July 2000 • Volume 6 • Number 7
Share views online during 'Keystone III'
Specialty will assess itself, brainstorm possibilitiesBY JANE STOEVER
The specialty's leaders are convening a think tank, "Keystone III," to take stock of the present and grapple with the future.
They want your views, too. You can read papers for the Oct. 4-8 meeting on the days they're presented and respond online.
The meeting at the Cheyenne Mountain Conference Resort outside Colorado Springs, Colo., follows in the footsteps of Keystone I and II, held in 1984 and 1988 at Keystone, Colo. Gayle Stephens, M.D., of Birmingham, Ala., created the early Keystones as times of meditation in the mountains, times for family physicians to stimulate each other's thinking, provoke each other, inspire each other.
Keystone III, at the meeting and online, will ask:
- Is where we are where we were going?
- What is the domain of family practice (scope, role and function)?
- How should family physicians care for patients in the context of family and community?
- How does a changing country change family practice?
- What can technology do to and for family practice?
- What is the science base of family practice, and how will it be developed?
- How are family doctors agents of political and social change?
- What opportunities have we missed, and what bad deals have we made?
- What does family practice need to do next?
"We'll examine the soul of the discipline of family medicine," says AAFP Executive Vice President Robert Graham, M.D., who will serve as convener during Key-stone III and edit its proceedings.
"If we don't attend to our own evolution, no one will do it for us," says Stephens. "The natural evolution of medicine in the United States will not be, in and of itself, supportive of things family practice stands for. We don't 'own' any part of the body or any machines that give us identity. Our identity is connected to our patients, our communities, our role -- a front-line, communicative role. It's hands-on. It's hard to delegate. Our deepest meaning is in the personal dimensions of medical care and helping patients deal with the way their lives are affected by their medical problems."
Family physicians know when people are suffering because they don't have health insurance or because the health system is hard-nosed and oppressive, says Stephens. "Even though family practice, from its unpromising beginnings, has become the second-largest U.S. specialty and has political strength, the problems in medicine have multiplied, and we're at the mercy of what's out there."
The Society of Teachers of Family Medicine is managing logistics for Keystone III, and the AAFP Center for Policy Studies in Family Practice and Primary Care is coordinating the program. About 80 persons will attend the meeting, including 40 chosen by lottery from applications submitted last month. For more information, see http://www.aafp.org/keystone.
Chapters tell states
Use tobacco settlement funds for healthBY SHERI PORTER
When Illinois Gov. George Ryan announced a recent town hall meeting and invited citizens to speak their minds, FP Christine Petty, M.D., grabbed the chance. She marched to the microphone to voice her disapproval of the state's recently passed 2001 budget that targets 53 percent ($760 million) of the state's initial tobacco settlement money for property tax relief.
"I think that it's an absolute misuse of the tobacco money," Petty, president of the Illinois AFP, told FP Report. Her statement at the May 4 meeting -- that Illinois has an obligation to use tobacco money for health purposes and smoking prevention -- brought a round of applause from the audience of 300.
Petty, of Rockford, Ill., promises to go back and fight for more money in next year's budget. "The more people we can get involved, and the more people we can get talking to our legislators, the more likely the tobacco money will be spent in the proper way," said Petty.
Christine Petty, M.D., questions Illinois Gov. George Ryan about the allocation of tobacco settlement money at a town hall meeting.
Petty's action exemplifies the way AAFP chapters are bending the ears of their state officials. John Jordan, executive vice president of the Pennsylvania chapter, said his chapter dogged the legislature relentlessly. "We testified in six hearings," he said.
When PAFP leadership and members testified before a committee of the state legislature, they went prepared with handouts tailor-made for the committee. "There's no doubt that the legislative body knows our position on tobacco," said Jordan.
Laura Hahn, Indiana AFP's director of government relations, said she made sure that members were informed. "We did some fax blasting to our membership about calling our legislators, and we provided them with background information on the pending legislative bill," Hahn said.
Hahn said coalition-building helped the cause. The combined voices of the IAFP, Indiana State Medical Association, Indiana Primary Healthcare Association and others helped drown out the appeals of other groups "that came out of the woodwork in hopes that they would receive some of the money," she said.
Mississippi AFP President-elect Tim Alford, M.D., of Kosciusko recently learned that 20 FP residencies will be funded through interest earned on Mississippi's share of the money, which totals $4 billion.
"We knew it wasn't quite manna from heaven; we knew we had to do some work to make it a reality," Alford said. "One of the things we did was keep our ear to the ground -- so when this bill about funding residencies got dropped in, our chapter swung into action. We immediately alerted our membership to contact legislators asking them to support this bill."
The state has allotted up to $25,000 per year per resident for the next 10 years.
Alford couldn't be happier. "Since FPs are the best trained to advocate against tobacco, who else would you rather put on the battlefield than a family physician to fight that cause?" he asked.
Opportunity in midst of chaos
BY PAULA BINDER
AAFP Executive Vice President Robert Graham, M.D., will leave what he calls "the best job in medicine" in August, when new EVP Douglas Henley, M.D., joins the Academy staff. What's ahead for the specialty? What has the AAFP accomplished on Graham's 15-year watch? Graham discussed these and other issues with FP Report recently.
FP Report: What are the biggest challenges -- and opportunities -- yet to come for the Academy and family practice?
Graham: The biggest challenge is that we serve a membership and a public that are struggling to deal with a health care system that can be fairly described as dysfunctional. And it's not clear that the path of evolution today is necessarily toward a better system. Of the four major participants -- purchasers, third-party intermediaries, providers and patients -- not a one of those interests is satisfied, and not a one has confidence that tomorrow is going to be better than today.
But there's an opportunity in the middle of this.
What our members do for and with their patients is really the heart of what the health care system is supposed to be about: They provide support, care and cure. Get that transaction right. Make sure patients continue to have confidence that they have access to that sort of care. Then build the rest of the system around that, making sure every American has a personal physician -- that's the opportunity the Academy has.
FP Report: Has there been a favorite moment of yours as EVP -- or a most challenging moment?
Robert Graham, M.D.:
"We serve a membership and a public that are struggling to deal with a health care system that can be fairly described as dysfunctional."
Graham: Nothing jumps to mind as a particular moment of agony or triumph. Instead, I think one of the successes of the organization is our steady progress along a number of fronts. For example, in a 10-year period we have essentially become wired, but it's been done in a stepwise, steady fashion. We have a tremendously active Web site, with participation by members and the public.
We've also expanded our Washington presence. This has fostered a sense within the Washington policy community and our peer medical associations that the Academy is a central player on health services issues.
There have been significant moments when I've watched the Board vote and felt they adopted something very important. That's the way I felt when they approved the conference for special constituencies and placed representatives of women, minority and new physicians in the Congress of Delegates. That's the way I felt when they decided to play a strong advocacy role in universal coverage. And that's the way I felt when they decided to take the financial risk and launch Family Practice Management.
FP Report: What comes next for Bob Graham?
Graham: I'll spend the next nine months on a structured sabbatical, with 20 hours a week as a scholar in residence at the AAFP Center for Policy Studies in Family Practice and Primary Care in Washington. I also plan to do a lot of reading on core competencies for leaders of organizations in chaotic times, such as right now.
And I'll run more. I'll see if I can get back into shape and maybe become age-group competitive.
FP Report: What about your legacy as EVP? What would you want members to remember you for?
Graham: I don't think CEOs define their own legacy, but I would hope people would say, "You really used good organizational development practices." The AAFP has come to be a learning organization. And we've developed a huge depth of talent among members and staff to do the daily tasks and to make the big decisions.
When I talked to the AAFP Congress for the last time as EVP last year, I wanted to make sure they understood this is the best job in medicine, and the reason is the people you work with, on the member and staff sides, and the values they pursue.
I want members to know how tremendously important it is that they write that dues check each year, in terms of our validity as an advocacy organization that's able to speak for some 89,000 members.
And I want them to know there are lots of people in this building in Kansas City who really care about what's going on in their professional lives. The focus in this building is on our members and the patients they care for.
Get aboard the e-train!
A record number of participants -- almost 3,700 -- attended the Medical Record Institute's TEPR: 2000 (Toward an Electronic Patient Record) conference May 9-11 in San Francisco, but it was the full house of folks at one specific class that spoke volumes.
"Learning to Fly: Pragmatic Computing" -- a basic course -- had most everyone completely enthralled.
"Not long ago, we had few people in these classes, and they looked bored," said FP John Bachman, M.D., of South Rochester, Minn. "Now they're saying, 'Give me more. I need this stuff.' The attitude has changed."
Family physician John Bachman, M.D., held near constant vigil in the tech court at the recent TEPR: 2000 (Toward an Electronic Patient Record) conference in San Francisco.
Bachman knows. He's been giving classes like this for years and was among the first docs to recognize the value of computers, e-mail and electronic medical records in the practice.
The value of computers, e-mail and electronic medical records in the practice.
Nothing you haven't heard before, likely thousands of times.
"If you're not using computers to assist with your practice, you should," Bachman said.
Most computer users, Bachman said, even those who are reasonably competent, use something like only 15 percent of a computer program's capability to do about 80 percent of their paperwork.
Yet the development of newer, flashier computer programs marches along; the computers get faster and somehow more intimidating; and that proverbial train, which left the station long ago, starts looking like a dot off in the distance.
"This has changed the way we practice medicine," said Bachman, double-clicking his way to another impressive demonstration.
"Just get started"
It's been a theme of the late spring months. Some heard Academy President Bruce Bagley, M.D., of Albany, N.Y., say it at the Annual Leadership Forum in late April in Kansas City, Mo. He participated in a panel discussion on EMR systems, and FPs in the audience asked for specific product recommendations."If you're not using something now, use anything," Bagley answered. "Just get started."
Others heard it in the two days prior to the TEPR: 2000 conference, when representatives from AAFP and other medical organizations met with software developers to talk about EMRs. A tearsheet from a brainstorming session offered a clue: Would the use of EMRs eventually be required by insurance companies to help weed out problems with handwriting inaccuracies?
Better/stronger/faster.
Sounds like Bachman.
"Give folks a laptop and they'll work longer and more creatively," he stated in his class. "And just imagine what will happen to the world when a Pentium III computer is as cheap as 16 megabytes of RAM are now (a few dollars)."
If that last comment flies over your head, don't worry. As Bachman said, showing software to inexperienced users: "Whenever you don't know what to do, but you see a button that says 'OK,' click it."
This is a little bit tongue-in-cheek, but you get the idea.
Click yet?
If you haven't caught on to anything electronic yet, Bagley suggested that you buy any computer capable of handling electronic mail, get some training and institute the use of e-mail in your office. That way, he said, when you're ready to go with a full-fledged EMR system, you and your staff will have much of that digital thinking in place already.You'll be eliminating the fear and unfamiliarity, in other words.
If you're a little further along but not living/breathing digital, Bachman said you might start investigating simple spreadsheet programs before you throw multiple thousands of dollars at a "real" EMR system.
"A spreadsheet is a stopgap measure until you're fully integrated, but perfect for a doctor's office. And it will allow your computer to do the dull, repetitious work it's perfect for," he said.
The spreadsheet Bachman had in his course showed exactly what he's talking about -- a spreadsheet that sings, with everything you might need just one click away, and all thanks to software that's affordable and quickly accessible to just about anyone who puts forth the effort.
By learning a little bit.
"The difference between me and someone with no skills is about four months," Bachman said. "That's about the time it takes to learn about a new disease ... and just look at what you can do."
Time for the ol' crystal ball
Video phones aren't quite as widespread in 2000 as futurists 30 or 40 years ago predicted they would be, but forecasting new technology's future is a little bit easier now.
What we're going to see is more "convergence."
That's been a buzzword for years, and for good reason. Computers have gone from room-filling beasts surrounded by numerous techies in lab coats to portable devices qualifying as "tiny," shrinking by the day. Have you seen the cellular telephones that allow access to the Internet? Or the palm-based devices that take notes, keep calendars and get e-mail? That's convergence.
And just think, the way things are coming together, what if you could access all the information available on any one computer from any other computer device on earth? There's no reason you couldn't.
The relevant acronym is ASP, and it stands for application service provider. ASPs were one of the hot topics at the recent TEPR:2000 (Toward an Electronic Patient Record) conference in San Francisco. You might figure ASP falls under the spell of the digital generation's younger set, but not so. This server/client situation is eerily remin iscent of the terminal/server arrangement computing meant in the '60s and '70s.
Only now, instead of ugly, glowing green monitors and time-share situations, we have graphically pleasing personal machines that go everywhere.
Here's how it will work: You tell your Web browser to visit www.some-asp-place.com, and up comes the exact same computer interface you see on your office machine. The same programs start up, and you gain immediate access to the same records you get back at the office. That's because they reside in the software application on the ASP Web site, not in your office.
The only thing holding that trend back at this point is "bandwidth," or the speed at which information can flow through all reaches of the Internet. But that hurdle is about to crumble with high-speed lines being buried or strung all over the country.
That means DSL (for digital subscriber line) and several other such acronyms, none of which is terribly important. Just think "speed," much like changing channels on the cable television, and you'll start to understand. Or think, "No more screeching modems."
Click to access a file on your computer or any other, and boom, it'll be there. This seamless experience is not here yet, but it's about to be.
That's the "network" part of the Internet. That's what it was all supposed to be about in the first place. We're almost there.
'You just gotta believe'
Wenner: king of EMR advice
"Passionate" is not a strong enough word to describe Allen Wenner, M.D.
Wenner, a practicing FP and clinical application design VP for Prime Time Medical Software in Columbia, S.C., drew large crowds at the recent TEPR: 2000 (Toward an Electronic Patient Record) conference in San Francisco, even when some of his sessions were meant for small groups. Why? Wenner has all kinds of advice about electronic medical record systems.
"You better get on the train, because it's leaving the station," he said several times.
But everything Wenner says is not so cliché. He'll remind you of the way Wal-Mart adopted bar code scanners when all those other retailers turned them down. And the way pharmacists (pharmacists!) transformed their business practices with electronic record systems. And the way the banking industry resuscitated itself by implementing electronic methods and cutting labor.
You'll also hear about the way some doctors find more time to sit and listen and learn by using patients to help input EMR data while waiting for their appointments.
That might be just a minute or two in the exam room, but think a moment about what that might mean to your practice.
"You just gotta believe," Wenner says. "The world is not flat; you will go on; you will win."
Wenner will just as easily admit to the problems with EMRs. First, he says, if you can't see past two years -- the two years an EMR system will be more trouble than it's worth -- forget it. Because you will indeed lose money.
"The challenge?" he asks. "Can you do it before you go broke?"
And he'll readily point to statistics showing unreal amounts of money practices are spending to get rid of their EMRs.
But just assume your future includes several more computers than you have now, says Wenner. It probably will, given the way those devices have cropped up elsewhere in society.
Put a few in the waiting room. Have them running a Q&A program designed to gain valuable patient data. Assume that anyone currently familiar with e-mail can operate it. Also figure that the majority of those folks unable to deal with the process will be accompanied by someone who can.
If you're Allen Wenner, you took those incremental steps years ago and now boast such an electronically oriented setting that not even dictation is permitted in your office. His method works and works well, and he'll challenge any other doc under the sun to an efficiency and speed duel.
And you know who'll probably win? Wenner. He had a head start.
Security issues still raise concerns
Few can mess with that pad of paper in your pocket, and hardly anyone can get to that file folder in the cabinet.
But when your "stuff" is on a computer network, either locally or on the Internet, there's a little more risk. That risk, and the concept of security, was on the minds of many at the Medical Records Institute's TEPR: 2000 (Toward an Electronic Patient Record) conference in San Francisco recently.
The bottom line? There's money to be made here, so someone's going to make it. Which means your data will be increasingly secure over time -- it just comes down to what it's going to cost you.
Among the cool stuff shown off at TEPR: 2000 was something called "biometrics." In short, this encompasses any one of several Star Trekish systems that use a device to scan your hand or your eyeball to ensure that you are you, and you are the one who should gain access to your information. It's out there now. It's costly but will be in range eventually.
Closer to home, TEPR: 2000 revealed that networked data is fairly safe with legacy methods -- those that are currently cutting edge now, and will become even better as the software industry continually adopts better sets of standards.
And as always, the best recommendation is awareness. Don't put anything in e-mail that you wouldn't want to read on the front page of the newspaper, and don't forget to password-protect all your patient information.
Short of a biometrics system, using passwords that aren't your nickname or the word "password" itself is a good start.
Check out Academy's expanded Web site - http://www.aafp.org
If you've ever gotten lost in the depths of a complex Web site, you'll appreciate the Academy's diligence in making your visits to AAFP's redesigned Web site at http://www.aafp.org a positive experience.
After months of strategic planning that included extensive input from member online surveys and focus groups, the Academy launched its enhanced Web site on May 1. See features below.
1. You're busy, so the streamlined AAFP home page gets you where you want to go fast, with select groupings on the left and right edges of the page.
2. The center of the Academy home page features fresh information every day. Test your mettle with the Daily Question, and increase your knowledge with the daily Practice Pearl.
3. Click on "My Academy" in the upper right-hand corner to customize your personal portal page.
Once you've clicked on My Academy, choose up to four Academy resources you use the most, such as CME records, Academy publications or patient education. Your selections stay at your fingertips in the top right corner as you navigate the site.
The My Academy box at the top of the page remains with you as you roam. A simple click takes you back to the home page or to one of eight main sections of the AAFP site.
While you're on your personal portal page, create your own free Web site (hundreds of members have already done so). Follow directions and click to get started. Then enter your medical practice information in the easy-to-use template.
You have lots of options here. Post a photo, supply a road map, or direct patients to their congressional representatives through Speak Out, the AAFP legislative action center.
Your site can provide links to patient resources, including handouts and self-care flowcharts created for familydoctor.org and personalized with your address and phone number.
Most important, you control the content of your Web site, which you can modify and update 24 hours a day.
See story below for one member's experience with creating his own Web site.
Member lauds Academy for providing physician Web site opportunity
Just hours after the Academy's revamped Web site was launched on May 1, David Howlett, M.D., of East Granby, Conn., had his AAFP member Web site ready to go.
Connecticut AFP President Howlett is no stranger to the Internet -- he has three Web sites featuring his practice. But his Academy site (http://familydoctor.org/egfp) is his hands-down favorite.
This family physician describes his technology comfort zone as above average, but still he struggled for months to create a Web site on his own. Then Howlett saw a demonstration of the new service at the Annual Leadership Forum in April in Kansas City, Mo.
"I thought, 'Oh my goodness, this is a great opportunity.' Everything I saw on this Web site is what I was trying to do," he said.
The beauty of the site, Howlett said, is its simplicity. "In a matter of minutes, I can go in and update and change without any special software or special training."
The patient information section is popular with Howlett and his patients. "Patients can go right to this Web site for good, reliable information, rather than searching willy nilly and finding information that may be inaccurate," he said. "When I hand patients my Web site address, they are thrilled."
Within five weeks, Howlett counted 158 visitors to his site. That number is bound to escalate in the future, when the Academy links physician sites with Internet search engines.
Insurance providers may supply the push
Physicians who resist "teching up" may feel a strong push to do so from insurance providers.
AAFP Past President John Tudor Jr., M.D., of Murray, Utah, currently serves as medical director of a managed care organization in the state. Tudor sees a growing trend toward establishing instantaneous online access to all transactions between physicians and managed care organizations. "Physicians need to figure out how to plug into that," said Tudor. "Are you going to be in the system or cut out of it?"
Aetna U.S. Healthcare spokesperson Jill Griffiths said physicians benefit from Aetna's E-PayTM program, implemented in 1998. "If physicians submit referrals and claims electronically, we pay them within 15 business days," Griffiths said.
Currently, Aetna is receiving 40 percent of claims and 50 percent of referrals electronically, Griffiths said.
To encourage physicians to increase their electronic sophistication, Aetna is poised to launch a Web site that will give physicians in its network quick access to valuable information, including performance reports, coverage policy bulletins and links to organizations such as the CDC.
Nutrition campaign attracts national media attention
President Bruce Bagley, M.D., of Albany, N.Y., signs an oversized copy of "Prescription for Change: Ten Keys to Promote Healthy Eating in Schools" at a press conference launching a new school nutrition campaign.
One in five children in the United States is overweight, and the Academy hopes to engage schools in turning that statistic around. The AAFP and four other associations have joined the U.S. Department of Agriculture to issue a joint call to action, "Healthy School Nutrition Environments: Promoting Healthy Eating Behaviors."
"Healthy eating habits are essential for leading a healthy life, and healthy children are more likely to be healthy adults," said AAFP President Bruce Bagley, M.D., of Albany, N.Y. "For these reasons, the Academy would like nutrition to be a priority in every school."
Participating organizations -- which also include the American Academy of Pediatrics, American Dietetic Association, National Hispanic Medical Association and National Medical Association -- launched the new campaign at a news conference June 7 in Washington. National media outlets covering the event included Time, The Washington Times, Hearst, Reuters, and the NBC, CBS and Fox networks.
The campaign is offering a guide to help communities reap the benefits of teaching children healthful eating habits. Read "Prescription for Change: Ten Keys to Promote Healthy Eating in Schools" at http://www.aafp.org/news/tenkeys.html.
Staying ahead of the game AAFP poised to revamp clinical CME accreditation system
BY CINDY McCANSE
The Academy has taken the initiative in responding to concerns of the Federation of State Medical Boards about using CME as a criterion for physician relicensure.
The concerns stem from the fact that current accreditation systems may allow credit for courses that promote or teach unproven therapies. In particular, accreditation review protocols have proven difficult to apply to activities discussing complementary and alternative practices.
Background
Early last year, the Commission on Continuing Medical Education began laying the groundwork to develop an evidence-based system for classifying CME clinical content. The COCME drafted a preliminary proposal to the AAFP Board of Directors to modify AAFP standards for evaluating and classifying clinical CME and collaborate with other national accrediting and credit-granting organizations.The COCME outlined five goals for the proposed new system:
- maximize the fairness and consistency of the CME review process,
- ensure the integrity of Prescribed credit and its acceptance for licensure and relicensure by the FSMB,
- enable the Academy to better withstand the scrutiny and concerns of other national organizations,
- assume a leadership position in this area and
- simplify the national CME landscape.
The Board approved the measure in concept in March 1999, and the COCME established the Subcommittee on Clinical Content.
Nuts and bolts
The SCC proposes that CME clinical content be classified into one of two categories:
- eligible for Prescribed or Elective credit hours -- evidence-based or customary and generally accepted medical practice, or
- eligible for Elective credit hours -- neither evidence-based nor customary and generally accepted practice, but not dangerous.
CME activities promoting any diagnostic or therapeutic intervention deemed dangerous would be ineligible for credit.
"Every intervention has evidence. It's a matter of determining what grade -- what quality -- of evidence exists." The new accreditation standards would pertain only to clinical CME topics; nonclinical topics would remain eligible for Prescribed or Elective credit under existing criteria. Both traditional and nontraditional therapies would be reviewed according to the same standards.
Identifying appropriate sources of evidence and defining a sufficient level of evidence to designate a program as Eligible for Prescribed or Elective Credit Hours have been key to the process. (See EBM story on page 7.)
As SCC member Lee Green, M.D., of Dexter, Mich., put it: "Every intervention has evidence. It's a matter of determining what grade -- what quality -- of evidence exists."
Other issues considered during this process have been the prospective roles and responsibilities of CME providers, AAFP staff and member reviewers. The concerns of AAFP constituent chapters have also been taken into account and will continue to be addressed.
Looking ahead
The COCME approved a final version of the plan last month, and it is now before the AAFP Board for action later this month. If approved, the measure will go to the Congress of Delegates this fall. If it passes muster with the Congress, an implementation plan will be developed with input from chapters, selected CME sponsors and others. A national launch date of April 2001 has been proposed.
Is this why primary care match declined?
To the editor:
Did you know that the average 73-year-old person in the United States takes 17 prescription medications? Can you imagine how complex directing the administration of this regime must be?
What seems like a fair salary for this medical director? Medicare has agreed to give physicians $180 an hour, based on Medicare's reimbursement rate for 60-minute office visits for established patients.
Would you be interested in a job that pays $180 per hour? Before volunteering, read on:
(1) You will be paid for 26 hours per week but will work 70.
(2) Your job will constantly expose you to the threat of litigation.
(3) You will have to go to school for four years and train for several years after that.
(4) There will be many other expenses, including an office; employees; utilities; malpractice, health, business, fire and theft insurance; telephone; lab fees; taxes; and medical staff dues. These costs total $152 per hour to run my office, so after 25 years of practicing medicine, I am earning $28 per hour ($180 -- $152).
Under current Medicare guidelines, a physician working 70 hours a week, taking two weeks off for vacation and receiving five holidays would receive an annual salary of $35,672 ($28 per hour X 26 billable hours X 49 weeks). Do you know what is really "sick"? The starting salary for an attorney at a major San Francisco Bay area law firm is $160,000.
I grant that you will always be able to obtain medical services by paying for them yourself (face lift, varicose vein treatment, etc.), but who is going to manage your 17 medications when you're 73?
B. Patrick Harpole, M.D.
Pleasant Hill, Calif.
AAFP leader asks how presidential candidates will promote primary care
AAFP President-elect Richard Roberts, M.D., J.D., was the first panelist to ask presidential candidates' health advisers a question about primary care at a June 6 debate in Washington.
President-elect Richard Roberts, M.D., J.D., right, a panelist at the June 6 debate about presidential candidates' health strategies, asks for a stronger focus on primary care. At left are panelists Richard Smith, vice president of the American Association of Health Plans, and Mary Jane England, president of the Washington Business Group on Health.
Roberts fired away: "Many of us who take care of patients feel the health care strategies of the candidates should focus more on the golden circle of care than the brass ring of cure, more on making care accessible than on chasing every proposed innovation. What are George W. Bush and Al Gore going to do to promote primary care, preventive services and restorative care?"
The health experts answered in terms of the candidates' proposals to expand the services of community health centers and improve the safety net for citizens who fall through the cracks in the health care system.
Roberts, of Madison, Wis., joined representatives of other health-related groups at the National Press Club for the debate, covered widely in the media. The session was sponsored by two umbrella groups the Academy belongs to, both based in Washington: the Health Care Quality Alliance and the National Health Council.
What's all this ruckus about EBM? Why should you care?
BY CINDY McCANSE
Evidence-based medicine: What is it, and why should you care about it?
The definition established by the Subcommittee on Clinical Content of the Commission on Continuing Medical Education takes its cue from EBM guru David Sackett, professor and former director of the Centre for Evidence-Based Research, Oxford, England. The SCC definition blends Sackett's three basic EBM tenets -- research findings, clinical judgment and patient values -- with a fourth dimension:
See CME accreditation story on page 6. "Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. For family physicians, evidence-based medicine is also of value in making decisions about the care of families and communities."
The SCC definition adds that CME content is considered evidence-based if its recommendations "are labeled and presented with the highest levels of available evidence, according to an evidence-grading scheme accepted by the AAFP."
The SCC has devised a classification hierarchy as a starting point for assigning an "evidence value" to a given diagnostic or therapeutic recommendation. Four levels have been proposed, ranging from meta-analyses to expert consensus statements.
Promoting an evidence-based approach to patient care is not new to the Academy. The Home Study Self-Assessment® program devoted a monograph to the topic in February 1998, and a recent HSSA monograph on hypertension highlighted an evidence-grading system developed by the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure.
The Family-Centered Maternity Care course encourages prospective faculty to provide supporting evidence for their recommendations. And the Advanced Life Support in Obstetrics program is codifying a system for incorporating EBM into its provider curriculum.
But critics of EBM challenge the need to apply this methodology in all aspects of patient care. In a session on EBM at the May 3-7 Society of Teachers of Family Medicine annual spring conference in Lake Buena Vista, Fla., several attendees cited a paucity of time for critical review of available clinical evidence, as well as a lack of the statistical training necessary to independently assess the value and validity of certain types of evidence.
Facilitator Paul Lyons, M.D., of Temple University in Philadelphia acknowledged these difficulties but pointed out, "You don't have to be able to program computers to know how to use one effectively. So perhaps you don't need to know all the nuts and bolts of EBM to use it effectively."
Electronic resources such as the Cochrane Library (http://www.update-software.com/cochrane/) and Bandolier (http://www.jr2.ox.ac.uk/Bandolier/index.html) present "predigested" evidence-based literature analyses on many medical topics, often abrogating the need for physicians to conduct their own critical appraisal of multiple individual studies.
Another session participant noted that some physicians may be discomfited by searching the literature for evidence of an intervention's efficacy, only to discover just how meager that evidence is in many cases. Often, too, different sources of evidence conflict. Lyons responded by saying it's important to bear in mind that building a collection of evidence for or against a given intervention is an ongoing, dynamic process that doesn't always follow a linear path.
What he has found to be key in the educational setting, he added, is ensuring that students comprehend the limitations of EBM: "As teachers, we must guard against instructing students to base clinical decisions on one study. If we're teaching them something that they are then using in an unsophisticated manner, we may be leading them down the path to bad decisions."
Copeland objects to numbers-based privileging criteria
Your hospital likely received a memorandom in May from Academy Board Chair Lanny Copeland, M.D., of Albany, Ga., regarding privileging criteria that are published by the Credentialing Resource Center in Marblehead, Mass.
The memo, addressed to hospital executives and medical staff officers of about 5,700 non-federal hospitals, highlighted AAFP's increasing concern about hospitals' blanket adoption of CRC criteria.
The AAFP says privileges should be based on individual qualifications -- documented training and/or experience, demonstrated abilities and current competence. By contrast, the CRC recommends assigning privileges based on numbers of procedures performed, a concept that is not supported by scientific evidence.
Copeland shot off the memo after the Academy heard from many FPs who objected that their medical staffs were adopting CRC criteria as written, rather than using the CRC data as a tool to draft their own local policies.
Pain relief act might inhibit use of drugs to fight pain
The Academy is continuing to battle the proposed Pain Relief Promotion Act.
Take action: Write or e-mail your senators by going to http://www.aafp.org/gov and clicking on "Speak Out" and then "Write to Congress." Letter to Clinton. The Academy recently urged President Bill Clinton to raise the possibility of a veto with the bill's supporters. "H.R. 2260 may put physicians who are appropriately prescribing pain narcotics at risk for both civil and criminal liability," wrote AAFP Board Chair Lanny Copeland, M.D., of Albany, Ga.
The Academy stands firm against assisted suicide as being inconsistent with the physician's role as healer. But H.R. 2260, which aims to outlaw physician-assisted suicide, calls for Drug Enforcement Administration agents to investigate and conduct enforcement actions concerning deaths involving prescribing controlled drugs -- provisions the AAFP says threaten patient care.
Senate staff briefing. H.R. 2260, which passed the House of Representatives last fall, may soon come up for a vote in the Senate. A Senate committee revised the bill, and the AMA and some medical societies now support it; the AAFP and about 40 other groups still oppose it.
To try to influence the Senate vote, the Academy coordinated a briefing June 6 for senators' aides. Speakers included AAFP President Bruce Bagley, M.D., of Albany, N.Y.; representatives of the American Pain Foundation and Oncology Nursing Society; a patient with chronic pain; and the mother of a 4-year-old girl who died of cancer.
Briefing materials about the bill warned, "It would inhibit aggressive use of controlled substances to fight pain."
Research indicates patients in pain may need more medicine, not less. In a 1993 study of 897 oncologists, 86 percent of respondents said cancer patients' pain was undertreated. A 1998 study found that 24 percent to 38 percent of cancer patients in nursing homes were in pain every day; more than a quarter of them received no pain medicine. A recent unpublished study shows that New York state physicians already fear governmental oversight and may be underprescribing for half of their patients in pain.
Order from AAFP at (800) 944-0000 unless otherwise noted.
"Colonoscopy by Family Physicians," a position paper, may help you pursue credentialing and privileges to perform colonoscopies (#R744, free; online at http://www.aafp.org/x6656.xml).
The Family Health Month kit contains news releases, posters and other tools to promote your practice and your patients' health in October. The kit (#R039, $20) focuses on managing medications for the elderly, talking with children about tough subjects, and preventing and treating colorectal cancer and asthma, allergies and respiratory infections.
Prepare for exams for certificates of added qualifications in sports medicine or geriatrics with Sports Medicine: An In-depth Review Audio CME (#R286, $595); Geriatrics Resource Packet (#R179, $35); Geriatric Medicine for the Family Physician Audio CME (#282, $345).
Proven value: To save $100 and have greater course selection, sign up for the AAFP Scientific Assembly by Aug. 16. After that, you can register on-site. Fun nighttime events during the Sept. 20-24 meeting in Dallas include the first AAFP Foundation Auction, the Presidents' Reception and the All-Member Event starring Reba McEntire. Register by mail, fax or online at http://www.aafp.org/assembly/2000.
Proven value: AAFP Placement Services, now fully electronic, lets you search for the ideal position, practice or partner seven days a week, 24 hours a day. Log on at http://www.aafp.org/placement or call (800) 274-2237, Ext. 6814.
FP Report is published by the AAFP News Department. Copyright © 1999 by American Academy of Family Physicians.
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