March 2001 • Volume 7 • Number 3
With EMR or paper charts, security's the issue
BY TODD SIMCHUK
McNealy's statement might gripe you if you're still acclimating to the so-called Digital Age. The problem is, he's probably right. All this Web-browsing activity might be marking us. And not a day goes by that you don't hear about Internet account passwords made public, or people caught because they left incriminating electronic tracks, or a database compromised in some way.
Scott McNealy, Sun Microsystems CEO/president/founder, 1998:
"You already have zero privacy. Get over it."But on the other hand, just how secure are paper records anyway? It all depends on your security measures -- for both paper and electronic records.
One FP embracing the Digital Age and all it brings is Chip Bounds, M.D. In this small community about 30 miles northwest of Charleston, S.C., he sits down in front of a high-powered laptop and checks the information flying through the internal practice network. He's got messages coming from the reception area, and data generated from four hand-held touch pad computer devices, carried by other docs, are routing through his machine.
From where the doctors stand, the data fly from wireless network cards into receivers in the hall outside, and then into fat cables on the way to a large server in back.
Chip Bounds, M.D., records patient information on his touch pad computer device.It's a thick electronic stream that is sometimes right in front of you and sometimes out there. Somewhere. Most agree the system is better than the old paper-based one, but is it really safe?
"It all comes down to, 'Can I keep people away from it who don't have a reason or need to look at it?'" says FP Michael Eichelberger, M.D., an electronic medical record aficionado in Littleton, N.H. "I think an EMR is easier to do that with than a roomful of paper charts, especially if you want to maintain any kind of access to the information."
Bounds has been a computer hobbyist since 1983. He started using them in his practice in 1986 and was amazed at how efficient the spreadsheet was at certain record-keeping tasks.
Then, six or seven years ago, when computer processors became speedier and computers a little more user-friendly, Bounds saw the value of the EMR. Twenty years of paper record-keeping came to an end.
Today, he and the other docs at Berkeley Family Practice in Moncks Corner use their EMR system exclusively, and it seems to work just as advertised. They input data on the hand-held units during their patients' visits and walk out of the exam room moments after their patients do, ready for the next task.
If they're away from the touch pads, they "log out" of the computer program to secure it from straying eyes.
"In that alone, this is safer than a note on a desk," Bounds says.
Bounds checks the flow of information making its way around his Moncks Corner, S.C., practice on a recent afternoon.Key: education
But because the data leave the device for storage on the server, the issue grows. How to guarantee the safety of information that's here, there and in between?
Bounds answers with one word: education.
The staff studied enough to know they needed a wireless system too weak to broadcast beyond the practice's four walls. And education created good workstation security practices -- log out and log back in. Passwords have been set at many levels.
And Bounds will tell you: Absolutely do not bring a floppy disk or CD-ROM in from home, with software or files on it, and stick it in an office computer. That's an open door to a virus that might compromise the integrity of the network or damage patient files.
Careful use of the Internet is a given, to avoid introduction of viruses, and staff at Berkeley Family Practice do not send or receive external e-mail via their office computers. Bounds, a frequent e-mailer with certain, almost self-selecting patients, e-mails them from home, from behind a mess of software and hardware firewalls with intimidating names such as BlackICE Defender. Encryption is a key word here, and various standards are being adopted by the software industry to keep stuff safe.
All in the name of protecting information or, in your case, patient records.
In late January, Bounds was planning to upgrade the Moncks Corner facility to a high-speed digital subscriber line (DSL), which means that for the first time, his internal network, the one housing the patient records, will essentially be just another address on the Internet, just one click away from anywhere. That means he's also planning addition of a software or hardware firewall -- something to keep bad guys out and data safe.
Many family physicians are in that position already and are using practice networks dotted with numerous Internet connections. Maybe you are. Are you keeping this stuff separate? Do you have a firewall, a device or computer between you and the outside, keeping stuff (and people) that shouldn't get in, out? You should.
"That's beyond common sense," Bounds says. "We're virus-scanning everything now, and we're not even getting data from the outside."
Yes, it's safe, mostly
Top five security risks
according to Chip Bounds, M.D.
- People bringing stuff from home
"I didn't think bringing a disk in would hurt."- The Internet
The danger is, you've got the whole world at your fingertips and at your doorstep. On the Internet, you are as accessible to the world as it is to you.- Lack of workstation security procedures
Log in/log out. Log in/log out.- Failure to back up data
Data loss is data loss. Make sure you've got an electronic copy.- Hackers
Shady characters, dark rooms, late nights. Unauthorized access.Bounds' network, right now, is about as safe from outside intervention as it could be. But when the DSL line goes in, his system will be one step closer to the vulnerability that is the Internet. The EMR data will be parked on a server and accessible from just about any computer.
Your system might be like that now, but assuming that standards are followed and passwords are kept private, you can sleep easy at night.
"Lots of eyes can look at a paper chart," Eichelberger says. "And there's absolutely no audit trail on paper. Electronically, you know. You know who's been in it, and to some extent you know what they've looked at. From my point of view, it's more secure than a paper record."
Eichelberger should know. His practice, Ammonoosuc Community Health Services in rural New Hampshire, was the first place in New England to use the EMR system called Logician, from Medscape, back when the company wasn't even called that. He became president of Medscape's national EMR user group.
When used correctly, Eichelberger says, a computer is a tool that goes miles toward providing better patient care.
"I'm sure there are locked chart rooms out there," he says. "But how many charts are scattered around on people's desks?"
Check it out
In this well-connected day and age, you probably have patients referring to information they've found online or coming in to see you with stacks of information they've printed out.
Use your judgment in choosing reliable sources; encourage your patients to use theirs, too; and maybe even visit Web sites with your patients in your office to discuss the types of information they're seeing.
Their questions can be a great excuse to show them your practice's Web site.
If you're still in the planning stages of building your online site, check out http://familydoctor.org and click on FP Web Directory to see what other FPs in your area and across the country are displaying. And -- at http://www.aafp.org -- click on "My Academy" to create a site for your practice.
Your site on familydoctor.org can link to AAFP health information, such as drug information at http://familydoctor.org/druginfo, patient handouts at http://familydoctor.org/handouts and self-care flowcharts at http://familydoctor.org/flowcharts.
On two counts
You should get paid after all
In two situations in which Medicare has not paid for separate services, the tables have turned. The Health Care Financing Administration recently corrected two payment glitches.
Effective Jan. 26, HCFA suspended, retroactive to last Oct. 30, Correct Coding Initiative edits that bundled evaluation and management services into certain procedures when both types of services were provided on the same date. The procedures are those to which HCFA's usual global surgical package concept does not apply.
You can now bill for E/M services with such procedural services, if the work entailed in the E/M service is significant and separately identifiable from the procedural service.
Claims denied as a result of one of these Correct Coding Initiative edits should be resubmitted with a "-25 modifier" attached to the E/M code -- alerting the claims processor that you're billing for a significant E/M service separate from the procedural service.
In addition, effective Jan. 1, HCFA told Medicare carriers to no longer bundle E/M services into vaccine administration services when both are provided the same day.
If you billed for an office visit and included the code for administering a vaccine, you probably were denied payment for the visit. That occurred with influenza virus vaccine, pneumococcal vaccine and hepatitis B vaccine. If you resubmit the claims, you should be paid for both the visit and the vaccine administration.
AAFP responds to early initiatives of Bush, Congress
President George W. Bush and federal lawmakers announced plans for health initiatives in the first few weeks of the new administration, and the Academy quickly responded.
Seniors' drug benefit
"President Bush has taken an important step with the new Congress early in his administration by calling for a prescription drug benefit for seniors," AAFP President Richard Roberts, M.D., J.D., of Madison, Wis., said Feb. 1. "However, the administration's draft proposal falls far short of what is needed."
Roberts said turning the benefit over to the states to establish programs separate from Medicare would take too long "and would establish an inconsistent patchwork of programs."
He added, "President Bush is right to give priority consideration to those below or near the poverty level, but those in the next higher income bracket would find the $6,000 out-of-pocket threshold for participation prohibitive and might continue to do as many do now, stretching out prescriptions or not filling them."
Patients' bill of rights
Early last month, several representatives and senators announced a bipartisan proposal for managed care reforms, and the AAFP welcomed the plan.
The proposal would allow patients to sue their health plans but would cap patients' civil assessments (similar to punitive damages) at $5 million. The cap is a new feature; most of the proposal resembles legislation the House passed last year, introduced by Reps. Charles Norwood, R-Ga., and John Dingell, D-Mich.
A patients' bill of rights "is clearly a priority for the people of this country," said AAFP President Roberts. "Family physicians know the tough choices many of our patients face when health plan accountants make medical decisions for them. That's why we think it is critical that America put patients and doctors back in charge of health care."
Tobacco control
A bipartisan group of senators are cosponsoring a bill to give the FDA authority to regulate tobacco products and marketing.
"We are far beyond the question of whether tobacco is a drug: It is," said Roberts in a Feb. 7 statement supporting the bill. "Nicotine, a key ingredient in tobacco products, is addictive. Like other substances of abuse, it should be regulated by the proper authority. The FDA should be given that authority."
Pain, pain, go away
How new pain standards impact FPs
BY SHERI PORTER
"Pain can be beneficial; it can warn us something is wrong with our bodies. But when it persists, it has no redeeming virtues. None!" So said June Dahl, Ph.D., a professor of pharmacology at the University of Wisconsin-Madison. She spent two years working with the Joint Commission on Accreditation of Healthcare Organizations to develop the new Pain Standards for 2001 (see box). It was Dahl who initially brought the issue to the JCAHO table.
The new standards, which took effect Jan. 1, apply to JCAHO-accredited hospitals and health care facilities. The standards call on these facilities to ensure that pain is assessed and managed appropriately. The JCAHO accredits 80 percent of the nation's hospitals, which account for 96 percent of inpatient admissions.
"Pain now has become a major issue," Dahl said. "Look at the media attention. It's put pain on every hospital's radar screen. "
As it should be, she said. "Undertreated pain is a major public health problem. It's more than an unpleasant sensation -- it adversely affects our bodies and our minds."
And pain is costing the United States plenty -- more than $100 billion annually in health care costs and lost productivity.
Richard Brown, M.D., associate professor in the family medicine department at the University of Wisconsin-Madison, said he hopes the new focus on pain management will evoke a positive change in practice patterns for FPs. Brown has traveled the country conducting seminars on pain-related topics for health care professionals.
"I think FPs vastly underrecognize and undertreat chronic pain. I hope these standards sensitize more FPs to ask patients more frequently about their pain and lead them to prescribe appropriately," he said.
Pain management practices of the past need updating, said Brown. And one area ripe for reform is education.
"We're not well-trained in pain assessment. We're not well-trained in pain management," said Brown. "Many issues in pain management overlap with addiction medicine, and we're not well-trained in that, either."
Excerpts from JCAHO standards*
- Patients have the right to appropriate assessment and management of pain.
- Pain is assessed in all patients.
- Policies and procedures support safe medication prescription or ordering.
- The patient is monitored during the post-procedure period.
- Patients are educated about pain and managing pain as part of treatment, as appropriate.
- The discharge process provides for continuing care based upon the patient's assessed needs at the time of discharge.
- The health care organization addresses care at the end of life.
- The organization collects data to monitor its performance.
Go to http://www.jcaho.org/standard/pm.html for these standards, explanations of their intent and examples of implementation.
Some initial basic education in a standard CME format is imperative, said Brown. But he doesn't think pain training should stop there.
In the seminars he's led, audience responses have been revealing.
"I'm aware sometimes at the end of my talks that physicians feel motivated to try the kind of opioid prescribing that I'm recommending, but they feel they won't have anyone to turn to, to ask the questions that inevitably will come up," said Brown.
He envisions a national resource network of knowledgeable pain experts available for phone consultations. He would also like to see the Academy develop a pain management kit with flowsheets, patient contracts and clinical algorithms.
Paul Van Gorp, M.D., of Long Prairie, Minn., chair of the AAFP Commission on Quality and Scope of Practice, serves on a JCAHO professional and technical advisory committee. Van Gorp said the new standards will help practitioners think of pain assessment "almost like another vital sign measurement."
Van Gorp reports a positive trend already occurring in his state: a new awareness of the appropriateness of opioid analgesic prescription. "This will be an important factor in improving pain control, because many practitioners have been downright afraid to use controlled substances in adequate doses for fear of reprisal or investigation by their board of medical examiners," Van Gorp said.
But Van Gorp voiced a concern as well. "Some patients just don't need a pain assessment; to assess every patient's pain would sometimes be a waste of time."
Another issue was raised by John Beasley, M.D., professor of family medicine at the University of Wisconsin-Madison.
"All patient health issues are worthwhile -- but as soon as you get into mandating one specific thing, you're saying this is more important than everything else," Beasley said. "This is just one more issue to add to the complexity of the agenda for primary care physicians."
Michael Ashburn, M.D., president of the American Pain Society, based in Glenview, Ill., said growing scientific evidence shows that treatment of a patient's pain, as well as the underlying disease, is important to the patient's survival.
"Our patients tell us this is important," said Ashburn, a professor of anesthesiology and medical director of the pain management programs at the University of Utah Health Sciences Center and the Primary Children's Medical Center in Salt Lake City.
"These standards are more than just writing a new policy," said Ashburn. "They're about implementing a system-wide change to address the needs of people with pain. That's a huge task."
Read more about pain at these Web sites
- JCAHO standards at http://www.jcaho.org/standard/pm.html
- American Pain Society at http://www.ampainsoc.org
- American Pain Foundation at http://www.painfoundation.org
- National Guideline Clearinghouse at http://www.guideline.gov
- American Alliance of Cancer Pain Initiatives at http://www.aacpi.org
Being gay can be anything but
Know your patients -- and know the issues
BY CINDY McCANSE
It's an unfortunate reality: Segments of the American population continue to fall through cracks in the U.S. health care system.
Judith Chamberlain, M.D., encourages patients in her Brunswick, Maine, family practice to speak openly about their sexual orientation. Having that knowledge, she says, enables her to better meet their medical needs.Lack of insurance coverage, geographically limited access to health services, cultural or language barriers -- all play a role.
Yet there's another obstacle too often encountered by hundreds of thousands of people every day -- the stigma of being gay, lesbian, bisexual or transgender.
Create an open, caring atmosphere
George Gay, M.D., of Cambridge, Wis., is a self-proclaimed advocate of gay civil rights and the rights of gay patients. He's also an openly gay family physician practicing in a small rural community.
Gay says there's an interesting phenomenon associated with being a physician who's gay or lesbian. "Gay family physicians tend to be out as medical students and sometimes even into residency. Then they go back into the closet until their practice has been established for about five or six years, and then, depending on their experience, they may come back out again," he says. "Hanging out a pink triangle with your shingle isn't exactly a practice builder -- unless you live in a very unusual neighborhood.
"I came pretty close to not going into rural family practice," Gay adds, "because I used to think it would be impossible to be a family doctor and be gay. I lived 20 miles from my office for my first six years in practice. But people here have been very kind to me and my life partner of more than 20 years."
Judith Chamberlain, M.D., cares for a number of GLBT patients in her Brunswick, Maine, practice. She suggests that welcoming these patients is about knowing what not to say as well as what to say.
"I don't think it's the patients as much as it's us," says Chamberlain. "It's up to us to create an atmosphere that allows patients to talk about their sexual orientation. If you greet a woman at the door by asking 'Who's your husband?' she's not going to be willing to come out to you."
Gay also warns against making assumptions: "If the box just reads 'married/divorced/single,' you're not leaving any other options open, and your gay patients aren't going to tell you they're gay."
Know the care issues
George Gay, M.D.:
"Hanging out a pink triangle with your shingle isn't exactly a practice builder -- unless you live in a very unusual neighborhood."Just as you shouldn't make assumptions about your patients' sexual orientation, don't make faulty assumptions about their health based on that orientation. Because well-designed, population-based GLBT studies are scarce, it's hard to find reliable evidence on which to base care decisions.
"We have to be careful not to go on generalizations or assumptions predicated on false data," says Chamberlain. "Are all gay people depressed? I don't think so. Are they dealing with the stress of coming out to family and friends? Well, of course they are."
"Medical schools teach very little about cultural competency in this area," says Gay. "They may teach about ethnic issues, but not about the needs of GLBT patients."
The key is not to overlook the full range of health care services. "Don't dismiss certain types of screening because a patient is gay," Chamberlain advises. "Like screening for STDs in lesbians, because many of these women have had sex with men at some time in their life. With gay men, I think it's important that we don't presume that HIV/AIDS care is all there is. These patients need to have their cholesterol checked, they need to be told not to smoke."
Overall, says Chamberlain, "I think our job as family doctors is to bring these patients into the mainstream."
However, she says, do use your knowledge of a patient's sexual orientation to tailor the interview: "Ask about specific sexual practices because that may reveal risks you're not thinking about."
Some of the GLBT care issues the Gay and Lesbian Medical Association has on its radar screen, says FP Ronald Falcon, M.D., of Minneapolis, are hepatitis A and B vaccination of gay men; breast cancer and cervical cancer screening in lesbians; and education about the hazards of club drugs, such as ecstasy and amyl or butyl nitrate.
Expand your horizons
For more information on issues relevant to your gay, lesbian, bisexual and transgender patients, check out these resources:
Gay and Lesbian Medical Association
(415) 255-4547 -- http://www.glma.orgParents, Families and Friends of Lesbians and Gays
(202) 467-8180 -- http://www.pflag.orgAnd, unfortunately, it's important to look for red flags. Domestic violence among gay and lesbian patients presents unique problems. Think about it, says Gay. "If you're a gay man and you get beat up by your partner, where do you go? You can't go to a women's shelter; they don't want you there. And if you're a lesbian, they don't want you there, either. So you stay at home and get beat up again."
Family physicians must educate themselves about caring for these patients, says Gay. Resources are available to help FPs learn about GLBT issues (see box).
Recent efforts to expand FPs' research on GLBT populations should help, Gay says (see story at top of page 5). But he adds, "None of that is going to be real helpful until the social stigma is gone."
Gay, lesbian issues to be in Healthy People 2010 initiative
It took more than two years of spirited negotiating, but after the dust had settled, a national coalition including the Gay and Lesbian Medical Association had won the incorporation of sexual orientation into 29 health objectives in the HHS document, Healthy People 2010.
According to AAFP member Ronald Falcon, M.D., of Minneapolis, the coalition's victory is a watershed event in promoting the rights of lesbian, gay, bisexual and transgender individuals. For the first time, improved data collection and analysis of issues pertaining to LGBT populations will be goals of the federal government.
"There's never been inclusion of LGBT issues -- health measures and so forth -- in the Healthy People documents," said Falcon, who sits on the GLMA Board of Directors. "We decided it was time to get that changed."
HP 2010 represents America's public health blueprint for this decade. The document details the nation's plan to eliminate health disparities across geographic, ethnic, racial, gender, age and -- now -- sexual orientation lines. Such differences include variations in pediatric immunization rates in urban versus rural settings and varying access to high-quality health care services based on racial or ethnic factors.
The tide turned, apparently, when the Health Resources and Services Administration threw its support behind a collaborative effort to develop the paper, "Lesbian, Gay, Bisexual and Transgender Health: Findings and Concerns." This document summarizes research on LGBT issues and outlines the need for further data collection. Go to http://www.glma.org/policy/whitepaper to access the paper, developed by the National Coalition for Lesbian, Gay, Bisexual and Transgender Health (including GLMA) and the Center for Lesbian, Gay, Bisexual and Transgender Health at Columbia University in New York.
HRSA also provided funding for the Healthy People 2010 Companion Document for Lesbian, Gay, Bisexual and Transgender Populations, which is under final review and is scheduled for publication this spring.
This report discusses about 130 health objectives from 17 focus areas in the federal HP 2010 document that are most relevant to LGBT health. For each objective, the companion document discusses such topics as model programs and resources and makes recommendations regarding research and education needs, services and policy development.
HIV treatment guidelines updated
HIV infection has affected the lives of hundreds of thousands of Americans in the past two decades and millions of people worldwide. Although it's far from being a "gay disease," as it was once characterized, members of the gay, lesbian, bisexual and transgender community have an immense stake in new insights into dealing with this health scourge.
New federal guidelines recommending a delay in beginning HIV treatment in asymptomatic individuals were announced at the Eighth Annual Retrovirus Conference in Chicago last month. The guidelines fly in the face of the previous "hit early, hit hard" strategy in effect since widespread use of anti-HIV "drug cocktails" began in the mid-1990s.
In short, the Panel on Clinical Practices for the Treatment of HIV Infection recommends waiting to begin treatment until the body's supply of CD4 cells drops to 350 per milliliter of blood or until the viral load exceeds 30,000 copies per ml as measured by the branched DNA test (55,000 per ml as measured by the polymerase chain reaction test). The panel is a collaborative effort of HHS and the Henry J. Kaiser Family Foundation.
Recent studies suggest that while highly active antiretroviral therapies can knock the amount of HIV in the blood back to undetectable levels, the therapies fail to eradicate the disease as once hoped. Thus, patients must continue on lifelong treatment.
Therein, say HIV researchers, lies the problem. These highly potent drugs carry hefty side effects over the long term, including anomalies in body fat distribution and fat metabolism as well as osteonecrotic changes, particularly in the hip. One major concern is spawning an epidemic of coronary disease in HIV-infected patients using these treatments; these drugs can precipitate startling elevations in cholesterol and triglycerides.
The guidelines include new drug-specific recommendations. Go to http://www.hivatis.org to view them. Single copies can be ordered by calling (800) 448-0440.
Financial, legal barriers plague many same-sex partners
Mary S. loses her cashier job -- and her health benefits -- because of "downsizing" at the local hardware store. Luckily, her husband is able to add her to his health insurance policy through his employer, a car dealership.
Across town, Joanne R. loses her job at the waterworks plant. Her partner of 17 years, Lynette T., also works at the car dealership. But when she attempts to add Joanne to her health plan, she's greeted with an unequivocal, if sympathetic, "no."
It's a common scenario: Gay, lesbian, bisexual and transgender individuals routinely suffer discrimination in housing, employment and basic civil rights, says family physician Ronald Falcon, M.D., of Minneapolis, a board member of the Gay and Lesbian Medical Association.
In the health care arena, such disparate treatment can have devastating consequences. Health insurers often refuse to extend to committed gay and lesbian couples the same benefits that married heterosexual couples regularly receive. Instructions documented in a GLBT patient's durable power of attorney for health decisions that name a same-sex partner as the decision-maker are frequently overruled by the patient's biological family.
It's another facet of GLBT health that is being targeted by the GLMA, says Falcon. "Physicians should look beyond their responsibilities to these patients in the office setting," he notes. "Physicians need to advocate on their patients' behalf in all aspects of the health care experience."
A stepwise approach to a GLBT-friendly office
Step one: Exorcise any of your own demons. "Get your head screwed around so you're not still holding onto all those homophobic attitudes you learned from your family or your friends growing up," says George Gay, M.D., of Cambridge, Wis.
Judith Chamberlain, M.D.:
"Don't out your patients! Ask them, 'What's OK to have in your record, and what's not?'"The same goes for your office staff -- talk with them and work through their questions about gay, lesbian, bisexual and transgender issues.
Step two: Know the symbols. "If a patient comes into your office wearing a rainbow or a pink triangle or a lambda, say something about it. If you don't say anything, they'll think you don't know what it means," Gay says.
Step three: Let your office environment showcase your intent. "I have posters and reading materials in my waiting room that indicate it's OK to talk about these issues," says Gay.
Step four: "Don't out your patients!" warns Judith Chamberlain, M.D., of Brunswick, Maine. "Ask them, 'What's OK to have in your record, and what's not?'"
Guarding your GLBT patients' privacy may take a little creativity. For example, Chamberlain uses a small lambda symbol to identify the medical charts of her lesbian patients. And Gay uses a tiny "G" or "L" as an identifier.
New commission on resident, student issues gets the nod
The AAFP Board of Directors has given the go-ahead for creating a Commission on Resident and Student Issues. The commission will replace the recently disbanded Task Force on Student Interest and Committee on Resident and Student Affairs.
The task force, at its meeting Jan. 17-18, recommended creating the new commission. After analyzing AAFP's commission/committee structure, the TFSI found no group within AAFP that would "permit the necessary analysis of data, generation of ideas, dissemination of information and evaluation of projects" called for in TFSI's proposal. On Jan. 20, the Board agreed in concept with the need for the new commission.
Chief among the functions of the CRSI would be identifying and monitoring factors influencing specialty choice by medical students.
Other proposed functions include evaluating current resident/student initiatives and developing new strategies to meet emerging needs of these groups; collaborating with constituent chapters to improve support for family practice residents and students interested in family medicine; and utilizing existing resources within organized medicine to further mutual goals related to resident and student issues.
The Board's action was spurred by increasing concern about the recent downward trend in student interest in the specialty. The number of applicants filling family practice residency slots through the National Resident Matching Program reached a high in 1997: of 3,262 available positions, 2,905 applicants matched in the specialty. The numbers have steadily declined since then. Last year, 2,603 positions were filled out of the 3,206 slots available.
Jennifer Aloff, M.D., of Midland, Mich., resident Board member, and Andrew Mills of Tulsa, student Board member, will serve on the new commission ex officio. Although other details about the commission's membership and charge won't be hammered out until the Board meets March 1318 in Washington, "This is a very positive step in light of ongoing concerns about declining student interest in family practice," said Deborah McPherson, M.D., assistant director of the Division of Medical Education.
'Fergie' commends AAFP for wellness stance
Sarah Ferguson, Duchess of York, recently commended the Academy for allowing a lunchtime Weight Watchers group to meet in its headquarters building.
A Weight Watchers spokesperson, Ferguson visited AAFP Jan. 23 and spoke to staff. She said her own weight problem began at age 12 when her mother left England to marry a man from another country, and she stayed behind. "I started eating all the time," said Ferguson, admitting she didn't know not to overeat. "I wish at 12 I'd had someone who would listen to me, take me by the hand and say, 'This is the way to go.'"
Ferguson asked the AAFP staff members to value their insights, their needs, their assessment of what was best to do for their mental and physical health. "It's so important that we take courage in our own truth," she said.
Help youth kick back at Big Tobacco April 4
It's coming soon -- the biggest youth-led anti-tobacco initiative in the world -- and you can help. April 4 is Kick Butts Day, an annual event from the Campaign for Tobacco-Free Kids that engages thousands of students nationwide as tobacco control advocates. The AAFP is a sponsor of the day.
Visit http://tobaccofreekids.org or http://kickbuttsday.org to learn more about the day. While you're there, request the free poster and event guide, which can help you plan, coordinate and implement a Kick Butts Day activity in your town.
Register your event at http://kickbuttsday.org or return a completed registration form by mail. You'll then get a Kick Butts Day registration kit, which contains stickers, temporary tattoos and iron-on decals for T-shirts. More information may also be obtained by visiting http://tarwars.org or by calling the AAFP's Tar Wars program at (800) TAR-WARS.
Pilot project to test CME accreditation system
The pilot project for using AAFP's New Criteria for Evaluating and Categorizing the Clinical Content of CME begins this month, one of several phases before the national launch of the criteria Jan. 1, 2002.
David Baldwin:
"The Academy strongly believes an evidence-based approach to CME will lead to improved medical practice and patient outcomes."The new criteria, developed by the Commission on Continuing Medical Education, encourage AAFP-accredited CME providers to incorporate the principles of evidence-based medicine into their CME programs on an optional, incremental basis.
"The Academy strongly believes an evidence-based approach to CME will help ensure the validity of clinical content and will lead to improved medical practice and patient outcomes," says David Baldwin, AAFP's manager of CME accreditation.
The new criteria reflect concerns that current accreditation systems may allow credit for CME activities promoting unproven therapies. In particular, it has been difficult to apply existing accreditation procedures fairly and consistently to CME courses discussing complementary and alternative practices.
The new criteria establish consistent standards for both traditional and alternative therapies. Any clinical content will be eligible for Prescribed credit if it is evidence-based or customary and generally accepted medical practice. CME content that is neither evidence-based nor customary and generally accepted practice but is not dangerous will be eligible for Elective credit.
A blueprint for the new system was sent for comment to chapters, national CME accrediting agencies and other medical groups last fall. Comments ranged from lauding the AAFP for its leadership in encouraging a move toward evidence-based learning to concerns that the new system would pose a burden on providers seeking approval for evidence-based clinical content.
Eighteen state, regional and national organizations will pilot the system through the summer. To ease into the system, pilot providers are encouraged to incorporate principles of evidence-based medicine into just one or two presentations at a CME event. This may result in "split" credit -- a combination of Prescribed and Elective.
Data collected from the pilot groups by May will be considered by the COCME in June. The commission will make recommendations to the Board, which will then revise the criteria, implementation plan and materials.
A formal announcement of the national launch of the criteria will be sent to AAFP CME providers, chapters and colleague organizations this fall.
COCME members, a new subcommittee, consultants and staff will assist providers in adapting to the new system.
Against Medicare drug benefit
To the editor:
I understand that the Academy supports a prescription drug benefit for seniors as part of Medicare (see "AAFP responds to early initiatives of Bush, Congress"). Stop and think:
- Medicare has always been fiscally unsound. The only way politicians keep it afloat is by increasing taxes or reducing physician payments. Another benefit would require payment cuts or increased taxes.
- Is it within the founding forefathers' ideas that we should establish a social welfare program for a societal segment? And is using age as an entry criterion consistent with our other nondiscrimination tenets?
- Payment for a Medicare office visit is below my cost. Adding a benefit that funnels funds away from caregivers to drug companies will not improve FPs' plight.
- Accepting assignment is a flawed premise. One of my patients is worth millions but is very healthy. Medicare is his only insurance. I have to accept from him less than my office expenses for his visit.
Medicare should pay a certain amount for a visit or for labs, X-rays or whatever, according to a schedule. The physician should be able to bill for or write off the additional. What hurts FPs is that private insurers have adopted this Medicare model. When they don't pay, we're stuck.
Try concentrating AAFP's efforts on fighting for what is good for FPs. Quit focusing on social and socialistic issues. When your members are properly compensated, without the major hassles involved in insurance today, then the patients also benefit.
John Fieler, M.D.
HoustonAnother breast-feeding obstacle
To the editor:
I agree that physicians need to promote breast-feeding as normal. However, another obstacle was not mentioned in the January FP Report article on breast-feeding. Many of my patients who would be interested in breast-feeding, but do not, cite problems at work. There is no place to pump or store milk and no support from supervisors to do so.
I doubt that breast-feeding rates will increase much until it is seen as a societal good and employers are encouraged to offer opportunities for mothers to nurse their babies at work or to pump and store breast milk.
Being my own boss in solo practice, I was able to make my own rules. My baby was in a day-care center a few blocks from my office. I made sure almost every day that I went to see her at lunch to nurse her until she weaned herself when she was 1 year old.
Teresa Beckman, M.D.
Evansville, Ind.Health care coverage for all
To the editor:
I feel strongly that we should have universal health coverage (as the AAFP recommends in its proposal described in the December 2000 and February 2001 issues of FP Report).
Practically, it would cost less to have a screening M.D. or R.N. in emergency rooms and refer patients not really in emergency situations to their personal M.D. than to treat all the patients, as we do now, at a cost of $200 to $500 for conditions that could wait.
By reducing what we spend to keep nuclear weapons on unnecessary alert, we could find the funds.
M.A. Glover, M.D.
Nanakuli, Hawaii
To the reader: Write us letters of 200 words or fewer (subject to editing), using the FP Report address pbinder@aafp.org or FP Report, 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672.
Georgetown, AAFP center join forces in research venture
BY JANE STOEVER
In a first for Georgetown University and U.S. academia-at-large, the three primary care departments at GU Medical Center are collaborating with the Robert Graham Center in Washington.
The venture has three components:
- developing a research "home" (staff and projects) in the GU departments for family medicine, general internal medicine and pediatrics;
- educating medical students, residents and fellows about research; and
- creating a practice-based research network, a laboratory for primary care research.
In the third component, a few hundred FPs, general internists and general pediatricians will have the opportunity to incorporate research into their practices. Most of the physicians -- in and around Washington -- have served as preceptors for GU medical students for years.
"Our departments and the Robert Graham Center will complement each other's functions in this project," says Jay Siwek, M.D., professor and chair of Georgetown's family medicine department. "Our departments will benefit from participating in some of the center's research activities, infused with a health policy perspective. The center will gain a tie-in to a local clinical base, a new practice-based network of physician researchers."
Siwek, who also is editor of American Family Physician, was principal investigator for GU's proposal requesting a Primary Care Research Infrastructure Grant from the Health Resources and Services Administration. GU and the Robert Graham Center finalized a contract Jan. 18 for collaboration in the research effort.
As the GU proposal evolved, Robert Phillips, M.D., the center's assistant director, conferred with GU faculty. He will facilitate the center's response to GU's grant-related needs.
"Our center is directly contributing to building the capacity for primary care research at one of the nation's leading universities and to preparing primary care researchers for tomorrow," says Phillips.
Demographics may make the GU network distinct from current ones. "A lot of Georgetown University Medical Center preceptors have many Medicaid patients," says Phillips. "Most U.S. practice-based research networks don't have patients who are predominantly low-income, underserved, on Medicaid. The demographics of this new network may make it attractive for collaborations with other networks, such as those in the Federation of Practice-Based Research Networks." The cross-fertilization may yield results different from those coming from networks with higher-income patients.
So what's new for Georgetown University and the Robert Graham Center will most likely pave the way for more collaborative research in years to come.
Evaluate your practice -- easily
The February Family Practice Management features "The FPM Practice Self-Test," an easy way for FPs to evaluate their practices. An interactive version of the test that calculates scores automatically is available online via http://www.aafp.org/fpm/20010200/41thef.html.
The self-test covers everything but the purely clinical aspects of practice. Users receive a score in each of nine different scales, and those who share their responses with FPM can receive a report comparing their responses with the pooled results. The online version of the self-test generates comparative data on the spot. Results and contact information are kept confidential.
Sign up as key legislative contact
Do you want to influence the views and votes of your U.S. lawmakers? Do you have a relationship with your members of Congress or want to build one?
If so, consider becoming an AAFP key legislative contact.
You'll have an inside track on health-related bills in the congressional pipeline. The AAFP will send you background on proposed laws and "alerts" asking you to share your views with lawmakers about bills coming up for a vote.
To volunteer as a key legislative contact, e-mail Jennifer Lee in AAFP's Washington office at jlee@aafp.org, or call her at (888) 794-7481.
Order from AAFP at (800) 944-0000 unless otherwise noted.
For the first time, AAFP's National Conference of Special Constituencies includes a constituency interested in gay, lesbian, bisexual and transgender issues. Other groups at the meeting are women, minority and new physicians and international medical graduates. The April 26-28 conference will be held in conjunction with the April 27-28 Annual Leadership Forum, which offers up to 9.6 Prescribed CME credit hours. For more information, use AAFP Express (see "Quick Fax" at left).
All members recently received the syllabus for the Video CME program "Allergic Rhinitis and Asthma: A Clinical Practice Update," part of the Annual Clinical Focus 2001: Asthma, Allergy and Respiratory Infections. You now can buy the companion video at a discount (#R859, $10).
The syllabus for the latest Video CME program, "Current Approaches to the Management of Parkinson's Disease," was mailed to all AAFP active members Feb. 19. You also can buy the companion video and post-test (#R820, $17.95).
A shipping fee may apply; Kansas residents pay a 7 percent tax.
FP Report is published by the AAFP News Department.
Copyright © 2001 by American Academy of Family Physicians.
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