redress perceived wrongs," he said.

Kelly pointed out that Aetna will create an office of ombudsman to assist HMO members in dealing with appeals and complaints. He said the agreement ushers in a new era in managed care.

"We think many of the principles that are embodied in the Texas agreement provide a foundation for some of the adjustments that we're considering for our business practices elsewhere in the country," Kelly said.

But critics argue that the Texas deal can't be used as a national template because the settlement relies heavily on existing Texas law to plug loopholes. In addition, many of the provisions duplicate existing Texas law, leaving some people to wonder why Aetna was not assessed penalties.

Tom Banning, director of legislative affairs of the Texas AFP, said, "To let Aetna off the hook without even collecting investigative costs the state spent on this case amounts to a slap on the wrist. This settlement sends the wrong message to other companies who are violating Texas law."

The AAFP has not officially commented on the Aetna settlement. But Banning said, "This agreement may turn out to be a better deal for managed care than for physicians and patients."

Call to action
Ask senators to defeat pain relief act

Who should decide whether a prescription is for pain relief or the patient's suicide -- a physician or a federal agent? The Pain Relief Promotion Act, now in Congress, calls for training Drug Enforcement Administration agents to investigate prescriptions for controlled substances used at the end of patients' lives and to carry out enforcement actions concerning the prescriptions.

The bill would outlaw physician-assisted suicide. The Academy, which opposes physician-assisted suicide, is fighting this legislation. Why? Because, under the bill, physicians who prescribe needed medicine may be put at risk for civil and criminal investigation and liability.

The House of Representatives approved the bill, H.R. 2260, by a vote of 271-156 on Oct. 27, 1999. The Senate Judiciary Committee heard physicians' outcry over the bill and amended it April 27. But the committee left intact the bill's provisions for training law enforcement officers to review complicated end-of-life decisions.

"The AAFP cannot support legislation that may create an environment in which physicians are fearful of treating their patients appropriately," said the Academy in written testimony to the committee. The bill may soon come before the full Senate for a vote.

Time to act: Call, write, fax or e-mail your senators about H.R. 2260. Let them know what effect the bill might have on your patients.

Easy e-mail: The Academy's online service Speak Out lets you e-mail your senators an adapted version of a letter on H.R. 2260.

Access Speak Out at http://capitol.aafp.org.

For help using Speak Out, go to http://www.aafp.org/gov. Click on "directions for first-time users" of Speak Out and print the instructions as a guide.

Students get dose of health care, humor from family physician

It's not hard to understand why Jay Kravitz, M.D., M.P.H., likes to hang out in schools. Cracking jokes, making fun of himself, spouting wild exaggerations and bursting with energy, he almost seems like one of the kids. But the New York FP strolls the halls with a purpose: meeting the health needs of students and staff.

Kravitz checks eighth-grader Jamiel Pryor's weight and height during a recent visit to Hackett Middle School in Albany, N.Y.

Kravitz, who maintains a private practice in Rotterdam, is employed as the school physician by two school districts. Mohonasen, a small middle-class community with just four schools, contrasts sharply with Albany, a large urban district with 34 buildings, including three high schools. With the aid of his physician assistant and school nurses, he spends about 200 hours a year addressing Mohonasen's health needs, while the Albany district consumes about 20 hours a week.

What's a typical day like? There's no such thing.

One day, he might perform health assessments for new students, meet with a committee to discuss special services needed by a child with a learning disability, serve as a liaison with the media on an E.coli breakout and report on a facility problem that poses a health threat. At the next visit, he might conduct bus driver physicals, meet with a superintendent to discuss a budgetary concern, touch base with the county health department regarding a measles epidemic and spend time in the classroom talking with students.

"Each day is different, and that's the beauty of it because there's so much going on and it's multi-faceted and ever entertaining," said Kravitz, who's been a school physician for about 18 years.

His mission is twofold: Keep everyone healthy, but also show students that health care doesn't have to be intimidating or scary.

Most of his hands-on work comes in the form of state-mandated health assessments at the schools for all new students entering the district. Students are encouraged to get thorough physicals from private physicians, but many never do. "All of the health assessments I do are because, for whatever reason -- finances, timing, the kid didn't take the note home -- the child has not been 'physicaled,'" Kravitz said, lamenting the limited time he can spend with each child and yearning for them to receive high-quality continuity of care. Yet he does frequently identify health problems, such as scoliosis, heart murmurs and skin ailments, and refers children to private physicians.

An enthusiastic class of third graders fires health questions at Kravitz during an "ask the doctor" session at Jefferson Elementary School in Rotterdam, N.Y.

Although the health assessments afford the greatest opportunities to address health concerns head-on, Kravitz wonders whether his interpersonal activities don't have a greater impact. "One of my favorite jobs is to sit in a third-grade class on a chair, and the kids crowd all around and ask me anything," he said. "'Why did my grandpa die?' 'What makes up snot?' Why this, why that? You'd be surprised at the questions you get. I always try to interject a lesson during that conversation. While I'm entertaining them, amusing them, I'm also trying to instill 'wear your helmet, wear your seatbelt, say no to strangers, tobacco and drugs.'"

Kravitz hopes that children will feel more at ease with health care providers after their experiences with him.

"It's something I really enjoy," he said. "There's a certain warm fuzzy you get from it. Admittedly, when you're doing 500 physicals on a Saturday afternoon in the middle of August when everyone's hot and sweaty, it's not a great joy. The real pleasure is the recognition that the kids say 'there's the doctor' when you pass them in the halls, and being able to make a positive impact so they're not scared of their doctor. I wanted to be more than just a campus quack; I wanted to have a real impact."

His advice for other FPs interested in school health employment is: Do your research. Determine how much time you're willing to commit and how much money you need to offset your absence from the office. Kravitz said most community school districts need the equivalent of one morning every other week.

"Recognize that it is a time commitment, and you don't want it to sour because you bit off more than you can chew," he said. "It has to be a positive experience or it just loses all of the quality that makes it so joyous. It's very important to be real with the kids and let them know you're there not as a punishment, but as a resource."

Six risk behaviors pose deadliest threat for youth

Health problems that most often lead to death among people ages 10 to 24 trace back to just six categories of behavior, according to the Centers for Disease Control and Prevention.

These behaviors wreak havoc on the health of young people -- and lead to cardiovascular disease and other health concerns in later years, said Lloyd Kolbe, Ph.D., director of the CDC's Division of Adole-scent and School Health.

"The bottom line is that these behaviors contribute to the most serious health, educational and social problems that we as a nation face," he said.

Here are the risk behaviors and details from the CDC's 1997 risk assessment survey of U.S. high-school students (1999 data will be available this summer):

Tobacco use -- Every day, nearly 3,000 young people take up daily smoking. Seventeen percent of students said they smoked cigarettes on 20 or more days during the past month.

Unhealthy dietary behaviors -- Almost three-fourths of high schoolers don't get the recommended servings of fruits and vegetables each day, and 40 percent are trying to lose weight.

Inadequate physical activity -- Daily participation in physical education classes has dropped to 27 percent, and most students report little physical activity on a regular basis.

Alcohol and other drug use -- More than half said they drank alcohol during the past month, and more than a quarter reported using marijuana during the last month.

Sexual behaviors that can result in HIV infection, other sexually transmitted diseases and unintended pregnancies -- Every year, almost 1 million adolescents become pregnant, and about 3 million become infected with an STD. Almost half of high schoolers said they've had sexual intercourse.

Behaviors that may result in intentional injuries (such as violence and suicide) and unintentional injuries (such as motor vehicle crashes) -- Nineteen percent of students said they never used safety belts, 37 percent reported riding with a drunken driver during the past month and another 37 percent had been in a physical fight during the past year.

Studies show that societal institutions have a powerful influence on youth, Kolbe said. Families, schools, religious and community groups, media, employers and government could make a major impact by working together to spread a common message: Reduce risk behaviors.

That's where FPs come into the picture. Kolbe urged family physicians to get involved at the office, in schools, in the community and in legislatures.

Youth pay attention to their physicians' advice, he said. They may not act on it the first time, but they hear what you're saying.

"Family physicians can also counsel family members on how to address risk factors and can be enormously persuasive with other organizations," Kolbe added. "Decision makers really do listen to family physicians."

Want more information on school health?

Read about the CDC's adolescent and school health initiatives online at http://www.cdc.gov/nccdphp/dash/. Link to details on federal efforts to address youth risk behaviors and school health funding opportunities.

Here are some AAFP resources to help you get involved in adolescent health in your community. Call (800) 944-0000 to order unless otherwise indicated.

Academy policies on adolescent health care. Visit http://www.aafp.org/x6613.xml on the AAFP Web site. Follow links to policies on school-based health clinics and health education.

2000 Family Health Month kit. October is Family Health Month, and this year's theme is communication. Research shows that teens want their parents and other adults to talk to them about tough subjects such as drug use, sex and eating disorders. The kit (item #R039) includes everything you need to promote Family Health Month in your community. $20 for members.

Stand Up & Speak Out to Teens! This kit will help you present speeches to adolescents on alcohol abuse, tobacco, sexually transmitted diseases and mental health. Item #R047, $50 for members.

Stand Up & Speak Out to Teens! brochures. These new brochures were written for young people and complement the Stand Up & Speak Out! speeches. Topics are: alcohol (#R090), stress (#R091), eating disorders (#R092), tobacco (#R093), sex (#R094) and STDs (#R095). Package of 100, $25 for members. See brochure content online for free at http://www.health4teens.org.

Tar Wars. Reaching children with an anti-tobacco message early on has the best chance of keeping them tobacco-free. Tar Wars features an established interactive curriculum for fourth- or fifth-grade classrooms. Call (800) TAR WARS or visit the Web site at http://www.tarwars.org.

School Health Survey
- (a printable PDF file to complete and mail or fax to AAFP)

Volunteer reviewers needed
National project to craft online resource

Participants in the Health, Mental Health and Safety in Schools project have done their homework. Now they're ready to share findings with the rest of the class.

The four-year project -- sponsored by the American Academy of Pediatrics and the National Association of School Nurses and supported by a grant from the Maternal and Child Health Bureau -- aims to develop a comprehensive online resource of national guidelines to promote student health and safety. Four family physicians and an Academy staff person are participating.

Lani Wheeler, M.D., a pediatrician and one of four project chairs, said school health coordinators currently don't have easy access to information that would help them evaluate their services. The compendium ultimately will assist schools in justifying state funding for programs, help parents working for safer playgrounds or more school nurses, and provide information that advocates will need to prove the value of appropriate school health services. "We hope that it will result in children being healthier and more ready to learn," she said.

The project features 14 panels with representatives from health care, law enforcement, education, social work, community leadership and families. Each panel is collecting information on a specific facet of school health.

FPs Jay Kravitz, M.D., M.P.H., of Rotterdam, N.Y.; Lily Ning, M.D., of Honolulu, Hawaii; and Penelope Tippy, M.D., of Carbondale, Ill., serve on panels, and Jeannette South-Paul, M.D., of Bethesda, Md., and Barbara Widmar, AAFP health education manager, are central steering committee members.

South-Paul said up to 50 percent of school doctors are FPs. "We have a much broader perspective on health of the family," she said. "We know that kids don't function in a vacuum. They are a reflection of what's going on at home. And because we see the other members of the family, that's something that we can be aware of."

South-Paul said she's been pleased with the level of collaboration among the various groups despite the dizzying array of perspectives and agendas. "Almost more important than the final product is the teamwork, the discussions," she said. "It's not every day that you get physicians, educators and policemen sitting together to talk."

Draft guidelines should be available later this year, and project organizers need volunteers to review them. If you're interested, contact Lydia Bologna at (847) 981-4980 or by e-mail at hmhss@aap.org.

School-based health centers provide safety net for adolescents

Adolescents are the only age group in the United States with rising death and disease rates. Many engage in behaviors with serious health risks while clinging to their privacy and autonomy -- a combination that causes youth to fall through cracks in the health care system.

One solution is to catch kids where they fall: at school. Holley Galland, M.D., on the faculty at the Louisiana State University family practice residency in Baton Rouge, said school-based health centers can provide preventive services, ongoing treatment and counseling to youth who otherwise might not get appropriate health care.

"These centers were started to give kids access," said Galland, medical director for Health Care Centers in Schools, a not-for-profit organization that operates the eight centers in her area. "School-based health centers are often located in the areas where the need is greatest, so the kids come from families where they might not have someone at home to supervise; they might not have insurance."

An estimated 1,300 schools across the country house health centers for students and families, and more than half the states provide support for school-based health centers, according to Making the Grade, a grant program that supports community-state partnerships to establish the centers. The program's Web site (http://www.gwu.edu/~mtg/sh/intro.htm) spells out common features of comprehensive school-based health centers:

Holley Galland, M.D., examines a patient at a school-based health center.

They are located in schools.

Parents must provide written consent for children to enroll.

An advisory board of community representatives provides oversight.

Centers work cooperatively with school nurses, counselors, coaches, teachers, principals and staff to ensure the health center is an integral part of school life.

A qualified health provider (hospital, health center, health department, group medical practice, etc.) takes responsibility for providing clinical services.

A multidisciplinary team of nurse practitioners or nurses, clinical social workers, physicians and other health professionals cares for students.

Centers provide a comprehensive range of services that meets the health needs of young people in the community.

Galland said the centers offer plenty of opportunities for FPs to get involved. "The wonderful thing about school health centers is they're a microcosm of family medicine," she said. "Kids usually come for acute medical problems, mental health crises or relational problems -- everything from fighting to not getting along well with their parents. They come in with a vague generalized problem, and you can help pinpoint it. So often a child will present with a stomachache, but it's really a psychosocial issue."

One of the toughest challenges is keeping parents in the loop, particularly when they work several jobs, abuse substances or just don't take an interest, Galland said. "We have parent liaisons to make sure parents are involved. They know where parents can go when we're closed. And I call or write a parent note for about 50 percent of the children I see. At the elementary level, we try to have a parent there for the first visit to the center."

Although critics of school health centers bemoan the lack of a personal physician, Galland said her centers strive to reinforce existing doctor-patient relationships and provide primary care for adolescents without physicians of their own. "It's very important to have a link with an ongoing primary care provider. If they have doctors, we try very hard to make sure they go to those doctors; we stay in touch with those doctors," she said. "The last thing we want to do is sever a good relationship with a doctor.

"But we also offer continuity, screening, immunizations, acute and chronic care, collaborative care with mental health providers and patient education. These are all things we focus on."

Residents head back to school for training in adolescent health

After eight years of college and medical school, many family practice residents are clamoring for more time in school. But this time around, they're heading to elementary, middle and high schools to learn more about adolescent health and provide community-based care for children.

Elizabeth Feldman, M.D.
"We're really focused
on health career training
in a broad way."

Since 1996, residents at the Ravenswood/University of Illinois Family Practice Residency in Chicago have trained in school-based health centers, said Elizabeth Feldman, M.D., medical director of the Ravenswood School-Based Health Center Initiative and assistant clinical professor in the UIC family medicine department. The program sponsors two health centers in high schools bordering poor inner-city neighborhoods.

"The mission was not only to provide good-quality health care to adolescents in a way that was accessible for them, but also to provide the training site for family practice residents so they would have a lot of exposure to the types of issues that adolescents bring," said Feldman, who is collaborating with other FPs to draft curriculum guidelines for residency training in adolescent health.

Residents work with physical therapists, nurse practitioners, psychologists and other health care providers, as well as students, interns and residents in various fields and specialties. "We're really focused on health career training in a broad way," Feldman said. "The residents see the multidisciplinary team in action. In the schools, the NPs run the show. The doctors are less important, which is just fine for giving the FP resident a dose of humility."

In their first year at Ravenswood, residents spend half a day each week at one of the centers during the pediatrics rotation. "That's a small amount of time, but it's enough for them to get a flavor of community-oriented medicine," said Feldman. The focus is on taking a thorough health history, improving communication skills and helping teens make informed lifestyle decisions. Residents also learn about confidentiality and what types of care require parental consent.

In year two, residents work in the centers for half a day each week during the pediatrics and community medicine rotations. They start providing more care on their own with input from a preceptor and other team members.

In the third year, residents spend three or four half-days in the centers as part of the adolescent medicine rotation. They get more autonomy in directing care and may have more involved cases such as sports injuries or prenatal care, Feldman said. "We work hard to make sure the residents get interesting patients and have time to get to know the kid."

The residency is adding opportunities for even more hands-on experience with youth. Starting in July, a third-year resident will spend half a day each week in a school health center for six to 12 weeks, developing her own patient panel. And starting next year, a resident will work with a clinical psychologist to co-facilitate a group that helps boys confront anger and learn conflict resolution skills.

The health centers and supplemental materials offer residents greater insight into adolescent health than traditional models do, said Feldman. "I think the residents are realizing what an artificial environment it is when they see an adolescent for care in their office. The school is where the kid lives; it's comparable to doing a home visit."

Involving residents in school health is a growing trend in family practice residencies, according to Deborah McPherson, M.D., AAFP Medical Education Division assistant director. "School nurses are so overburdened now that it's a great opportunity for partnership," she said.

In addition to working in school-based health centers, residents are presenting health education programs in the classroom, serving as team physicians and acting as mentors for youth, she said. An added benefit: Adolescents interacting with residents may also be inspired to pursue medicine as a career.

Gifts to physicians from industry
Sidestepping an ethical quagmire

BY CINDY McCANSE

It's a familiar refrain but one that bears repeating: Physicians should be cautious about accepting gifts from industry.

Norman Kahn Jr., M.D., left, vice president for education and science, talks with attendees at the AAFP Annual Leadership Forum session on ethical guidelines.

That's the word family practice leaders received in a breakout session at this year's AAFP Annual Leadership Forum in Kansas City, Mo. Facilitators Norman Kahn Jr., M.D., vice president for education and science; Clayton Hasser, vice president for publications and communications; and David Baldwin, CME accreditation manager, used case histories to drive home their message about interactions between physicians and pharmaceutical interests.

"The point of being here today is to re-acquaint you with the ethical guidelines," said Kahn at the April 28 session. "It's easy to say that if you're ethical, you're good, and if you're unethical, you're bad. But let's wallow around in that middle area. We have to struggle with these issues."

Consider the following scenario:

A pharmaceutical firm invites physicians to a southern resort for a three-day consultant's conference. Participants arrive on Friday. The clinical program Saturday morning features two 45-minute didactic presentations, a one-hour discussion of case studies and a one-hour consulting session. Saturday afternoon is devoted to recreational activities, with choices ranging from golf to a manicure and pedicure. Departure is on Sunday. Each physician receives a $500 consulting fee. The program sponsor pays lodging and air travel.

Is this an ethical arrangement? Probably not. What if the consulting period were increased to three hours? Seems better, doesn't it?

According to guidelines developed by the AMA's Council on Ethical and Judicial Affairs in response to increased federal scrutiny of gift-giving activities, a couple of issues still must be addressed before an ethical green light can be given in this case.

AMA's "Gifts to Physicians from Industry" reads, in part, "It is appropriate for faculty at conferences or meetings to accept reasonable honoraria and to accept reimbursement for reasonable travel lodging and meal expenses. It is also appropriate for consultants who provide genuine services to receive reasonable compensation and to accept reimbursement for reasonable travel, lodging and meal expenses. Token consulting or advisory arrangements cannot be used to justify compensating physicians for their time or their travel, lodging and other out-of-pocket expenses."

Physicians must examine their personal motives as well as those of the sponsoring entity in such cases, Kahn said. Does the physician have sufficient expertise to qualify as a bona fide consultant?

Also, physicians should be on guard about the type of input solicited and how it will be used, particularly in situations in which a sponsor asks for feedback on a new drug or medical device, Hasser said. "If they're in the late stages of a marketing campaign, they're probably not going to really listen to what you have to say."

Another potential ethical problem with this scenario is the value of the social activities. The AMA guidelines stipulate that such activities be of modest value, generally defined as no more than $100.

This is only one example. Far more common are office visits from pharmaceutical representatives offering free samples and industry support for CME programs. As much as physicians may protest that they emerge from such marketing barrages unscathed, recent literature paints a different picture.

A study in the Jan. 19 Journal of the American Medical Association found that physicians' dealings with pharmaceutical companies do change their prescribing and professional behaviors. Although the type or degree of behavior change varied according to the specific interaction, overall, physicians were more likely to prescribe the company's drug regardless of any demonstrable benefit over similar drugs and more apt to request that it be added to their hospital's formulary.

Patients often view such interactions as inappropriate. A study in the March 1998 Journal of General Internal Medicine found that more than one-third of patients surveyed believe acceptance of any industry gift obligates a physician to prescribe that company's drug.

As one session attendee said: "All you have to do is think of how this would look on 60 Minutes if Mike Wallace were talking about it."

Review the AMA guidelines at http://www.ama-assn.org/cmeselec/cmeres/cme-6.htm.

Ethical? Or not?

Each of the following scenarios is followed by comments regarding whether it’s ethical according to the AMA Council on Ethical and Judicial Affairs "Gifts to Physicians from Industry" guidelines:

Speakers Bureaus

Scenario: A pharmaceutical firm offers a speaker training workshop in Palm Beach, Fla. Travel and hotel expenses are covered, and each participating physician receives a $1,000 honorarium. The workshop focuses on a product promoted by the sponsoring company.

Comments: In general, physicians who are being trained as speakers or faculty for educational conferences and meetings may not accept travel expenses from industry. If a physician is presenting as a so-called independent expert at a CME event, the fact that this type of training has been provided and the physician reimbursed for travel and lodging raises questions about the physician’s independence. In this instance, the training itself represents a gift because the physician’s role is generally more analogous to that of an attendee than a participant, and the offer of an honorarium is clearly inappropriate. (Note: Speaker training sessions are distinctive from consultative meetings with leading researchers that are funded by industry and designed primarily for an exchange of information about important developments or treatments — including the sponsor’s own research — for which reimbursement of travel expenses may be appropriate.)

In a similar vein, if a company invites physicians to visit its facilities to become educated about one of its products, travel expenses should not, in general, be reimbursed. Physicians should consult with their medical specialty society regarding the appropriateness of travel reimbursement in cases in which it is clearly more practical for the physician to make an on-site visit, such as when a large piece of medical equipment is the focus of attention, or in cases in which the company insists on such visits as a means of protection from liability for improper usage. In no case would honoraria be appropriate, and any travel expenses incurred should be only those that are strictly necessary.

Gifts

Scenario: A pharmaceutical company mails an invitation to physicians to attend a speaker clinical discussion on the role of maintenance drugs in the treatment of a common disease entity. There will be a 40-minute presentation by a thought leader followed by a 20-minute question-and-answer session. For their participation, physicians will be mailed a $100 gift certificate to be redeemed for a medically relevant item.

Comments: Gift certificates fall into a gray area that is not per se prohibited by the AMA Council on Ethical and Judicial Affairs guidelines. Medical textbooks are explicitly approved as gifts under the guidelines. A gift certificate for educational materials — that is, for the selection by the physician from a catalog composed exclusively of medical textbooks — would not seem to be materially different. The issue is whether the gift certificate gives the recipient a sufficient level of control as to make the certificate similar to cash. Cash payments should not be accepted. Preselection by the sponsor removes any question.

Physician Groups

Scenario: A pharmaceutical company provides a grant to a large physician group for an electronic medical records system. Such a system will obviously provide the practice with numerous benefits, including the ability to generate printed, rather than handwritten, prescriptions. The system will also be programmed to track the number of prescriptions written by physicians according to their therapeutic and product categories and report that information back to the pharmaceutical company.

Comments: No gifts should be accepted if there are strings attached. For example, physicians should not accept gifts if they are in any way related to the physician’s prescribing practices. All that said, it is doubtful that the monetary value of such a grant would fall under the $100 limit set by the AMA’s "Gifts to Physicians from Industry" guidelines.

IMGs make the most of new forum status

We want it all, and we want it now," someone hollered as physicians participating in the new international medical graduates forum gathered to talk strategy at the National Conference of Special Constituencies April 27-29 in Kansas City, Mo.

The tongue-in-cheek remark wasn't a battle cry, but it did reflect the frustration of a group that represents almost 15 percent of AAFP's membership and yet was meeting as a forum for the first time. In the past, IMGs submitted their resolutions to the conference via other constituency groups. This time, they could submit resolutions as a group.

Ben Oteyza, M.D., right, of Bel Air, Md., drives home a point during the IMG forum while Bharat Patel, M.D., of Williston, N.D., listens.

Ben Oteyza, M.D., of Bel Air, Md., said he attended his first conference in 1993 -- and the same issues were being discussed in 2000. "I'm tired of baby steps," Oteyza said. The Congress of Delegates in Orlando last year decided that IMGs should have a forum at NCSC, when what they really wanted was a caucus, he said. "Well, we're here, and we're going to fight."

What are members of the IMG forum fighting for? They want that caucus status and slotted seats in the Congress.

Lee Hawkins, manager of AAFP's special constituency department, understands the IMGs' restlessness. "They want the same parity as the other groups (women, minorities and new physicians) -- that's their big push and always has been. They believe everything else will come when they get the seats," he said.

The IMGs worked diligently at NCSC, eventually submitting 10 resolutions, seven of which were accepted and forwarded to the Board of Directors for consideration by the Board or Congress of Delegates.

Virgilio Licona, M.D., of Denver is happy that IMGs are taking advantage of what he sees as a window of opportunity. Licona, who serves on the Commission on Legislation and Governmental Affairs, said, "I'm absolutely thrilled with the level of participation and the positive fashion in which physicians contributed to the forum."

What role will FPs play in the genetics revolution?

BY CINDY McCANSE
Lake Buena Vista. Fla.

Patients with genetic disorders need a physician who can both treat their everyday health problems and apply the latest research findings to meet their special needs. In other words, they need someone like a family physician, said genetics researcher Holmes Morton, M.D.

Morton came to Strasburg, Pa., more than a decade ago to translate his genetics work into applied pediatrics. He chose an isolated setting and, with the aid of its Amish and Mennonite communities and others, created the Clinic for Special Children.

Morton gave the Blanchard Memorial Lecture at the May 3-7 Society of Teachers of Family Medicine annual spring conference. He told nearly 1,000 physicians of his experiences since leaving Johns Hopkins University in Baltimore to care for a rural population disproportionately affected by genetic disorders due to a tradition of intermarriage.

Morton said that in many ways, these patients are little different from any others: "We have children coming in with ear infections, with vomiting and diarrhea, with all those curses of childhood that you struggle with."

The difference lies in limiting the effects of these common ailments on the genetic condition, he said. "Those illnesses have a tremendous impact on an underlying disease such as maple syrup (urine) disease. You must control the underlying biochemical disorder in the context of primary care illnesses or those children lapse into coma, suffer neurologic injury and are disabled."

"It always surprises physicians when I say that of the 60 to 70 disorders I've seen in the past 12 years in Lancaster, I consider them to be no less treatable than what you see every day in your office," Morton said. He bases this on a survey he did that's similar to one done by the author of the classic resource Cecil Textbook of Medicine in 1929. Russell Cecil surmised that about 20 percent of disorders known at the time were invariably fatal, 20 percent were easily treatable and the remaining 60 percent required extensive management to effect a positive outcome. Those same proportions, Morton said, apply to the genetic problems he works with.

"About 20 percent are lethal; there's nothing I can do," he said. "But these children, regardless of the fact that they may only live six or 12 months or two years -- they still have problems. They still get ear infections, they still get colds, they still have fever, they still need care."

But he focuses most efforts on that middle 60 percent of patients.

"Caring for a child with maple syrup disease is hard work," he said. "It requires a level of care -- a level of understanding -- that is very similar to care of a child with diabetes. With good care, access to care during intercurrent illnesses, early detection and access to hospital care when needed, we can tremendously limit the effect of that disease on the child's life."

Ultimately, Morton said, recognition of disease by primary care physicians is the key to helping patients with genetic disorders. "It requires a physician who cares for them, knows them and brings them to the attention of physiologists who know about these systems. It requires a physician who helps translate the information these researchers have into meeting the needs of the child. That's my role, and that's your role, too."

In a later breakout session, family physician Nancy Stevens, M.D., M.P.H., stressed the importance of injecting the family practice perspective into genetic medicine.

"We really need to get into the dialogue of genetics as quickly as we can because our perspective is underrepresented in these conversations, and as a result, our patients' perspectives are underrepresented," said Stevens, a faculty member at the University of Washington.

Stevens described her work on an expert panel convened by a Washington state HMO charged with creating guidelines for BRCA1 gene testing. Mutations in the BRCA1 gene have been associated with hereditary breast/ ovarian cancer syndrome. During her tenure on the panel, Stevens came to realize that the usefulness of this testing is severely limited because the "cure" may be worse than the disease.

The only patients who stand to benefit from BRCA1 testing are those from high-risk families in which a family member has cancer caused by the gene mutation. If the individual gets tested and doesn't have the defect, the risk is dramatically reduced. "That," Stevens said, "is a useful test. But if you go through the testing and you have the gene, then you're really in trouble because nobody knows what to do."

Currently, the only management strategy for women who test positive is prophylactic removal of the breasts and ovaries. Even then, there's no guarantee that cancer won't develop -- just as there's no guarantee that it will.

"Why do we want to prevent the cancer?" Stevens asked. "So these women will have a life. But what if they lose their chance for a reproductive life? What if you do the testing in a 19-year-old woman and it's positive? There's a lot of life between then and the time when she might develop cancer."

Maine residency helps Vietnam develop specialty

The family practice department and residency of the Maine Medical Center in Portland have consulted with the Socialist Republic of Vietnam Ministry of Health since 1995 and have led train-the-trainer and curriculum sessions at Vietnam's three medical schools. One faculty member from Ho Chi Minh City University is taking a family practice fellowship at Maine Medical Center now, and another will come next year.

How will the Physicians With Heart project in Vietnam bolster this effort? "AAFP's model for teaching family medicine will be invaluable in continuing to educate Vietnam's physicians and educators about family medicine," says Alain Montegut, M.D., of Brunswick, Maine. "The medical products -- which we hope will include small medical equipment, supplies and pharmaceuticals -- will go in part to the family practice centers to assist in their development and further the work of the new family physicians." The training of family physicians in Hanoi, Ho Chi Minh City and possibly Thai Nguyen is slated to begin next February.

"Over the years, many AAFP members have asked Physicians With Heart to go to areas in addition to the former Soviet republics," says Daniel Ostergaard, M.D., AAFP vice president for international and interprofessional activities. "Vietnam wants to change its health care structure and develop competent generalist physicians, and it is already working with AAFP members. The Vietnam project is a great opportunity to further our goal of developing family practice around the world."

Airlift to help Vietnam in 2001

Twenty-five years after the Vietnam War, Physicians With Heart is embarking on an effort to improve health care and promote family practice in the Southeast Asian nation. Early next year, Physicians With Heart will bring donated medical products and CME sessions to the medical sites of three new family practice residencies: Hanoi, Ho Chi Minh City and rural Thai Nguyen in northern Vietnam.

Since 1993, Physicians With Heart -- a project of the Academy, the AAFP Foundation and the humanitarian organization Heart to Heart International -- has airlifted donated medicine and medical supplies to republics of the former Soviet Union. These annual airlifts, supported in part by the U.S. State Department, will continue.

The AAFP Foundation aims to raise $50,000 through its international fund to augment funds and logistical support from Heart to Heart for the Vietnam project. To contribute, call Sandy Panther at (800) 274-2237, Ext. 4450.

If you'd like to join the early 2001 journey to Vietnam -- or the Oct. 6-15, 2000, airlift to Azerbaijan, a former Soviet republic -- contact Maya Singh at msingh@hearttoheart.org or (405) 787-5200.

Student preceptors

To the editor:

This letter responds to the article "Can Students Add Value to Your Practice?" in the April FP Report. The article reports the proposals of Drs. Kallenberg and Schwenk regarding "mak[ing] the most of students while teaching them." They present possible activities for preceptors to assign to their students.

What is concerning about a good number of the proposals is their similarity to the dreaded "scut work," which the medical institution has so greatly striven to eliminate. What is more, these same proposals do well to assist with revenue generation for the preceptor, but appear at first glance to fail in providing a meaningful education to the medical students in their charge.

The desires of the preceptor to educate students while cultivating a thriving practice must be met. However, when one of these desires overtakes the other, someone loses out, be it the patient or the student. I applaud the attempts to rectify this situation, and I also feel that many of these proposals have tremendous potential if altered. For example, rather than finding and organizing patient education materials, students could synthesize materials based upon literature searches and preceptor input. In addition, students could provide valuable education to patients regarding their medical conditions.

The balance of patient care, private practice and medical education is often a difficult one, but with the combined efforts of practitioners, patients and students, it is quite attainable.

Eric Anderson, M4
Coralville, Iowa

Judge preserves primary care gains, dismisses lawsuit

A judge's action April 14 maintains the 2000-01 shift of about $495 million from Medicare payments for hospital-based services to payments for office-based services.

Chalk one up for primary care.

Judge Ann Williams dismissed a lawsuit that sought to make the base year 1991 or 1997, instead of 1998, for calculating Medicare payments for practice expenses.

In 1998, primary care received a $330 million "down payment" on resource-based practice expenses. Formerly, Medicare covered practice expenses according to historical charges, which favored hospital-based services. The new resource-based system better reflects costs for expenses such as staff, equipment and overhead.

Because Medicare fee changes must be budget neutral, more pay for some services means less for others. On Nov. 2, 1998, the Health Care Financing Administration proposed 1998 as the base year for the gradual transition to full RBPE implementation by Jan. 1, 2002. Eleven subspecialty groups objected to 1998 as the base year, suing Donna Shalala, Ph.D., secretary of the Department of Health and Human Services. The Academy and the American College of Physicians-American Society of Internal Medicine led office-based societies in supporting HCFA with an amicus brief.

"The judge's decision is a big victory for family medicine," says AAFP Board Chair Lanny Copeland, M.D., of Albany, Ga. "The court confirmed what Congress has intended all along: a fair transition to higher pay for primary care."

Williams dismissed the case on a technical issue, saying the law precludes judicial review of relative value units in the Medicare fee structure. She also criticized the merits of the case and defended Shalala. "The (RBPE) transition formula used was a reasonable interpretation of an unclear statute and is, therefore, not (as the suit charged) arbitrary, capricious, an abuse of discretion or contrary to law," Williams said in her ruling for the U.S. District Court for the Northern District of Illinois, Eastern Division.

Family physicians' Medicare income will be about 2 percent higher in 2000 and another 2 percent higher in 2001 than it would have been if the subspecialists' suit had succeeded.

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

"Family Physicians in Emergency Medicine" explores controversies related to FPs' provision of and credentialing for emergency care. For this position paper, go to http://www.aafp.org/x6777.xml or request #R742, free.

"Improving Care for Major Depressive Disorder" outlines steps you can take to help your patients battle depression. Request item #R744, free, or go to http://www.aafp.org/quality.xml and click on "Quality Projects" for this quality improvement module and links to other resources.

Proven value: You probably received the AAFP Scientific Assembly brochure by mail recently; if not, call (800) 944-0000. New this year: "Interactive Geriatrics," "Ask the Computer Expert," and free three-hour courses and career consultations. Bring your guests to these evening sessions: "Inside the Tobacco Industry," related to the movieThe Insider, and "Musical Medical Education for Adolescents." Register for the Sept. 20-24 meeting in Dallas by mail, fax or at http://www.aafp.org/assembly/2000. To save $80, register before June 28.

Proven value: The Fundamentals of Management Program is now open to practice, group or health care organization leaders accompanying AAFP active members. The program includes a 3 1/2 day training course, a mentored project you'll use in your work, and advanced course work at the 2001 Scientific Assembly. For more information, call (800) 274-2237, Ext. 4114, or visit http://www.aafp.org/fom. Free brochure, #R722.

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

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