January 2001 • Volume 7 Number 1
Speak out for patients despite 'inscrutable' politics
BY CINDY McCANSE
"Health policy has always been political. It's now becoming bitterly partisan," says Emily Friedman.
Frustrating as it may be, no one should be surprised that the 106th Congress failed to pass the sort of sweeping patient's rights legislation backed by the AAFP and other medical organizations.
At least, that's the opinion of Emily Friedman, noted author and lecturer on health policy and social ethics.
"I find it astonishing that any health policy ever gets made," Friedman said in her keynote address at the Nov. 17-18 AAFP State Legislative Conference in New Orleans. "The reason is that this is really hard stuff."
Typically, she said, health policy is adopted in increments. She pointed to the establishment of Medicare and Medicaid during the 1960s as a notable exception, one not likely to be repeated any time soon. That accomplishment, Friedman noted, was due largely to the "talents" of former President Lyndon Johnson -- both his commitment to this social cause and the fact that "he had stuff on everybody in Congress."
A native of Los Angeles now based in Chicago, Friedman is no stranger to political maneuvering. She recalled the likes of Chicago's storied father/son mayoral duo, Richard J. and Richard M. Daley, and long-time Louisiana governor Huey Long, as she spoke about the intricacies of forging political alliances to accomplish legislative goals.
"It's important to remember that our priorities are not necessarily everyone else's priorities," she explained to 125 family physicians, health policy-makers, and chapter executives and lobbyists. "Health policy hasn't been a priority for Republicans; national defense hasn't been a priority for Democrats.
"Health policy has always been political," said Friedman, "but it's now becoming bitterly partisan."
Party members these days adopt the position of their party whether or not they actually understand the issues involved, she claimed. "A word to those of you who will be working with members of Congress: There are quite a few dim bulbs on both sides of the aisle."
Special interest lobbyists with deep pockets often guide the actions of legislators, said Friedman. And the introduction of state term limits has further complicated matters, she added. "When there's no consistency, when there's no continuity -- lobbyists make the policy."
Even so, it's essential for health care providers to take every chance to speak out in the best interests of their patients, said Friedman. "Front-line health care professionals know more than anybody else about how health policy affects patients. Use that credibility. Use your influence to increase the amount and quality of civil discourse."
In one sense, Friedman said, initial disappointments at the national level can offer even greater opportunity to enact meaningful health policy in the state legislatures, in turn providing greater impetus for the U.S. Congress to revisit these topics in future years. For example, although there's little chance for any major federal policy gains until 2002, "One issue -- pharmaceutical drug costs -- will probably be addressed at a national level at that point because so many states will have acted on this very issue," Friedman said.
Which makes it all the more important for physicians to press for those goals in every legislative venue, she said.
"Stand up for what you believe in and act on it," Friedman urged. "Even if you don't think you can win, even if the politics are inscrutable, even if you can't see the light at the end of the tunnel -- be a voice."
Be on the lookout for possible polio importation, CDC says
Polio outbreaks in Haiti and the Dominican Republic have led U.S. health officials to issue an alert. The CDC is urging physicians and public health departments to consider the possibility of polio in patients with acute flaccid paralysis who have recently immigrated from or traveled in those areas.
Family physicians should be especially vigilant, said Herbert Young, M.D., director of the AAFP Scientific Activities Division. "A lot of our family practice residencies provide care for these patients," Young said. "Many of our members donate their time to public health facilities and free health clinics."
This outbreak in the Americas reinforces the need to ensure that all children receive appropriate vaccination for polio and other infectious diseases, Young added.
Physicians who suspect polio in a patient should immediately contact their local health department.
The CDC has issued a one-page alert about this potential health risk, advising physicians about the need to consider polio as a part of the work-up for patients with acute flaccid paralysis. You may obtain a copy of that document via "Quick Fax".
Practice errors far more clerical than clinical
BY JANE STOEVER
In the first nationwide study of patient safety in primary care, family physicians have reported many more system errors than mistakes in medical judgment or treatment.
The 42 family physicians in the study reported things that should not have happened in their offices -- things the FPs hope will not happen again.
Based on a preliminary review of the data, the overwhelming majority of errors relate to:
- office management systems that don't prevent, for example, filing patient information in the wrong place or ordering the wrong tests, treatments and pharmaceuticals;
- poor communication with patients and with others in the practice or outside the practice; and
- payment problems, including those caused by referring a patient to a provider outside the patient's health plan.
"We don't have to think about how we can avoid chopping off the wrong leg," says Susan Dovey, M.P.H., principal investigator for the study. "Instead, we have to think about some more 'down home' things. And they're not trivial. About half the errors reported resulted in some adverse effect on patients."
Dovey presented preliminary results from the study during the annual meeting of the North American Primary Care Research Group Nov. 4-7 on Amelia Island, Fla. She serves on the staff of the Robert Graham Center, AAFP's policy center in Washington. The physician researchers, each of whom was asked to report 10 errors, belong to AAFP's National Network for Family Practice and Primary Care Research.
"Almost all the information about medical errors to date has been focused on hospitals," says Dovey. "This study is churning out exciting results that will add to the body of knowledge. Early intervention to remedy errors in primary care may avert patients' need for secondary care."
The study, which points to the need for more extensive research, is expected to be completed and published in 2001.
Join renewed campaign to promote breast-feeding
BY SHERI PORTER
Despite years of studies proving the benefits of breast-feeding for babies and moms, experts are still trying to convince the public that "breast is best."
As part of a renewed educational effort, the Department of Health and Human Services released its HHS Blueprint for Action on Breastfeeding last fall. The plan recommends that infants should be exclusively breast-fed for six months and that, ideally, breast-feeding should continue through the first year of life. Announcing the plan, Surgeon General David Satcher, M.D., Ph.D., said, "Low breast-feeding rates documented in the HHS Blueprint are a serious public health challenge, particularly in certain minority communities."
Satcher, a family physician, referred to statistics revealing racial and ethnic disparities. In 1998, only 45 percent of black American women breast-fed their newborns, and the figure dropped to 19 percent after the babies were 6 months old. By contrast, figures for American mothers as a whole were higher, with 64 percent breast-feeding after delivery, but only 29 percent still nursing six months later.
What's going on? For one thing, many physicians sorely lack breast-feeding expertise. Addressing this problem, the HHS plan calls for increased training for health care providers, including continuing education requirements.
But the lack of physician expertise in this area isn't new. A 1995 study co-authored by Gary Freed, M.D., and published in the Journal of the American Medical Association found, "overall, physician involvement in breast-feeding promotion was endorsed by 90 percent of respondents, yet only half rated themselves as effective in counseling breast-feeding patients." Back in 1993, Freed wrote in JAMA, "It is indeed time to teach what we preach."
Position paper due next summer The AAFP's Commission on Public Health, chaired by Leah Raye Mabry, M.D., of Pleasanton, Texas, is developing a breast-feeding position paper with input from an 11-member advisory committee. FPs, including Alicia Dermer, M.D. (see story on this page), are working on the paper, to be published next summer. Mabry, who also chairs the breast-feeding advisory committee, called breast-feeding a "natural wonder." She said the purpose of the paper is to "provide the family physician with an understanding of breast-feeding and its impact on the infant and the family." Wherever possible, Mabry said, "content will be evidence-based and supported by experts." The commission received funding for this project from the HHS Maternal and Child Health Bureau.
Alicia Dermer, M.D., of the family medicine department at the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School in New Brunswick, couldn't agree more. Dermer presented a session on the family physician's role in encouraging and facilitating breast-feeding at the Conference on Patient Education Nov. 16-19 in Albuquerque, N.M.
Physicians have a responsibility to promote breast-feeding, Dermer said, because it's a critical public health issue: "Any time a physician misinforms a woman and has her wean, that decision has a direct health impact on her baby and, potentially, on her."
Tap your enormous power of influence, Dermer said. "Use teachable moments in the practice to normalize breast-feeding -- make it part of what you teach every day in interacting with patients."
What you don't say counts, too. "The omission of a statement has a powerful effect. If physicians don't talk about breast-feeding, people may assume it's not that important," said Dermer.
But winning a woman over to breast-feeding is only the beginning. Keeping new moms nursing can be just as challenging. Encourage your breast feeding moms with positive feedback, said Dermer. "When mom brings the healthy 4-month-old in for a check-up and says he hasn't been sick at all, smile and say, 'Wonderful ... it's because you're breast-feeding.'"
Discourage bottle-feeding by making your office a formula-free zone. "That's not to say we can't prescribe formula if someone needs it, but we shouldn't give out samples and literature from formula companies," Dermer said.
She makes her office breast-feeding-friendly, and her growing practice proves it, as nursing moms flock to her for the support they weren't getting elsewhere.
"In fact, there is another reason to learn about and support breast-feeding. As mothers become more educated, they want a supportive doctor who won't constantly tell them they should be weaning -- and they're going to vote with their feet," said Dermer.
Strategies to promote breast-feeding
- Educate yourself.
- Make it clear that breast-feeding is the norm.
- Hang pictures of nursing moms in your office.
- Post a sign, "You are welcome to breast-feed here."
- Discuss breast-feeding whenever the topic is relevant.
- Train your staff to present a consistent, positive message about breast-feeding.
- Help patients work through breast-feeding challenges.
- Utilize resources such as the HHS Blueprint available at http://www.4woman.gov/Breastfeeding/index.htm and AAFP's Physicians' Breastfeeding Support Kit available at https://secure.aafp.org/cgi-bin/catalog.pl?uid=cat100949 or by calling (800) 944-0000 (request #R926, free).
Q&A
Richard Roberts, M.D., J.D.'Keep the faith -- good things are coming for family physicians'
Drops in income. The complexities of coding. The frustration of practice in a disintegrating health care system. Difficult transitions. Lives out of balance. Not enough family physicians to go around.
For many FPs these days, meeting the demands of practice is an increasingly tough row to hoe -- that's what President Richard Roberts, M.D., J.D., of Madison, Wis., has been hearing from AAFP members. In this Q&A, Roberts discusses problems facing FPs today, reasons for optimism about the future -- and his ambitious plan for keeping in touch with Academy members and their issues.
What are you hearing -- why are many family physicians saying they are frustrated and discouraged these days?
It's clear that family physicians see the U.S. health care system as a timeworn, cobbled-together patchwork, with themselves stretched like lifelines across the fraying fabric. And many of them are feeling just as worn and frayed as that patchwork system.
The economically robust '90s were good for FPs. Expanding health plans showered us with money to buy our practices and make us their employees. Student interest in the specialty zoomed -- and so did FP incomes.
But then came the managed care backlash. The system's chaotic disintegration accelerated. Student interest in family practice began to decline. Median FP income leveled off -- it even dropped last year. Now, many FPs feel caught in a practice noose that grows only tighter.
What's the impact on you as Academy president?
I broke with tradition. The AAFP president usually leads a new task force to work on one project of interest. Instead, I'm doing three things. I'm shepherding several existing Academy projects to completion and into the hands of FPs to help them. I'm focusing on our members with a message of appreciation and hope. And I'm announcing to America that we need to create a health care system where every American will be able to choose an FP and every American will want one, with the intent of reframing the health care debate and giving our members a sense of pride and responsibility. I want FPs to hold on and keep the faith -- good things are coming their way!
Can you describe some of those AAFP initiatives that make you optimistic?
One is our proposal for health care coverage for all in the United States. Right now, every member can comment on AAFP's proposal -- just go online at http://www.aafp.org/unicov/ or call (800) 944-0000 for a copy (item #R016). The AAFP Board will consider all input and submit a plan to the Congress of Delegates next fall.
Beginning next month, the Academy will communicate the value of family practice to the public and policy-makers with an exciting Public Awareness Campaign. This three-year, $3.5 million effort will include ads in USA Today and The Washington Post, as well as support of National Public Radio's Morning Edition and All Things Considered. Stay tuned for campaign specifics in the February FP Report.
In addition, our nearly $8 million investment in family practice research is bearing fruit. You'll soon see a growing volume of literature demonstrating the high-quality, cost-effective, patient-centered care that FPs provide. Our policy center in Washington will translate those findings into conclusions that even politicians and payers can understand!
And then there's the Practice Quality Enhancement Program, as well as AAFP's involvement in IDCOP, the Idealized Design of Clinical Office Practices initiative. The Academy also is working to put FPs on the cutting edge of information technology. And finally, the Academy is moving to an evidence-based system for classifying CME clinical content, which will ultimately help FPs provide the most scientifically valid care for their patients.
You've also committed yourself to an ambitious effort to call one member a day during your presidency. Can you give more details?
It's my Direct Dialogue campaign. I want to stay in touch with rank-and-file members and be aware of the issues they face and how the Academy could serve them better. In the Direct Dialogues I've had so far, a few members have said things are going well -- but many have said they're stressed and discouraged. Their concerns are across the board, from economic credentialing to Medicare fraud, from life balance to a family physician shortage.
I tell them not to give up, because all these good things are coming from the Academy -- things that will make our practices more effective and efficient and, most important, things that will help our patients and in turn help us to enjoy more of our moments with those patients. Because when all is said and done, the health of our patients remains our greatest concern, and our relationships with them remain our greatest source of professional satisfaction and strength.
It's 2020
It's 2020.
That's what participants at the recent Keystone III think tank on family practice envisioned.Two speakers were asked to take opposing views explaining the state of the specialty -- Larry Green, M.D., had the daunting task of assuming the specialty had failed and saying why; Marjorie Bowman, M.D., took the premise that the specialty had succeeded and suggested why. On these two pages are summaries of Green's and Bowman's main points. Keystone III was held last Oct. 4-8 in Colorado Springs, Colo., in the tradition of Keystone I and II in 1994 and 1998 at Keystone, Colo.
Don't brand the thought-starter ideas on these pages as predictions. They're imaginary scenarios with sketches of the evolution from now to 2020 -- given either the demise or triumph of the specialty by then.
If family practice has failed, why?
Larry Green, M.D., director of The Robert Graham Center in Washington, gives a report following an imaginary Keystone V in 2020, a small gathering of believers in family practice who discussed the widespread recognition that family medicine had failed. Green first offers a context for medicine in 2020 in which it's likely the specialty would not survive.
Social/Medical Milieu
By 2020, the division of wealth among the citizenry had widened, and there were proportionately many more very wealthy and many more very poor individuals.Medicine was still politics on a grand scale. Hospitals that survived had amassed enough capital to have the latest version of whatever technologies could be applied to generate revenue out of the medico-information complex, the economy's largest sector.
There had been no particularly accurate workforce predictions other than growth. The eruption of additional and alternative health care providers had continued for the first decade of the century, with one person in four making a livelihood in health care.
Outside of cities, general surgeons had reversed decades of decline and become the centerpiece of personal, face-to-face health care. Emergency medicine physicians comprised some 20 percent of all physicians. Midwives managed most maternity care. Nurse practitioners did some 80 percent of technical procedures and virtually all genetic counseling, and pharmacists were the first point of contact for the care of chronic conditions amenable to drug treatment.
In cities, "health care boutiques" were all the rage, each jockeying for a more enticing image, spending twice as much on advertising as on quality improvement. Their doctors were the heirs of medical subspecialization.
The psychiatrists had largely disappeared, their prescribing done by a host of others.
The OB-GYNs, after winning the skirmish with family medicine concerning maternity care, had abandoned obstetrics as not worthy of their training and expertise.
The public continued to seek more health care and openly fantasized about immortality, but despite "progress" remained as dissatisfied as ever. A decade after universal inclusion was achieved in 2010, it did not seem like everyone was guaranteed anything.
If there was a significant pocket of public dissent, it was among the wealthiest of the poor, struggling to break into the "good life" always just beyond reach. No one asked for a return to the good old days "when we had a family doctor." Yet Keystone V attendees reported anecdotes about individuals who expressed their frustrations about being treated as unknown objects by the health care enterprise and not feeling understood by anyone. The patient's message was, "How can there be so much known about me, while no one in the health care system knows me?"
The Specialty's Failure -- Why?
Participants in Keystone V -- there were only a couple dozen of these "residual believers" in family medicine -- first agreed that the steady decline in the proportion of health dollars and total dollars that went to FPs was a fact reflecting other factors and not an adequate explanation in and of itself. They also agreed that failure doesn't really exist as a thing, only from a position of judgment. To make the judgment, one must have a viewpoint. Thus, the residual believers organized their thoughts from different viewpoints.
Viewpoint 1: Family medicine didn't really fail; it abdicated. It made sense to turn over the care of the dying, the newborn, the adolescent, the athlete, the discouraged, the pregnant, the bed-bound, the postoperative person -- to someone else.
Viewpoint 2: Family medicine went down as part of the old paradigm. A few Keystone V participants had reminded family physicians during the past few years that the AAFP held a dominant position in the AMA as the AMA "went down."
Viewpoint 3: Family medicine failed because it chose the wrong tasks. Possibilities used to illustrate this viewpoint fell mostly into the following three categories.
- Nature of the work. Someone said family physicians woke up one morning about 2010 and couldn't remember what their particular clinical task was. Little wonder that the best and brightest no longer aspired to become doctors doing the tasks FPs did each day.
- Maturation of the discipline. A cardinal example was a protracted emphasis on producing more and more family physicians rather than the best family physicians.
- Intellectual advancement. As the years passed with family practice separated from curiosity and a vigorous quest for discovery, there was widespread recognition that breakthroughs always occurred somewhere else, followed by agonizing about how the family physicians just weren't doing the best things anymore.
Viewpoint 4: Family medicine failed because it never became part of the U.S. culture and was not radical enough to merit the opportunities inherent in being counter-culture. Family medicine was doomed from the beginning because of the culture of the United States, specifically its emphasis on consumption, fascination with the biological and physical sciences, and individualism. There was a certain disingenuity in family medicine's public display of its ambivalence about specialization while the populace was preoccupied with consuming the fruits of specialization. Everyone remembered the embarrassment of the specialty's being associated not with the best of modern medicine but with beer commercials and being denigrated as "medicine lite."
On the other hand, being located outside the mainstream of culturally sanctioned medicine was a primary reason family practice revenues were never greater than its expenses, always leaving the discipline short on capital in a capitalistic society and market-based medicine.
The residual believers uniformly regretted not speaking out more forcefully and effectively in academic centers, practice organizations, media and government for the core concepts of family practice and primary care.
If family practice is thriving, why?
Marjorie Bowman, M.D., professor and chair of the family medicine department at the University of Pennsylvania in Philadelphia, ponders the current state of family medicine and explores reasons the specialty may have succeeded by 2020.
Retrenchment Today
History can always identify our past errors, but we tend to overlook what we have done right. On the other hand, our biggest mistakes on occasion result in redirection that creates our successes.Considering what is happening today in family practice, I believe we have hit a period of retrenchment. We have fewer students interested in our field, some residencies are folding, and there has been an anti-gatekeeping backlash that is directed at us. Patients are clamoring for specialists and specialty care. The patient care bill of rights can be seen as anti-FP. The AMA has taken back its support for the Archives of Family Medicine.
I would like to think we are in a recurring cycle of ups and downs, that we are now on the downslope, even preferably to think that we have hit the bottom and are going into an upswing, but I have trouble convincing myself.
What will turn this around?
Reasons For Success By 2020
Some thoughts on what we will have done right by 2020:
We will have emphasized and continued to improve the quality of care, both that provided by family physicians and that of the entire system. We should be known as the quality doctors. We should have quality-based systems, we should advertise that we work on quality, we should publish on quality, we should find new methods that increase quality.
This includes quality of the doctor-patient relationship and quality of outcomes for the entire person -- not just the process of care or an individual disease. We know that quality requires appropriate systems. You can put a good physician in a bad system, and that physician will have trouble performing well. You can put a poor physician in a good system and improve the quality of his or her care. We will have developed systems that encourage good quality.
We will have pushed for and given every person in the United States the right to health care. Every patient should have health care in the richest country in the world. Every system has primary care at its base. In fact, within almost all countries, the primary care person of first contact is usually most akin to family practice in this country -- broad-based, easily accessible.
Assuring the right to health care is the right thing to do for the country and for family practice.
We will have gained political power. We will have advanced within the ivory towers of academic institutions, in state and federal legislatures, in medical political organizations. This requires time, effort and money.
Our goal should be to endow two or three professorships in family medicine at every medical school in this country by 2020. Endowment means faculty can have time to pursue research and education and not just patient care. Our goal should be to have as many or more funded NIH investigators at every school as departments of medicine have. We need a federal agency that sees family practice as a specialty to be nurtured and developed. We need to become the "go-to" doctors.
We will have developed technology that patients like and that supports our ability to provide high-quality care to people, for which people are happy to pay.
This means thinking about technology differently and using more of the technology that already exists. It may also mean that nationally we need to be innovative in forcing reimbursement changes and in helping family physicians know how to be paid for something other than visits. Nationally, we need to get technology innovations that will help us in our offices. Electronic medical records are a part of this -- without an electronic medical record as part of our system, it would be difficult to make that next step in increasing quality.
We will have advocated for research inside and outside of our own disciplinary walls that addresses multiple concurrent problems of patients. Federal spending is too individual-disease-specific. The end result is research that does not match our patient needs, since our patients have multiple concurrent problems (both mental and physical), are on multiple concurrent medicines, and thus often do not match the types of patients entered into federal research programs.
We will have made patients the masters of their own health care. Personally, I want to be in charge of my health care, but I admit I need help (from my family physician and others). Analogously, I want to be in charge of my bank account, my own legal situations (or fill in the blank), but I need help. Most patients agree with this, although sometimes we force them to show it in passive-aggressive ways.
We have often espoused this philosophy, but I do not feel we have implemented it fully. Patients who are active in their health care tend to have better outcomes. It is the epitome of all I have said here.
Continue the Keystone III dialogue regarding scenarios for why the specialty will have failed or succeeded by 2020. Share your thoughts on the future of the specialty by e-mailing fpreport@aafp.org or by faxing (913) 906-6089, attn: FP Report. Patients should be able to obtain health care. We should provide them high-quality care and also make sure they get it when they are not in our offices. We should use technology and research to their advantage. We should provide the tools to the patients and actively address this, not just talk about it when it is convenient.
We should be the high-quality, go-to doctors who put patients in charge. That's family practice -- that's our success.
From carve-outs to restructuring, AMA house takes action
The AMA House of Delegates, during its interim meeting Dec. 3-6 in Orlando, Fla., acted on topics including the following:
Carve-outs. The AMA pledged to try to eliminate mental health carve-outs, including drug rehabilitation carve-outs. The carve-outs separate mental health services and financing from other care and funding. AAFP delegates spoke against the carve-outs both in a reference committee and on the house floor.
Student delegates. The AMA house voted to have 18 student delegates in the house, with the students selected from various regions of the country according to the proportion of student members in the regions.
Provisional credentialing. The AMA house asked HCFA to allow provisional credentialing of new physicians by Medicare, Medicaid and managed care organizations, letting the physicians be paid for their services while completing lengthy credentialing processes. The house also encouraged expeditious credentialing of established physicians who move or change their practices.
Screening standards/preventive services. The AMA house voted to have a council study AMA's process for endorsing screening standards and recommend a process for dealing with resolutions on evaluating screening standards. AAFP delegates said the process should be evidence-based, as is the process used by the U.S. Preventive Services Task Force.
When the AMA house considered asking for increased Medicare coverage of preventive services, Academy representatives said an evidence-based process should guide Medicare's coverage of those services.
In the past, the AMA has sometimes taken stances at odds with evidence-based studies. For example, studies indicate the need for routine mammography screening for women beginning at age 50. But in an earlier meeting, the AMA endorsed routine mammography screening every two or three years beginning at age 40.
"The AMA house's acceptance of the Commission on Unity report was AMA's first official recognition there has to be systemic change. We can no longer just tinker around the edges."
Neil Brooks, M.D.
Restructuring the house of medicine. The Commission on Unity proposed a unified model for state and national medical organizations, all of which would automatically pay dues for all their members to belong to the national federation. The commission, including AAFP Past President Neil Brooks, M.D., of Vernon, Conn., met over a two-year period to explore ways to restructure and strengthen the house of medicine in the United States. Academy delegates testified in favor of the commission's overall report but did not support its one unified model.
The Advisory Committee on Membership proposed many models for membership, of which the AAFP supported an "organization of organizations" and a hybrid model allowing individual physician members. The committee will continue developing several models.
The AMA Board of Trustees will appoint a committee to continue the Commission on Unity's work, and the Academy expects to participate in that committee.
"The commission's charge was to look at more than the AMA, to study ways to increase the effectiveness of all of organized medicine and improve ways it represents physicians," says Brooks. "There's too much redundancy and wastefulness. Often, different organizations do not coordinate their efforts on subjects such as managed care. Multiple groups work on issues we're all interested in, including evaluation and management codes and Medicare fraud and abuse initiatives. The current system will continue to be dysfunctional; it won't work as we move into the future. The AMA house's acceptance of the commission report was AMA's first official recognition there has to be systemic change. We can no longer just tinker around the edges."
Help CDC study Lyme-like disease
The CDC needs your help to investigate a rash disease It's showing up in patients from the lower Midwest to Florida, and it looks a lot like Lyme disease. The problem: Investigators haven't found Borrelia burgdorferi (the bacterium that causes Lyme disease) when they've studied these patients.
And yet physicians in Missouri, Arkansas and points Southeast were seeing tick bites, rashes and some constitutional illness in 2000. The illness is tentatively called "Southern tick-associated rash-illness" by the CDC.
The culprit may be a newly recognized organism called Borrelia lonestari. As the name implies, this organism has been found in the Lone Star tick, Amblyomma americanum. Borrelia lonestari, however, is tough to identify and culture. The more information CDC gets on working with it and the illness, the better.
That's where you come in. Patients with tick-bite-associated erythema migrans-like lesions should be asked to provide informed consent via a consent form and to provide skin biopsy, blood and urine specimens to be tested using experimental laboratory tests. Specimens may not be tested immediately, but may instead be stored in an appropriate fashion to allow for future testing of various etiologic hypotheses once further testing is available.
The CDC wants physicians to contact CDC now so the physicians can receive background materials soon and be prepared to look for presenting signs in March, when ticks start biting again.
If you're interested in sleuthing out the new disease and have patients who are or have been in the lower Midwest or the Southeast, call Ned Hayes, M.D., principal investigator at the CDC, at (970) 221-6474. Barbara J. Johnson, Ph.D., is also investigating the strange illness. Reach her at (970) 221-6473.
Remembering Mike
To the editor:
On Oct. 8, my son, Michael Miller, J.D., the AAFP's deputy executive vice president and a 32-year Academy employee, died suddenly of a heart attack at age 57. How can we ever express our gratitude for the subsequent outpouring of love and support from Academy leaders, members and staff? While these have been the most difficult weeks of my life, your warmth and love have helped dull our deep hurt and pain.
Our family was overwhelmed by the Academy's thoughtful tribute to Mike's life after his funeral; the AAFP Board's decision to contribute to Mike's memorial fund and the many other contributions by members, organizations and staff; the beautiful flowers; and the many cards and letters we've received. It is comforting to know that someone we loved so much was loved by all of you. I know, however, that your affection was invited by his obvious love for you. No one could ask for a better life than he had, serving America's family physicians and their special organization.
On behalf of Mike's family, thank you all for seeing in him the same wonderful qualities that we did, and for making his life that much richer.
Helen Miller
Pratt, Kan.Editor's Note: At press time, $20,140 had been contributed to Mike's memorial fund. Contributions may be sent to: The Mike "Tubie" Miller Scholarship Fund, c/o The Williams Educational Fund, University of Kansas, 210 Wagnon, Lawrence, KS 66045.
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Don't assume health literacy
BY SHERI PORTER
Mary Avila portrays a distraught babysitter who can't read prescription instructions for a sick infant in a skit at the Conference on Patient Education. Avila and her two teammates from Voz Inc., a nonprofit communication training organization in Albuquerque, N.M., brought an air of realism to the health literacy workshop: All three women know the stigma associated with receiving welfare, and two, including Avila, are adult basic literacy students. "There's a heck of a lot of folks out there who can't read what we're giving them and can't understand what we're saying to them," said Audrey Riffenburgh, M.A., speaking to health care professionals about health literacy at the 22nd annual Conference on Patient Education Nov. 16-19 in Albuquerque, N.M.
Riffenburgh is a founding member of the Clear Language Group, a consortium of specialists in health literacy. She helps health care professionals create effective, reader-friendly materials.
Is health literacy important to FPs? You bet it is, said Riffenburgh. "The more we expect of patients in terms of taking responsibility for their health care, the more critical it becomes that they understand what we're telling them. The consequences of misunderstanding can easily be life-threatening."
Health literacy should not be confused with basic literacy skills, warned Riffenburgh. The two overlap, but health literacy goes further, requiring the ability to read and understand health-related information, she said. Health literacy includes an overall understanding of how to use the health care system.
We're all illiterate in some areas, Riffenburgh said. She asked the audience to name subjects in which they feel incompetent. "Finances," said one physician. "Technology," said another. "Auto mechanics," offered a third. Exactly Riffenburgh's point. Someone may be very literate reading Popular Mechanics and have low health literacy.
Riffenburgh divided workshop participants into small groups and gave them lists of common medical terms and concepts to simplify -- a key step in helping patients achieve health literacy. "Efficacy" became "how well it works." "Sublingual" was simplified to "under the tongue."
"You want to tell patients everything you would want to know," said Riffenburgh. "But the risk of overwhelming is much greater than the risk of not giving them what they need to know. Ask yourself, 'What do my patients need to know to do the action I need them to do?'"
And keep in mind this fact: The average adult American reads at an eighth grade level.
Frances Biagioli, M.D., assistant professor of family medicine at Oregon Health Sciences University, Portland, shows participants in a child seat seminar where to find the date of manufacture on an infant safety seat. The older the seat, the less likely it meets current standards. Helen Cooley of Las Cruces, N.M., takes part in a Conference on Patient Education seminar on the patient's perspective on arthritis. She follows instructions to wrap a rubber band tightly around her hand to simulate arthritis pain. Riffenburgh teaches office strategies to help physicians and patients communicate better. Some suggestions include:
- Use models patients can hold and touch.
- Draw pictures on the exam table paper.
- Use the teach-back technique by having the patient explain what you've said.
- Sit down, take extra time and actively listen.
- Ask "What questions do you have?" rather than "Do you have questions?"
- Help patients save face by taking responsibility for any misunderstandings.
- Star, circle and underline important sections of written forms so the patient can easily find those points later.
- Simplify office forms and assign a staff person to discreetly help patients who experience difficulty completing them.
Tempting as it might be, Riffenburgh strongly cautioned physicians against testing to assess patients' literacy levels. "Literacy testing in the physician's office can do irreparable damage to the trust between patient and physician -- and that's if the patient comes back at all," said Riffenburgh, who can be reached at plnenglish@aol.com. "We don't need to assess reading skills. We just need to learn how to communicate well with all patients."
Check out your 2001 CME opportunities
The "Quick Fax" column gives you the dates and locations for most of AAFP's CME conferences in 2001. "New for You," below, lists some CME-at-home resources, as well as the dates and drawing cards for the annual Scientific Assembly.
Also, if Africa's calling you, you may want to sign up for a tour in conjunction with the World Congress of Family Doctors in South Africa (see "Quick Fax"), sponsored by WONCA, the World Organization of Family Doctors. The AAFP and the Society of Teachers of Family Medicine are sponsoring 11-day and 18-day tours. E-mail targo@aafp.org for a tour brochure, and access http://www.wonca2001.org.za for conference information.
A shipping fee may apply; Kansas residents pay a 6.875 percent tax.
Order from AAFP at (800) 944-0000 unless otherwise noted.
Go to AAFP's Web site for drug information databases. Information for health care professionals concerning several thousand drugs is at http://www.aafp.org/members/drug.html within AAFP's members-only area. In addition, http://familydoctor.org/, AAFP's online patient education area, offers a drug database, a section on drug interactions and a section on herbal remedies.
Update your suturing and skin biopsy skills with three new CD-ROMs designed for family physicians: Basic Soft Tissue Surgery (#R1201, $70); Advanced Soft Tissue Surgery (#R1202, $60); and Skin Biopsy, Excision and Repair Techniques (#R1200, $60). The combined set is Soft Tissue Surgery for the Family Physician (#R1287, $230). A package of videos and texts on soft tissue surgery is also available (#R1287, $230).
Proven value: Other procedural skills learning packages for FPs by topic and format are a nasolaryngoscopy CD-ROM (#R1283, $50); nasolaryngoscopy syllabus and video (#R283, $75); esophagogastroduodenoscopy syllabus (#R236, $100); colposcopy CD-ROM (#R293, $110); colposcopy syllabus and video, including the loop electrosurgical excisional procedure (#R237, $225); and flexible sigmoidoscopy/colonoscopy syllabus (#R177, $120).
Proven value: The AAFP Scientific Assembly Oct. 3-7 in Atlanta offers you many hours of valuable CME, including active, hands-on learning; networking with colleagues from around the country; and contact with about 500 companies in the exhibit hall. Mark your calendar now to reserve time for great CME and the chance to enjoy the culture, cuisine, history and night life of the South in its entertainment capital. Your registration materials will be mailed in May.
FP Report is published by the AAFP News Department.
Copyright © 2001 by American Academy of Family Physicians.
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