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FP Report
October 2000 • Post-Assembly Edition • Dallas

First African-American elected to head the Academy

Warren Jones, M.D.

Warren Jones, M.D.
 
For other election results, see page 3.

The Congress of Delegates elected Warren Jones, M.D., of Potomac, Md., as president-elect during the delegates' meeting Sept. 18-20 in Dallas. Jones, a captain in the Navy, is the first African-American chosen to lead the Academy.

Jones, 52, grew up in New Orleans as the ninth of 12 children. He says his mother -- a cook, domestic worker, state leader of the Elks and longtime single parent -- gave the children the values of caring for each other and serving the community. He credits his late father, a chauffeur and delivery man, for challenging the children to use their abilities.

"We were always aware of the political issues around us and their impact on us as African-American children and poor people," says Jones. "But we were not allowed to think anything negative. We were taught education was the key: If you had a good education and coupled it with your abilities, the sky would be the limit."

The family instilled confidence. "Even though we sat in the back of the bus, behind the sign that said 'whites only' on the front and 'colored only' on the back, in my mind, I was always standing beside the bus driver," says Jones.

In the Navy, Jones has been special assistant to the surgeon general; family practice residency director in Pensacola, Fla.; chair of the family practice department in Charleston, S.C.; and director of medical and clinical services for the Pacific region. He is medical director of the Worldwide Tricare Military Health Program.

Within the Academy, he became president of the Uniformed Services AFP Foundation and was active in the National Conference of Special Constituencies.

Jones will serve one-year terms as president-elect, president and Board chair.

After the election Sept. 20, Jones introduced his wife, Gennie, to the Congress of Delegates. He suggested, "If we look in other than the usual and customary places, other than the usual and customary faces, just maybe we'll find those very special people who can help us reach our goals of providing quality health care and meeting the health needs of all of our people."


Your future is well connected

BY TODD SIMCHUK

Good cop/bad cop. That role-playing was working Sept. 20 in "Trends in Medical Technology," a computer lecture during the AAFP Scientific Assembly Sept. 20-24 in Dallas.

The session's instructors were Glen Christopher and David Voran, M.D. Voran followed Christopher's leadoff talk with an honest "he scared the hell out of you, right?"

Probably so. Christopher, a pro speaker/consultant/tech trainer out of Raleigh, N.C., played a techno-literate patient with no patience for techno-blind FPs.

"I am embracing change," he said. "And I am rejecting the status quo."

How so? Christopher is tired of writing his Social Security number every time he visits your office. He'd rather produce his Web-enabled telephone, point it at a similar device at your reception desk and wirelessly transmit all relevant data through the magic of newly emerging wireless data transmission technology.

Are you ready?

"I'm demanding that kind of technology," Christopher concluded. "And if I don't get it, I'll go to someone who can give it to me."

Depending on your techno-slant, Voran's follow-up was a little less ominous. But Voran, chief medical information officer at the Health Midwest hospital group in Kansas City, Mo., still told of perfectly networked futures, and washing machines that order their own soap, front doors that tell you about your dog, and a small ear clip that will allow your patients to wirelessly transmit health data from themselves -- no matter where they are -- straight into your system.

If you have one that can handle it.

"Too many FPs seem to have an impenetrable barrier around their practices," Voran said, noting the widespread adoption of home-based computers and e-mail usage in American homes. "We are not allowing ourselves to act in our practices like we do at home."

If FPs were, Voran said, they'd have Web sites in place -- and have them linked to patient record systems.

"If patients enter their own data, your costs go down and accuracy goes up," he said.

Also on your Web site, Voran said, you'd have a "portal"-type feature that would compile medical information from other sites and make it available to your patients in one trusted place. You'd start building a vast database of patient information that might help you or your patients recognize health troubles before they become trouble.

"Why is it we wait until someone is symptomatic before we start to treat them?" Voran asked.

Universal coverage

AAFP-wide debate begins

BY JANE STOEVER

The Academy is edging toward a blueprint for universal coverage. The Congress of Delegates adopted the report of the Task Force on Universal Coverage and a related resolution during the delegates' meeting Sept. 18-20 in Dallas.

The materials jump-start an Academy-wide discussion on reforming the health care system and providing basic health services to everyone.

Chapters and members will share their views on the materials with the Board of Directors by spring 2001, and the Board will send recommendations for action to the 2001 Congress.

"Health care reform is a must," (then) Board Chair Lanny Copeland, M.D., of Albany, Ga., the task force chair, told the delegates. "We, as the best advocates for our patients, need to be leading the way."

During the reference committee hearing, the report reaped criticism and praise. The document includes general guidelines (originally called principles) and specific elements for the universal coverage plan (see story, page 7).

"The principles don't use words suggesting single payer, but the plan does seem to be a national health system," said Stephen Benold, M.D., of Georgetown, Texas, a member of the Commission on Legislation and Governmental Affairs, speaking for himself.

"If it quacks, if it waddles, if it swims on top of the water, you can call it an eagle, but it's a duck," Benold said. No conservative think tanks were listed in the report's bibliography, he noted.

Task force member and alternate delegate Tanya Jones, M.D., of Atlanta said the task force had broad representation, from a managed care executive to a rural FP in solo practice, and included conservatives.

The Colorado AFP submitted a streamlined resolution with core values for health care reform, including community orientation and continuity of care. The reference committee recommended adopting the resolution instead of the task force report. That led to discussion of the merits of the resolution versus the report.

"The principles in the report are quite detailed; the principles in the resolution don't address specific issues," delegate Richard Wopat, M.D., of Lebanon, Ore., said. "We should have the national discussion among the chapters about the specifics."

"I don't think we should achieve unity by making things more simple and more vague," said delegate Judy Chamberlain, M.D., of Brunswick, Maine.

Referring to the report, Copeland said, "What we've come out with is not a perfect document. We want input."

Satcher urges collaboration, action in fight against asthma

BY TERRY SELBY

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"I don't have to tell you that asthma is an area in which we are struggling for answers," said Surgeon General David Satcher, M.D., Ph.D.

In the midst of a worldwide epidemic of asthma, the Academy is to be commended for its 2001 Annual Clinical Focus on Asthma, Allergy and Respiratory Infections, said U.S. Surgeon General David Satcher, M.D., Ph.D., at the Scientific Assembly Sept. 21.

ACF 2001, which kicked off at the Assembly, brings AAFP members state-of-the-art information on that subject area.

"I also thank you for your 2000 Annual Clinical Focus on mental health," Satcher said. "In July 1999, I issued the first-ever surgeon general's call to action on suicide prevention. And in December 1999, I issued the first-ever surgeon general's report on mental health. So the fact that you chose mental health as your focus for 2000 meant so much to me."

Satcher, an Academy member, also serves as assistant secretary for health. He discussed asthma in the context of Healthy People 2010, which he described as the nation's health plan for the next 10 years.

"I don't have to tell you that asthma is an area in which we are struggling for answers," he said.

He noted that over the past 15 years, the number of Americans afflicted with asthma has doubled. Since 1980, the number of children under age 5 years with asthma has tripled. Asthma today affects an estimated 4.4 million children in the United States, Satcher noted, and is the leading chronic disease causing hospitalizations in children.

"We don't really understand why this epidemic of asthma is happening," Satcher said. "Yet this is a disease, as you well know, that can be treated and controlled."

He added, "The most important role for those of us who are family physicians -- especially you who are on the front lines taking care of patients every day -- is to make sure patients are getting the kind of management that we know is effective. The National Heart, Lung and Blood Institute guidelines are key to this effective treatment and management."

See related story on page 10.

Because the asthma epidemic is such a public health emergency, Satcher noted, Healthy People 2010 emphasizes the disease.

The leading health indicators for Healthy People 2010 are physical activity, overweight and obesity, tobacco use, substance abuse, responsible sexual behavior, mental health, injury and violence, environmental quality, immunization and access to health care. These indicators should be our major focus for the next 10 years, Satcher said.

"You ask, 'What does this have to do with asthma?'" he said. "Actually, a lot. For example, we know that regular programs of physical activity can play a major role in the management of asthma."

And obesity in childhood also increases the risk of asthma, although we don't know why, Satcher said. "So you see that lifestyle indicators have a substantial impact on asthma."

Kitzhaber's challenge

Apply Oregon's lessons to national health system

BY SHARON DICKINSON DENT

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Oregon Gov. John Kitzhaber, M.D., had a crowd waiting outside the Assembly's main lecture hall after his keynote address.

The Oregon Health Plan, launched in 1994, targets many of the same problems that plague the national health care system. And lessons learned in Oregon can help shape the debate in solving those problems, according to Gov. John Kitzhaber, M.D., keynote speaker at the Assembly's opening ceremony Sept. 200.

In Oregon, the health plan has led to a dramatic expansion in access, improvement in health outcomes, and a greater sense of hope among physicians and patients, Kitzhaber said. However, the state also has seen a repeal of the employer mandate, collapse of the managed care delivery system in some parts of the state and failure to achieve universal coverage.

The plan's successes stem in part from the state's attention to fiscal limits and the need to be accountable for difficult choices regarding appropriation of funds, he said.

"Oregon is certainly one of the few states that has explicitly acknowledged the reality of fiscal limits and has attempted to set priorities based on clinical effectiveness," he said. "This reality -- that consumer demand and medical technology are going to continue to outstrip the ability of the public sector to pay for them -- is something the national government is going to have to come to terms with if they hope to extend coverage to the 45 million Americans who have none."

Although congressional and presidential candidates are debating health care issues, the concept of fiscal limits hasn't been adequately addressed, said Kitzhaber. Instead, proposed policies -- such as prescription drug benefits and a patient bill of rights -- focus on improving services for those who already have coverage.

Kitzhaber said managed care tenets clashed with the plan's premise that covering the poor is a social responsibility.

What can physicians do to help the federal government learn from Oregon's experiences and move toward high-quality health care for all?

Kitzhaber said he empathizes with the climate of disempowerment that pervades the medical community, but he refuses to be called a victim. "To be a victim is to admit that there is nothing you can do about the circumstances," he said, drawing loud applause.

He encouraged physicians to recommit to the goal of universal coverage, a basic benefit package, the need to address rising costs and the proposition that caring for the poor is a shared social responsibility.

"We have the moral authority to put the mission back into medicine," he said.

Success of your practice can depend on finding the right staff

BY TERRY SELBY

Hiring skilled, dependable office staff allows you to focus on your practice and serve your patients better. Key to this outcome, however, is attracting and retaining good employees, said Keith Borglum, M.A., in "How to Find, Hire and Keep Great Staff" Sept.20.

"Hiring a more efficient staff allows a physician to serve a larger community of patients. Retention of good employees helps in communication with patients and increases bonding between patients and the practice," said Borglum, a practice management consultant for Professional Management and Marketing in Santa Rosa, Calif.

Hiring the wrong person is an incredible burden on your practice. It affects your performance and the performance of your other employees, he noted.

"And it's an economic burden," Borglum said. "Turnover typically costs one to one and a half times the employee's annual salary."

Networking is the best way to find great staff, he said.

"People who are looking for work may not be the kind of people you want to attract," Borglum said. He suggested talking with colleagues, consultants, pharmaceutical representatives and others for leads on applicants.

"Like seeks like," he added. "If you have great staff people, they probably hang out with other great people. Offer your current employees a 'bounty' for referrals."

If networking doesn't help you fill your position, the next step is to advertise, he said.

If all else fails, he said, there are always placement agencies, temporary employment services and employee leasing services that might help.

One participant in the course said FPs often have trouble attracting qualified staff because they can't compete with the salaries offered by other specialty group practices.

"Then you have to compete in other areas," Borglum noted. "Advertise your 'family' work environment and the opportunities to make a difference on a small team. For many people, salary is not the deciding factor."

In some cases, benefits outweigh salary, he said.

Borglum offered tips on hiring and training of new employees. Once you've found the right person, he said, the focus should be on retention because median staff retention is only 23 months.

"You have to beat those odds by offering informal verbal support, formal written reviews, and bonuses such as profit sharing and scheduling flexibility," he said.

New AAFP officers, directors installed at Assembly

President
 President-elect
 Board Chair
President

Richard Roberts, M.D., J.D.
Madison, Wis.

President-elect

Warren Jones, M.D.
Potomac, Md.
Uniformed Services

Board Chair

Bruce Bagley, M.D.
Albany, N.Y.

     
Speaker
 Vice Speaker
  
Speaker

Michael Fleming, M.D.
Shreveport, La.

Vice Speaker

Carolyn Lopez, M.D.
Chicago

 
 
Directors
Director

Nancy Wilson Ashbach, M.D.
Loveland, Colo.

Director

Mary Frank, M.D.
Rohnert Park, Calif.

Director

Richard Wherry, M.D.
Dahlonega, Ga.

     
Resident Director
 Student Director
  
Resident Director

Jennifer Aloff, M.D.
Midland, Mich.

Student Director

Andrew Mills
Tulsa, Okla.

  

AAFP targets violent video games

The Congress of Delegates tangled with the nitty gritty of video games during its Sept. 18-20 meeting.

Some studies say exposure to violent video games may increase aggressive behavior and hostility. Delegates considered a resolution saying the Interactive Digital Software Association has created a voluntary rating system for video and computer games.

Alternate delegate Christine Petty, M.D., of Rockford, Ill., told the delegates, "I'm the mother of a teenager; I don't play video games; I was totally unaware a rating system exists."

She said there is some evidence that youngsters who've engaged in violence had previously isolated themselves playing video games. "We need to be the first national medical society to support this rating system," Petty told the delegates. They agreed.

They asked the AAFP to encourage members to tell parents about the system. Delegates also put the Academy on record backing efforts to:

Congress selects ABFP board nominees, AMA delegates

The Congress of Delegates named finalists for the AAFP seat on the board of directors of the American Board of Family Practice and chose delegates and alternates from the Academy to the AMA.

The three finalists for the Academy's seat on the ABFP board are: Frank Kane, M.D., of Sparta, N.J.; George Shannon, M.D., of Columbus, Ga.; and Del Barker Stigler, M.D., of Caldwell, Texas. The ABFP board will select one of the three finalists in April for a five-year term.

The seven delegates elected or re-elected by acclamation to the AMA House of Delegates are: Patrick Harr, M.D., of Maryville, Mo.; Larry Johnson, M.D., of Bremerton, Wash.; James Jones, M.D., of Surf City, N.C.; Edward Langston, M.D., of Lafayette, Ind.; Jerry Martin, M.D., of Bowling Green, Ky.; Charles Rodgers, M.D., of Little Rock, Ark.; and Joseph Zebley III, M.D., of Baltimore, Md.

The two alternates elected to the AMA are: Daniel Heinemann, M.D., of Canton, S.D., and Mary Elizabeth Roth, M.D., of Southfield, Mich.

Campaign begins in 2001

Multimillion-dollar effort will publicize specialty's strengths

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"The Academy is getting ready to launch a public awareness campaign designed to help strengthen the position of today's family physicians among opinion leaders and consumers," (then) Board Chair Lanny Copeland, M.D., of Albany, Ga., told the Congress of Delegates. He displayed a promotional piece about the campaign.

Academy members have been saying they want America to know what today's family physician has to offer. Their wish will get a head start on coming true, beginning next February.

Ads about family practice will run in USA Today and The Washington Post in February, the same month AAFP will sponsor National Public Radio's Morning Edition and All Things Considered. These media tend to reach educated audiences, including policy-makers.

"The early 2001 timing couldn't be better, with a new administration and newly elected Congress sorting out national health care policy priorities for action," (then) Board Chair Lanny Copeland, M.D., of Albany, Ga., told the AAFP Congress of Delegates Sept. 18.

Constituent chapters will be able to run the ads in state or local papers with matching grants from AAFP.

Academy members have said in surveys, meetings and interviews that they felt a need for better recognition of the specialty, especially by decision makers.

Research by the nationally recognized Mellman Group shows family physicians maintain an enviable position among doctors, said Copeland. "People identified family physicians as listening, caring doctors who know their patients and take time with them -- the exact qualities they desire in a personal doctor and find lacking in the current health system."

The campaign will reinforce the public's perception of family physicians and highlight family physicians' knowledge of up-to-date treatments and technologies.

The new publicity efforts, plus AAFP's ongoing public relations projects, will dovetail.

The three-year campaign has a $1.5 million budget for its first year.

'Stethoscope of tomorrow' puts medical information at your fingertips

BY DENNIS CONNAUGHTON

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Ever wished you could carry your office manager, PDR or Merck Manual around with you for quick and accurate answers to medical, scheduling or practice management questions?

Well, your wish has been granted in the form of a handheld electronic device: a personal data assistant, or PDA. And if the predictions come true that were made at the Assembly's course on PDAs in medicine, most primary care physicians will carry these gadgets in five years or less.

What's the lowdown on these nifty devices? And why should you carry one?

A PDA allows users to enter, link and retrieve data through various connecting interfaces, such as a personal computer or the Internet, said Michael Tuggy, M.D., assistant clinical professor of family medicine at the University of Washington's Swedish Family Medicine Residency in Seattle.

With a PDA, you can have instant access to: drug databases, medical formulas for calculating such handy things as a patient's cardiac risk, practice management software to track patient information and billing codes, prescription-writing software and graphics software to show the human anatomy.

Everyone will have one

"We think the PDA is the stethoscope of tomorrow," said Chris Vincent, M.D., clinical associate professor of family medicine, also from the University of Washington and Swedish Family Medicine Residency. "Within five years, everyone is going to have one. Already, maybe 20 percent of physicians have them."

There are a number of PDAs on the market today, including the Palm Pilot, Handspring and TRGpro. Each works with either a Palm operating system or a Windows CE operating system. Both systems interface with Windows operating systems on personal computers. The Palm OS also has a Macintosh interface. Palm offers a detachable keyboard, while Windows CE has an integrated keyboard.

Connect to your computer

All PDAs connect to desktop computers by cable, said the speakers. Some PDAs also allow you to send data and software programs by infrared beam, without using a cable, directly to other PDAs, to printers and even to desktop computers -- and to receive the same. Some have built-in modems for Internet access; others connect through a desktop computer.

Once your PDA is connected to the Internet, you can download data and software. To access, add or change data on your PDA, you use a stylus and a touch-sensitive screen -- or the detachable or integrated keyboard. When your PDA is connected to your desktop computer, you can make changes on both at the same time, Vincent said.

You can also keep an address book, appointment calendar, to-do list and other personal information on your PDA. Some allow you to access your e-mail directly without going through your desktop unit.

The future will bring more powerful PDAs, as well as integrated systems that will allow you to connect to hospital information networks for complete medical records.

Create your own Web site -- visit www.aafp.org

Wouldn't it be great to have a Web site for your own practice? The Academy makes it easy for you to create one at no cost. Just visit http://www.aafp.org, click on "My Academy" in the upper right-hand corner and follow directions to get started. You'll be able to enter your medical practice information in the easy-to-use template.

Your Web site can include practice information, photos, a road map to your practice, and links to patient resources, including a health tip of the day, handouts and self-care flowcharts created for the AAFP's familydoctor.org Web site. The patient resources will be personalized with your address and phone number.

 Photo

Assembly-goers thronged to computer demos at the Exhibit Hall. Computer courses proved so popular this year that an extra session was added on-site.

Award Winners

Family Practice Research Presentations

First place winners:

Second place winners:

Resident and Medical Student Exhibits

First place winner:

RS - 4160, "Herbal Medicines: Important Reactions and Interactions," Sharp Family Practice Residency, La Mesa, Calif.

Second place winner:

RS - 4259, "Effectiveness of Evidence-based Guidelines in the Delivery of Preventive Services in a Family Practice Residency Program," Santa Monica-UCLA Medical Center Family Practice Residency

Third place winner:

RS - 4157, "Smoking Susceptibility Among Pre-adolescents: A Survey of Third-grade Children," University of California, Irvine College of Medicine

Fourth place winner:

RS - 4159, The Senior Link Program: Impact of a Community Service-based Curriculum on Adolescents' Knowledge and Attitudes About the Elderly," University of Miami School of Medicine

Honorable mentions:

Outstanding Scientific Exhibit Awards

Medical Informatics Paper Awards

Medically Related Internet Applications:

"Internet-based Education for Medical Students in Community Practice," James Roman, M.A., Pittsburgh, Pa.

Electronic Medical Records:

"A Case Study: Will Patients Use Electronic Personal Health Records?" Ira Denton, M.D., Huntsville, Ala.

Informatics for Processes, Outcomes, Reporting and Management:

"Personal Digital Assistants (PDAs) for the Family Practitioner," Anil Chandrashekhar, M.D., Middletown, Conn.

Patient Education and Communications:

"Care Coordination to Assist with Treatment of ADHD," Bradley Tanner, M.D., Chapel Hill, N.C.

Best Practices in Applied Informatics:

"Identifying 'Best Practices' for Heart Disease, Hypertension, Diabetes and Preventive Services in the Practice Partner Research Network," Steven Ornstein, M.D., Charleston, S.C.

Music hath value in teaching teens health lessons

Photo

Matthew Clarke, M.D., left, and John Clarke, M.D., produce, write, perform, promote and distribute rap CDs on health topics.

BY DENNIS CONNAUGHTON

Music may indeed have charm to soothe. But it also is a key to the inner world of adolescents and a way to teach teens about health and social responsibility.

A rap CD about taking asthma medicine? Why not? How about rapping on drug and alcohol abuse, smoking, youth violence, or sex and HIV?

Matthew Clarke, M.D., a community-based family physician in New York City, and his brother, John Clarke, M.D., chief family practice resident at St. Vincent's Catholic Medical Center in New York City, described their program to educate adolescents on medical topics through rap music Sept. 21 at the Assembly. They not only talked about the program, they also performed some of the music.

The brothers Clarke produce, write, perform, promote and distribute the CDs because "adolescents respond to it," Matthew Clarke said. "Music is important to the identity of adolescents. It plays a large role in their socialization, and it helps them define important social and subcultural boundaries."

Rap music is the sound of choice for most adolescents, he said. About 71 percent of rap music CDs are bought by white kids, he added.

The Clarke brothers wanted to counteract the negative messages and images music videos send to teens and young adults about violence, substance abuse, sex and suicide. So they conducted a study among 125 high school students in Queens, N.Y., and concluded that rap music would be an effective way to reach this age group.

Photo

The FP brothers pitch their rap hit, "Asthma Stuff."

Their first CD, which they launched in Canada, was "Asthma Stuff." It encourages adolescents with asthma to take their medicine. The chorus of the song: "Two puffs of the asthma stuff twice a day stops the wheeze and helps you to breathe."

After the CD was released, the Clarkes began to get requests to perform the rap live.

"We created the song but didn't intend to perform it live," Matthew Clarke said. But they did perform it at schools in New York and other cities. They also added a reggae version.

The Clarke brothers distributed the song lyrics before they sang and then, afterwards, they discussed the complications of asthma with the adolescents to reinforce the message. They also passed out their CD.

Subsequent to the first CD, the Clarkes produced one on substance abuse titled "Have It All," another on smoking titled "Bad Breath and Brown Teeth," a CD on youth violence called "Talk It Out," and a fourth on sex and the risks of HIV infection that portrays HIV as a gangster.

They are looking for funding to produce a music video to use as a public service announcement on MTV.

The CDs and further information are available from the Clarke brothers on the Internet at www.mdmdinc.com, by e-mail at StopAsthma@AOL.com or by phone at (917) 208-2467.

Clinical CME evaluation moves toward evidence-based approach

BY CINDY McCANSE

The Congress of Delegates voted last month to change the way the AAFP does business -- CME business.

Delegates called for phasing in new criteria for evaluating and categorizing the clinical content of CME. The criteria will be phased in over the next year and re-evaluated in January 2002.

The revised system encourages CME providers to incorporate evidence-based medicine into their clinical offerings in an effort to cull activities promoting unproven therapies. The result: Some courses previously eligible for Prescribed or Elective credit hours may no longer qualify; others that were previously ineligible for credit may now receive it.

Here's how the new system will work:

CME providers will indicate on the AAFP CME credit application form how many hours they are requesting in the following categories of clinical credit:

"The purpose of phasing in this evidence-based medicine approach to the accreditation system is to help our members and CME providers voluntarily move toward including more of the available clinical evidence in the educational process," said Norman Kahn Jr., M.D., AAFP vice president for education and science.

After consideration of input from chapters, selected CME providers and national colleague organizations, the AAFP will launch the program nationally in April 2001.

Feed the Need helps Dallas agency address domestic violence

Corporate contributors

  • Abbott Laboratories
  • American Optometric
  • Association
  • Ascension Health
  • Bayer Corporation
  • Dermik Laboratories Inc.
  • Diversion
  • Eli Lilly and Company
  • Endo Pharmaceuticals Inc.
  • Focus on the Family
  • Forest Pharmaceuticals Inc.
  • FYIQUEST
  • GATE Pharmaceuticals
  • Gerber Products Company
  • Highlights For Children
  • Huntleigh Healthcare
  • The Journal of Family Practice
  • McNeil Consumer Healthcare
  • Mallinckrodt Inc.
  • Medical Economics Company
  • National Procedures Institute
  • Nestle/Carnation
  • Novartis Pharmaceuticals
  • Corporation
  • Ortho-McNeil Pharmaceutical
Texas
  • Pharmacia Corporation,
  • Diagnostics Division
  • Prescribing Reference Inc.
  • Roche Laboratories Inc.
  • Ross Products Division
  • Sanofi-Synthelabo Inc.
  • Schering Laboratories/Key
  • Pharmaceuticals
  • Sepracor Inc.
  • Slim-Fast Foods
  • Company
  • SmithKline Beecham Pharmaceuticals
  • Smith & Nephew Casting
  • 3M Pharmaceuticals
  • Whitehall-Robins Healthcare
  • Women's Health in Primary Care
  • The Writings of Mary Baker
  • Eddy
  • Wyeth-Ayerst Pharmaceuticals

New physicians, international medical graduates get more clout

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"The AAFP is missing the perspective of over 30 percent of its active members -- new physicians," Julie Wood, M.D., said.

Resident & Student News

The Congress of Delegates voted Sept. 19 for new physicians to have a Board seat and international medical graduates to have delegate status.

Bylaws amendments for the new positions will be prepared for the 2001 Congress.

New physicians. Members in practice fewer than seven years are considered new physicians.

The vote on the Board position followed the advice of (then) President-elect Richard Roberts, M.D., J.D., of Madison, Wis., in his address. "Like most of you," he told the delegates, "I climbed the leadership ladder one rung at a time. I do not believe someone else's gain necessarily results in my loss. We all gain by having a more representative Board."

New physician delegate Julie Wood, M.D., of Macon, Mo., told a reference committee that, at any given time, many constituencies lack Board representation. "However, the AAFP is currently missing the perspective of over 30 percent of its active membership -- the new physicians," said Wood. "Everyone (in AAFP) was, is or will be a new physician."

One of the few to oppose the new physicians' seat, delegate Charles White Sr., M.D., of Lexington, Tenn., told the Congress, "I rise at risk of life and limb, awash in a sea of loneliness. I'm against slotted seats. We lose these people to our state chapters when they come on the national Board."

Rebutting him, Wood said, "This position is not designed as a fast track to avoid state leadership. This supplements state leadership." Delegates backed the new physicians' seat in a voice vote, reversing votes in recent years.

IMGs. An AAFP survey indicates 9 percent of members are IMGs, and delegates said IMGs constitute 16 percent of active members.

"Because of overt and covert discrimination, IMGs suffer inequities in licensure and entry into medical groups," Virgilio Licona, M.D., of Littleton, Colo., convener of the 2001 National Conference of Special Constituencies, said at a reference committee hearing.

"If our patients could come here and speak, you'd see lots of our IMGs are serving in underserved areas," Abdul Nayeem, M.D., of Laurel, Md., a member of the Commission on CME, said.

Viviana Martinez Bianchi, M.D., of Muscatine, Iowa, alternate delegate for minority physicians, told the committee, "I'm an IMG, proudly trained in Argentina. We're submitted to criteria U.S.-trained physicians aren't."

On the floor of the Congress, Bianchi asked, "Do you need to be in a health professional shortage area to hire Maria, a wonderful candidate from Costa Rica who graduated from a fine residency program? Allowing IMGs to bring their issues forward to this floor will help the Academy grow in understanding of a difficult and poorly known reality."

The vote on IMG delegates, a standing vote, was 82-35.

Highlights of report

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The above ad appeared in journals at the Democratic and Republican national conventions this summer.

The report of the Task Force on Universal Coverage gives guidelines and specific elements for a plan to reform the U.S. health care system.

Guidelines. The guidelines say, for example:

Specific elements. The key elements include the following:

Phoenix rising: fashioning a new student interest initiative

BY CINDY McCANSE

The question of how best to continue courting student interest in family practice got big play Sept. 18-20 in the Congress of Delegates.

After the dust settled, one resolution addressing this issue received delegates' thumbs-up; a second goes to the Board of Directors for further study.

Resolution 603, submitted by residents and students in response to the sunsetting of the Task Force on Student Interest, calls for the AAFP to take a leadership role in developing a coalition of students, Academy members and representatives from other family medicine groups to continue addressing this critical issue. The resolution received overwhelming approval.

Resolution 608, calling for a standing committee on the future of family practice, garnered only limited support, and an amended version was referred to the Board.

Student delegate and incoming student Board member Andrew Mills of Tulsa, Okla., said that a consensus-building group such as that provided for in Resolution 603 is essential to preserving the mission of the task force.

"All the members of the family medicine family should address student interest," said Mills.

Delegate Thomas Norris, M.D., of Seattle led the testimony in favor of Resolution 608. The resolution, he said, fills the gap left by the dissolution of the task force and calls for the AAFP to sponsor a forum on the future of the specialty by 2002.

Resolution 603 is on target, he added, but fails to address the full scope of the problem.

"We need two resolves: We need to define our future, and we need to create a clear pathway for students to enter the specialty," Norris said. "Resolution 608 does both of these things."

Testimony against Resolution 608 focused on the fiscal demands of developing an additional meeting. Also, noted incoming resident Board member Jennifer Aloff, M.D., of Midland, Mich., the addition of another meeting stands to siphon attendance away from the National Conference of Family Practice Residents and Student Members.

"We'd hate to see something else pulling away from or competing with that conference that we love dearly and that we're continually working to improve," Aloff said.

Support a research journal, delegates decide

Financial constraints -- will they stop the presses for family practice research journals?

Fear of just that led eight chapters and a commission to tell the AAFP Congress of Delegates they want the Academy to support a journal for original clinical research in family practice.

New policy: "The AAFP will take a leadership role to assure the existence of at least one journal that publishes original family practice research."

"The definition of a discipline is that it must have a body of knowledge," said Stephen Spann, M.D., of Houston, chair of the AAFP's Task Force to Enhance Family Practice Research.

"Our journals are in peril," Spann told a reference committee. "Much of the difficulty has to do with stresses on pharmaceutical companies, fewer dollars available for ads in research journals."

The Congress adopted this policy from the Commission on Clinical Policies and Research report: "The AAFP will take a leadership role to assure the existence of at least one journal that publishes original family practice research."

AAFP Executive Vice President Douglas Henley, M.D., said, "We're in the third year of our five-year, $7.7 million initiative to boost family practice research. We've begun our national network of practice-based researchers. We anticipate more researchers, more manuscripts, more high-quality publications. The Board of Directors is committed to ensuring publication of the specialty's research."

A Board report to the Congress said AAFP's financial investment in the research initiative has already had tangible results.

"We're poised on the end of the diving board," said Director Charles Driscoll, M.D., of Lynchburg, Va. "Pulling the journals out would be like taking the pool out from under the divers."

AAFP's new research network attracts federal planning grant

It may be only 10 months old, but the Academy's National Network for Family Practice and Primary Care Research has already attracted a federal grant. The Agency for Healthcare Research and Quality has awarded the research network a $101,187 planning grant.

John Hickner, M.D.
"This will help to provide the foundation on which we will build a research lab for family medicine -- our family physicians' offices."

What's the network planning? "We're planning great things," says AAFP President Richard Roberts, M.D., J.D., of Madison, Wis., who has championed practice-based research for 14 years. "A grant like this will help us redefine the specialty and the practice of medicine in America by identifying better care for patients, which means better health for patients."

The 12-month grant is part of a $2 million initiative being coordinated by the AHRQ Center for Primary Care Research to enhance development of practice-based research.

According to Herbert Young, M.D., AAFP Scientific Activities Division director and principal investigator, the funds will help the network plan activities in four key areas: using technology to collect and analyze data, conducting research of importance to the health of minorities and underserved populations, efficiently translating research findings into clinical practice and identifying ongoing network funding sources.

The grant gives AAFP a seat at the table with other established primary care researchers around the country and recognizes the network's potential to deliver, says John Hickner, M.D., director of the network. "This will help provide the foundation on which we will build a research lab for family medicine -- our family physicians' offices."

Congress of Delegates tackles hassles

The Congress of Delegates tackled many of medicine's hassles and came up with some help. For example:

Economic credentialing. The Iowa chapter submitted a resolution on privilege problems in hospital systems in the throes of competition. Some physicians may no longer serve on the staffs of both large systems in Cleveland, but are being granted privileges and medical staff membership in only one system.

"It's major war," said Jeffrey Bachtel, M.D., of Tallmadge, Ohio, treasurer of the Ohio AFP. "Each hospital system is forcing physicians not to practice in the other system."

In response to this problem, delegates insisted credentialing must be based on training, experience and competence, and they opposed any form of economic credentialing.

Office inspections. During debate, delegates objected to inspections that are time-consuming, costly and lacking basis in scientific evidence. "Get all of these people out of our offices until they can prove they're doing good for our patients," said delegate Richard Hays, M.D., of Lake Worth, Fla. Another delegate said that facilities must be inspected to be accredited.

The Congress asked the AAFP to work with the Joint Commission on Accreditation of Healthcare Organizations to produce reasonable, evidence-based guidelines for inspections.

Reimbursement. Delegates discussed reimbursement problems in managed care organizations. A short list: improperly bundling packages of separately defined services, downcoding accurately coded services and disallowing covered services coded correctly.

The Congress asked the AAFP to develop partnerships with other primary care societies and MCOs to promote reimbursement fairness and coding accuracy and to prevent unfair, inconsistent payment practices.

Disappearing dentists. "It's difficult to get hold of a dentist after 2 p.m. on Friday or Wednesday or on weekends, and some dentists say 'Call your family doctor for pain medicine,'" said delegate Timothy Tobolic, M.D., of Byron Center, Mich.

The Congress considered patients' difficulties reaching some dentists and said the Academy should work with the American Dental Association about provision of after-hours dental care.

Experts examine common respiratory problems, solutions

Annual Clinical Focus

BY DENNIS CONNAUGHTON

You deal with respiratory problems almost every day in your practice. Some of the most common ones came under scrutiny in a course at this year's Assembly.

Asthma

"I hope that by the time you leave today, I can convince you that nebulizers are an obsolete way of treating children with asthma," said Leslie Hendeles, Pharm.D., professor of pharmacy and pediatrics at the University of Florida in Gainesville.

He recommended, instead, the use of albuterol delivered through a valved holding chamber device. "You can get the same clinical effect using a spacer with albuterol that you get with a conventional nebulizer system," Hendeles maintained.

When using albuterol, be sure to select an albuterol nebulizer product that does not contain a bronchoconstricting preservative, such as benzalkonium, he advised. Using levalbuterol, an active stereo-isomer of albuterol, for acute asthma in children is no more effective but much more costly than using albuterol, he said.

Otitis media and sinusitis

Rick Ricer, M.D., professor and predoctoral director of family practice at the University of Cincinnati, described the latest treatment options for otitis media and sinusitis. "Otitis media and sinusitis are very similar disease processes," Ricer said. "Many of the same things trigger each response. The bacterial causes are identical, and the antibiotics used are the same."

He said the first-line drug therapy for both conditions is amoxicillin -- 80 to 90 mg per kilogram per day for acute otitis media, except in very low-risk patients, and 40 to 90 mg per kilogram per day for sinusitis.

"Nebulizers are an obsolete way of treating children with asthma."

Up to 80 percent of acute otitis media cases may resolve spontaneously, Ricer said. Nonetheless, he recommended the use of antibiotics, saying they shorten the course of the illness, decrease otalgia, speed perforation healing and decrease the incidence of subsequent mastoiditis.

Not all cases of acute sinusitis need antibiotic therapy, Ricer said, but all cases need some type of drainage with decongestants or other options. Decreased use of antibiotics for colds masquerading as acute sinusitis may help thwart the problem of drug resistance, he contended.

Sore throat

For patients with pharyngitis, physicians should do a rapid strep test, said Louis Kuritzky, M.D., clinical assistant professor of family medicine at the University of Florida in Gainesville. If the test is positive, treat the patient with penicillin for 10 days or with similar antibiotics, such as erythromycin.

If the strep test is negative, consider false-negative streptococcal infection or other infections, such as those caused by Chlamydia, Mycoplasma, non-group A Streptococcus or Clostridium hemolyticum. Also ask the patient about his or her sexual practices because sexually transmitted diseases can cause a sore throat, Kuritzky said.

Community-acquired pneumonia

For community-acquired pneumonia, Kuritzky recommended outpatient care for patients at low risk of mortality, based on a risk stratification scale developed by the Pneumonia Observation Results Team. High-risk patients require traditional inpatient care.

AECB

Patients with acute exacerbation of chronic bronchitis should be managed with maximum bronchodilator therapy and postural drainage, Kuritzky said. Do not give them cough suppressants or sedatives, and advise them to stop smoking. Antibiotic treatment may have a small but beneficial effect.

AAFP in the 'Big D'

Fun, friendship and fervor for learning marked the American Academy of Family Physicians' 52nd Annual Assembly in Dallas.

Casting and Splinting workshop

Carrie Carlson, D.O., a chief resident from Sioux Falls, S.D., teamed up with Jim Jenkins, M.D., of Vienna, Va., in a Sept. 22 casting and splinting workshop.
 
Reba

Country music superstar Reba McEntire cut loose at the All-Member Event Sept. 23.

 
Dr. Roberts

"We will weave a new health care system where every American will be able to choose a family doctor and where every American will want one," Richard Roberts, M.D., J.D., of Madison, Wis., said in his speech to the Congress of Delegates as president-elect. "We will repair American medicine through our science, our service and ourselves." Roberts was installed as AAFP president Sept. 22.

 
Clinical procedures workshop

Shama Masani, M.D., of Horseheads, N.Y., participated in one of the Sept. 22 clinical procedures workshops on joint injection.
 
AAFP Family Fun Run

Assembly participant Karen Vedder hit her stride in the 19th Annual AAFP Family Fun Run Sept. 23.

 
Circle R Ranch

Ann Miller Pennebaker, 3, of Batesburg, S.C., was ridin' high during the Sept. 20 Youth Program at the Circle R Ranch.


CAM is everywhere: Here are tips for dealing with it

BY SHARON DICKINSON DENT

Complementary and alternative medicine is ubiquitous -- patients everywhere are talking about it and using it. One study found that patients make almost twice as many visits to CAM providers as they make to traditional providers. And one conservative managed care organization has approved five botanicals for its formulary.

Get CAM information online

Interested in complementary and alternative medicine? Visit these Internet sites:

So said Laura Patton, M.D., clinical director of the alternative services program at Group Health Cooperative in Seattle, in her presentation, "Complementary and Alternative Therapies: A Practical Approach for Clinicians," Sept. 21 at the Assembly.

In Washington state, all health plans are required to provide patients with access to all licensed providers, including licensed providers of CAM. In response, Group Health Cooperative has offered a program of covered CAM services since 1996.

Group Health offers referrals for acupuncture, naturopathy and massage therapy services based on specific clinical conditions, she said. (The group allows patients to self-refer to chiropractors.) The health plan continues to fine-tune the program and develop evidence-based guidelines for referrals, she said.

Issues cause discomfort

Patton addressed some issues about CAM that make allopathic and osteopathic physicians uncomfortable at times:

Integrating referrals

Patton offered tips for physicians interested in integrating CAM referrals into their practices.

First, find out what vitamins, herbs and dietary supplements patients are already using -- and patients may not offer that information easily. "Somehow, we need to instill in our patients the idea that these are medicines; they have a physiological effect on you," Patton said.

Ask patients whether they're already working with a CAM provider. One approach is, "Have you consulted anyone else about this pain?" If so, find out what therapies were used and whether they helped.

Patton encouraged physicians to make a definitive diagnosis and discuss conventional treatment options before suggesting CAM therapies. Work with the patient to identify the major symptom or complaint and a measure of success to indicate when further treatments for that problem aren't necessary. Then refer for a limited number of CAM visits and follow up with the patient again after the referral expires. "Patients like that you're interested and that they're playing a part in increasing your knowledge base," said Patton.

Advise your patients on questions to ask the CAM provider, such as: "How many people have you treated with my condition? How can I expect to feel after treatment?"

Whenever possible, keep in touch with the CAM providers caring for your patients, Patton said. Good communication will ensure you're informed on all the treatments your patients receive.

Tobacco team hits audience hard with message

BY SHERI PORTER

Photo

Mississippi Attorney General Mike Moore
"Washington, D.C., is the only place in the world where you can't give away $368 billion."

Call them the dynamic duo. Mississippi Attorney General Mike Moore and former tobacco company chemist Jeffrey Wigand, Ph.D., teamed up to bring a crowd to its feet at the close of the Sept. 20 AAFP Scientific Assembly special evening presentation, "Inside the Tobacco Industry."

The pair's grueling odyssey through the court system, which brought incriminating tobacco industry documents to the public eye and made the industry pay for damage to smokers, was made famous by the 1999 Hollywood film "The Insider."

Moore spoke first, and his message was clear: Don't let our hard work and sacrifice go to waste. "Millions of dollars didn't just fall out of heaven," Moore said, alluding to years of court battles.

"The settlement money can change the future of public health if it's used properly," said Moore as he strode around the stage in his shirt sleeves. He held up the state of Mississippi as an example of a state doing it right. Mississippi, he said, is spending 100 percent of tobacco settlement funds on tobacco education and smoking cessation programs.

Moore chastised states that are not. "Any of you from Texas?" he asked, squinting out into the audience. "We're gonna whop up pretty good on you because Texas isn't doing much." He was referring to the tactic many state governments have taken of squandering tobacco settlement money on unrelated budget items, such as tax cuts and road repair.

Photo

Former tobacco company chemist Jeffrey Wigand, Ph.D.
"Write to Congress to enact laws to regulate and control and bridle this industry."

'Logic-free zone'

Moore also took a jab at Washington, calling it the "logic-free zone" for its inability to pass a bill in 1998 for a federal settlement agreement that he sweated for and he claims "had everything in it."

"Washington, D.C., is the only place in the world where you can't give away $368 billion," he said, eliciting laughter from the crowd.

Wigand, now affiliated with Smoke Free Kids Inc. in Charleston, S.C., followed Moore and was introduced to the audience through clips from the movie. Wigand, like Moore, paced the long stage, detailing how he went from being a well-paid Brown and Williamson Tobacco Co. executive in 1989 to being the centerpiece of a Hollywood movie and a key player in the tobacco settlement case.

But Wigand's main message, like Moore's, was that there is a substantial pot of money available to states, and that money needs to be used to address a public health crisis.

"We have a settlement to prevent 3,000 kids a day from being addicted to a product that, when used as intended, kills you," Wigand said.

Plan of action

Wigand called for a plan of action from the audience as he noted a general lack of cohesiveness in the medical profession in its response to the tobacco industry.

"This is the only industry I know of with no regulatory body," Wigand said. "Write to Congress to enact laws to regulate and control and bridle this industry."

He touched on the tremendous power of advertising and called on the audience to work to combat tobacco advertising that hooks kids on an image. Use the kids as messengers against tobacco use, Wigand said. "Youth have a dramatic effect when we empower them as mentors."

Family Physician of the Year puts focus on underserved

Photo

Dennis Saver, M.D. was honored as AAFP's 2001 Family Physician of the Year by the Congress of Delegates.

The Academy's 2001 Family Physician of the Year has achieved national recognition for his community's efforts to care for the underserved, but his concern for that population was triggered before he even entered medical school.

Dennis Saver, M.D., had planned to pursue a career as a clinical researcher "with a capital R and a small C." While working as a health data analyst with an urban Philadelphia clinic, however, he saw the need for continuity of care in the community context.

"It showed me that there was a real need for taking care of people, and taking care of them in a larger sense than just treating them as numbers or encounter units," he said.

Upon completing a family practice residency in Gainesville, Fla., Saver took a National Health Service Corps assignment with a Rural Health Initiative in the rural Appalachian town of Newburg, W. Va.

At the end of his two-year obligation, he opted to stick around another eight years.

Saver took his family and his concern for underserved people back to Florida in 1990, where he subsequently became founding president of his current group practice, Primary Care of the Treasure Coast, in Vero Beach. In 1991, he volunteered to chair the county medical society's new indigent care task force, which developed a volunteer physician clinic using the Florida Medical Association "We Care" model. The program answered the county's plea for subspecialists to care for patients with Medicaid or no insurance. Although patients could receive primary care at the health department, subspecialty care had been difficult to obtain from private physicians, Saver said.

In the Indian River County We Care program, primary care physicians evaluate patients and then refer them to subspecialists when needed. Most of the subspecialists now treat the We Care patients in their private offices, volunteering on a rotating basis.

Saver chairs the county We Care committee and volunteers in the program. "It's usually a great thing for me to go in and be a doctor and do medicine and not worry about the business aspects," he said. "When I'm volunteering, I know I'm not getting paid, and I don't have to worry about paying someone's salary or the light bill or the workman's comp or whether the patient can afford this or that. I can really just carry my stethoscope, do clinical medicine and walk away knowing that had I not done it, it wouldn't have happened. The second aspect is that our program has gotten some publicity nationally, and I'm hopeful that it may spark other people to contribute in a similar fashion in their own communities."

As he continues to reach out to the community's needy people, Saver is now targeting the bureaucracy of Florida's Medicaid system. Reforms would enable more physicians to participate and, in turn, would give more people access to high-quality health care, he said. "Right now, you have to be really, really dedicated to participate in Medicaid. You have to jump over enormous hurdles, suffer incredible bureaucracy and tons of paperwork, and your reward is that you get paid less than your overhead costs, if you get paid at all."

The AAFP Congress of Delegates presented Saver with the 2001 Family Physician of the Year Award on Sept. 18.

Referring to his work at We Care, Saver told the Congress, "To my surprise, this activity for which I sought no personal gain has brought me an extraordinary honor." The clinic's patients and staff wrote letters nominating him as Florida Family Physician of the Year, which eventually led to his receipt of AAFP's 2001 Family Physician of the Year Award.

Rep. Henry Bonilla, others win AAFP awards at Assembly

The Congress of Delegates gave numerous awards recognizing contributions to the specialty on Sept. 18-19. The new National Leadership Award was presented to Rep. Henry Bonilla, R-Texas. "Many of us refer to Henry Bonilla as our health professions champion in Congress," said (then) AAFP President Bruce Bagley, M.D., thanking Bonilla for his support of primary care initiatives.

"I'm proud of my accomplishments in helping increase funding for health training programs," said Bonilla. "Despite the fact that we haven't gotten the budgets we needed from the White House or the Senate, we've been able to prevail."

Bonilla serves on the House Appropriations Committee and its Labor, Health and Human Services, and Education Subcommittee. Partly through Bonilla's work, Congress is likely to approve $86 million for Title VII primary care programs in fiscal year 2001, the amount the Academy backs, an increase of about $8 million over the FY 2000 funding.

The new award honors those who have helped improve the nation's health by furthering primary care through legislation or the support of public policy initiatives.

Other awards and their winners:

HIV infection: no longer a death sentence

BY CINDY McCANSE

There's good news and bad news in the battle against HIV infection.

"There have been so many advances in the treatment of HIV that it now can be considered a chronic illness," said Patrick Morrow, M.D., of Dallas at the Sept. 22 AAFP Scientific Assembly mini-course, "HIV Management."

"This is no longer a death sentence, and, with proper management, every one of our HIV patients can live a normal and full life."

The key, Morrow explained, is knowing what therapeutic options are available and how to use them effectively.

Management of HIV-infected patients is a complex process that starts with appropriate screening. Knowing when to order diagnostic testing is essential to early detection, said Morrow. And physicians who don't routinely care for patients with HIV infection should enlist expert help.

Even then, there's a caveat.

Patrick Morrow, M.D.
"The difference between dogma and dog manure in HIV treatment is six months. So anything I tell you today may be wrong six months from now."

"The difference between dogma and dog manure in HIV treatment is six months," Morrow said. "So anything I tell you today may be wrong six months from now."

The nearly 20 drugs currently used for HIV treatment are generally administered in standardized combinations. In medication-naïve patients, initial drug combinations usually consist of two nucleoside reverse transcriptase inhibitors plus a protease inhibitor; two NRTIs plus a non-nucleoside reverse transcriptase inhibitor; or three NRTIs. This type of regimen is known as highly active antiretroviral therapy, or HAART.

Patient adherence is key, Morrow added. Physicians must stress the importance of following the therapeutic regimen and educate patients regarding the potential consequences of noncompliance.

Still, viral mutations can cause one drug or another to lose effectiveness. Genotype testing can identify these mutations, allowing the physician to determine which drug is failing and adjust therapy accordingly.

Successful treatment with some HAART regimens is not without its costs. Body fat redistribution and lipodystrophy are being seen with increasing frequency. And the most recent apparent side effect -- avascular necrosis of the hip -- currently has the experts stumped.

Not good news, surely. But given the advances made in HIV care to date, it seems safe to say that these obstacles, too, can be overcome.


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


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