June 2001 • Volume 7 • Number 6
'Suicide prevention is everybody's business'
Surgeon general announces national strategyBY CINDY McCANSE
Calling suicide "a national public health problem," U.S. Surgeon General David Satcher, M.D., Ph.D., a family physician, recently announced a national effort to prevent suicide.
Satcher emphasized the need to recruit a diverse blend of individuals and organizations to become actively involved in suicide prevention. Key to those efforts will be primary care physicians, nurses, mental health care providers, schoolteachers, clergy, staff at correctional facilities, and police and other emergency personnel, to name a few.
"We should make it clear that suicide prevention is everybody's business," Satcher said May 2 in Washington. "Suicide affects all demographic groups in America."
Statistics more than bear out his observations:
- More than 30,000 Americans each year take their own lives. That pans out to 86 persons every day -- one every 17 minutes.
- More teens and young adults die from suicide than from cancer, heart disease, AIDS, birth defects, stroke, pneumonia and influenza, and chronic lung disease combined.
- For every two victims of homicide in the United States, three people commit suicide.
Satcher announced the release of a "National Strategy for Suicide Prevention: Goals and Objectives for Action." To review components of the document, go to http://www.mentalhealth.org/suicideprevention and click on "Summary."
Surgeon General David Satcher, M.D., Ph.D.The report, which was jointly prepared by the Substance Abuse and Mental Health Services Administration, Centers for Disease Control and Prevention, National Institutes of Health, and Health Resources and Services Administration, represents the first installment in a national action plan to combat this eighth leading cause of death in the United States. Future installments will be released as they are completed. A publication outlining preferred approaches to media coverage of suicide-related events is expected to be issued later this year.
The agencies collaborated with advocacy and physician groups in developing the document. Sharon Sweede, M.D., of Asheville, N.C., a member of the AAFP Commission on Public Health, reviewed the report on behalf of the Academy.
"Several of the objectives in the plan specifically address primary care doctors," says Sweede. "It's going to be pretty difficult for this to be successful without our involvement."
That involvement, she adds, takes several forms: "We need to see that family physicians include screening for suicide risk as well as availability of lethal means in routine health visits. And they need to document that screening."
But beyond screening, Sweede notes, family physicians are a logical choice to manage patients with depression or other mental illness. "A very large part of it is going to be screening," she says, "but it's also the continuing care and follow-through on treatment."
Eleven goals are outlined in the report, and 68 quantifiable objectives will facilitate outcome measurement by local, state and national organizations involved in preventing suicide and suicide attempts.
The goals range from promoting public awareness of this health scourge to attacking the stigma associated with seeking mental health services.
Also included is training (for those likely to encounter persons at risk for suicide) to recognize the danger signs and know what resources are available to help.
Expanding and improving surveillance systems is another priority area, as is supporting research on suicide and suicide prevention.
Privacy, security and you
BY JANE STOEVER
You protect your patients' privacy as a matter of course. The federal government, within a few years, will take steps to make confidentiality a cornerstone of health care across the country.
The idea's great. The federal rules may, at first, be hard to swallow.
Privacy regs. On April 12, President George W. Bush said the privacy regulations for the 1996 Health Insurance Portability and Accountability Act should be implemented. The administration has already suggested the rules will be modified before they go into effect in February 2003.
Through the privacy regulations, patients will have new rights to access their personal health information and control its use and disclosure, even disclosure to physicians' lawyers and accountants. Medical practices will need to obtain patients' consent and authorization and monitor the privacy policies of physicians' business associates.
Security regs. By fall, the administration may release the HIPAA security regulations, protecting the physical security of patient information and of information systems.
Help from AAFP. "We aren't just accepting the regulations as they've been promulgated," says Executive Vice President Douglas Henley, M.D. "In our comments on the proposed privacy regulations in March, we said they would make the compliance process cumbersome, costly and time-consuming. We'll keep working through regulatory and legislative channels for changes that will make the regulations more appropriate to the office environment, while still preserving the goal of protecting patient information."
The Academy will also make resources available to family physicians to ease the process of complying with HIPAA. "We're investigating options to give our members the education and the implementation tools they need," says Henley.
The AAFP may develop tools to help you identify the gaps between your current office operations and what will be required; checklists, sample forms and model contracts; and comprehensive compliance plans.
You can read up on HIPAA at http://www.aafp.org/fpm/20010300/43what.html, an article from the March Family Practice Management. An article on the HIPAA security standards is planned for the July/August FPM issue.
Another resource is on the Web site of the American Health Information Management Association. To view that information, go to http://library.ahima.org/bok/.
When one door closes ...
Rescue missions are nothing new to Janelle Goetcheus, M.D. As medical director of Unity Health Care, an amalgam of Washington's Healthcare for the Homeless program and two community health centers the federal government washed its hands of in 1995, she's well-suited for the role.
With the recent closing of District of Columbia General Hospital -- the district's first and only public hospital -- Unity Health Care will now add six more CHCs to that tally.
"This last year in the district has been very difficult in terms of public health," says Goetcheus, referring to the dissolution of the district's public health system, which ran the hospital and its six satellite clinics.
The decision to close the hospital and privatize health care for the city's poor and uninsured was handed down April 30 by the federal control board that oversees the city's financial operations.
Health services will now be administered by a consortium of private entities operating under a program known as the D.C. Healthcare Alliance Network. Inpatient care previously given at D.C. General will be split among several hospitals; outpatient services will be provided at the clinics.
The D.C. scenario reflects a growing national trend: Competition has forced mergers and acquisitions among many medical facilities, with public hospitals losing the most ground over the past two decades. According to the American Hospital Association, since 1999 -- the latest year for which figures are available -- the number of public hospitals was 1,197, down from 1,778 in 1980. That represents a 33 percent decrease. During that same period, the number of private facilities fell from 4,052 to 3,759, a reduction of only 7 percent.
The upshot? More and more uninsured patients are seeking care at community health centers, where health services are either free or based on ability to pay.
And who's providing those services?
"My hunch is that many of these community health centers nationwide are looking for family physicians to serve in both practice and administrative positions," says Goetcheus.
That's part of what led to the formation of a new administrative training fellowship sponsored by the Department of Family Medicine at Georgetown University in Washington, Unity Health Care and two other groups. FP Aviva Zyskind, M.D., is the first Health Center Director Development fellow. In that capacity, she works with Goetcheus in the UHC clinics.
"Family physicians are uniquely suited to work in community health centers because they're trained to see all types of patients," says Zyskind. "Also, many family practice residency programs emphasize caring for the underserved."
The need to expand the nation's network of community health centers is not lost on the Bush administration, which, in its 2002 budget proposal, has called for opening 100 new CHCs across the nation and expanding services at 100 others.
The irony is that the president also supports cuts in Title VII funding -- the very funds used to provide training for FPs and other primary care physicians.
"We need more primary care doctors," says Zyskind. "That keeps people out of the hospital. You have better quality of care and greater continuity of care. You have doctors who know the patients."
Diabetes care criteria
Groups release first uniform set of outcome measuresEvaluating care provided to adults with diabetes just got easier -- or, at least, more standardized. Last month, the AMA, Joint Commission on Accreditation of Healthcare Organizations and National Committee for Quality Assurance released a set of performance measures to evaluate adult diabetes care across multiple clinical settings. It's the first time a uniform set of measurements on any clinical topic has been disseminated.
The document uses an evidence-based approach to coordinate outcome measurement sets used by physicians, hospitals and health plans. Meeting the performance measures would eliminate redundancy and help health professionals make the best use of existing resources. The diabetes measures are the first in a series the three health groups intend to release. Future documents will address cardiovascular disease care, neonatal care and pregnancy care.
AAFP involvement
AMA, JCAHO and NCQA in 1998 created the Performance Measurement Coordinating Council to identify standardized performance measures that would apply across the physician, health plan and provider organization levels of the U.S. health care delivery system. Former AAFP President Neil Brooks, M.D., of Vernon, Conn., represented the Academy on the PMCC.
The diabetes document was developed by an expert panel of physicians and others. Theodore Ganiats, M.D., of La Jolla, Calif., who chairs both the AAFP Commission on Clinical Policies and Research and the Task Force on Outcome Measures and Systems for Family Medicine and Primary Care, served on the expert panel.
Outpatient care elements
The measurement set includes these aspects of outpatient diabetes care: management of hemoglobin A1c levels, lipid management, urine protein testing, eye examination, foot examination, influenza vaccination, blood pressure management and office visit frequency.
You can view the diabetes document online by going to http://www.ama-assn.org/ama/pub/category/3798.html and clicking on "Coordinated Performance Measurement for the Management of Adult Diabetes."
The diabetes care measures will now be tested in a demonstration project conducted by the Maine Medical Assessment Foundation, a not-for-profit health services research and quality improvement organization.
New diabetes awareness campaign targets Medicare beneficiaries
The National Diabetes Education Program has teamed up with HCFA to remind Medicare enrollees with diabetes about the need for close management of their disease. HHS Secretary Tommy Thompson announced the launch of the awareness campaign on May 4.
The NDEP, a federal initiative, will work with HCFA to reach patients age 65 or older with the disease, as well as younger diabetic patients with concurrent disabilities. The program offers information about the importance of routine self-monitoring of blood glucose levels and the expanded Medicare benefits available for equipment and supplies to perform such testing. Of an estimated 16 million Americans with diabetes, 4.5 million receive Medicare benefits.
Go to http://www.hhs.gov/news/press/2001pres/20010503.html to read a press release about the campaign. A fact sheet outlining HHS initiatives to combat diabetes can be found at http://www.hhs.gov/news/press/2001pres/01fsdiabetes.html.
AAFP reforges mental health policy
Call it serendipity. The Academy is right in step with the heightened emphasis U.S. Surgeon General David Satcher, M.D., Ph.D., has placed on improving mental health services (see 'Suicide prevention is everybody's business': Surgeon general announces national strategy).
The Academy has long championed the cause of patients' rights to mental health services. AAFP's 2000 Annual Clinical Focus was on mental health, and, this March, the Board of Directors approved major revisions to Academy policy on mental health that reflect much of what the nation's "first doctor" has proposed.
The policy says family physicians, as the specialists who "have traditionally focused on treating the whole patient" and who recognize "the mind, body and spirit connection," are "uniquely positioned to recognize and treat problems in the continuum from mental health to mental illness."
Further, the policy notes that FPs "are able to treat those individuals who would not access traditional mental health services because of the perceived stigma of mental illness."
Lastly, the new mental health policy statement calls on family physicians to "support appropriate public mental health policy and, when possible, support and coordinate with other organizations to promote better mental health services for those with mental illness. These efforts should include prevention of mortality through careful use of medications and suicide prevention."
FPs praise part-time practice
BY SHERI PORTER
On Wednesday, Joyce Simon, M.D., of Overland Park, Kan., delivered a
Joyce Simon, M.D., right, of Overland Park, Kan., and her daughter, Rachel, have time to plan Rachel's graduation party on one of Simon's days off.
Kim Barbel Johnson, D.O., of Jacksonville, Fla., romps with her 2-year-old son, Joshua, during a break from medical conference meetings in Kansas City, Mo.baby, performed a flexible sigmoidoscopy and saw another 14 patients in the office. On Thursday, she relaxed on her sunny back porch, sifting through recipes with her 18-year-old daughter and planning a high-school graduation party.
Simon, a part-time family physician since graduating from residency in 1982, deliberately chose this lifestyle.
And the advantages?
"Having a life outside of medicine," she says without missing a beat. "I've never polled them, but most of my patients don't even know I'm part time." Simon delivers all her patients' babies unless she's out of town, sees all her own patients without job-sharing and doesn't mind fielding phone calls on her days off.
But working three 8 1/2-hour days a week also means she has time for an exercise regimen, church activities and family. "Parenting is really high on my list," says Simon.
According to statistics compiled by the AAFP in Facts About Family Practice, FPs work an average of almost 51 hours a week. It's a safe bet that many work far more than that.
But figures culled from an annual AAFP survey of more than 1,900 members appear to tell another story. Some 3.6 percent of FPs surveyed worked 20 hours or fewer a week, and more than 25 percent reported working 40 hours a week or fewer.
Count Kim Barbel Johnson, D.O., of Jacksonville, Fla., a new convert. She recently left a full-time position at the Mayo Clinic in Jacksonville for a county health department position. She'll provide care to homeless and indigent patients in a 20-hour workweek.
At the hospital, "eight-hour days turned into nine hours, then 12 hours, and that was time away from other priorities in my life -- namely, my family," says Johnson, mother of a 2-year-old son, Joshua.
The balance Johnson seeks comes with a price. "Deciding to work part time meant compromising the benefits and salary I once had," says Johnson, who renegotiated payments on her six-figure student loan.
"The tradeoff is Joshua," she says.
But Johnson also feels that she can give her patients the time they deserve if she carries a smaller patient load. "I did not want to compromise my style and my compassion for the patients I serve," she says. "And a part-time physician is not less of a physician."
Johnson's sentiment is backed up by a study published in the April 2000 Archives of Family Medicine. It suggested that "overtime" physicians were less satisfied with the amount of time spent with each patient and with the amount of personal and family time in their lives.
Mary Helen Morrow, M.D., of College Station, Texas, took the part-time plunge several years ago. She's worked through obstacles such as finding reasonable part-time child care in a system designed for "8 to 5" professionals. Staff meetings consistently scheduled on Morrow's day off presented a particular challenge.
"You need supportive co-workers," says Morrow, adding that the smaller the practice, the more difficult scheduling becomes.
Physicians need time, for example, to conduct research, run for political office and assume leadership roles in professional organizations such as the AAFP. Every life needs symmetry.
"This is an issue for anyone who wants to live a balanced life," says David Hutcheson-Tipton, M.D., of Marysville, Wash. This FP, a father of six, is in his first military assignment out of residency, and he has a family-friendly schedule: 7:30 a.m. to 4:30 p.m., Monday through Friday. Hutcheson-Tipton says he'd seek a similar schedule if he were in private practice. "We tell patients to exercise and eat well and balance their lives, and we should, too."
NCSC speaker calls for 'fundamental transition' in family practice
BY TONI LAPP
Is there a new model for health care? One in which electronic medical records replace paper files, and patients wait only briefly in relaxed waiting rooms and make appointments by logging on to the Internet? Joseph Scherger, M.D., of Irvine, Calif., spoke of such a model in a plenary session at AAFP's National Conference of Special Constituencies held here in April.
Joseph Scherger, M.D., gives the plenary address at the National Conference of Special Constituencies.Scherger, a past AAFP director and former president of the Society of Teachers of Family Medicine, addressed the need for FPs to embrace emerging technologies to improve the delivery of health care in the 21st century. Such a transition will not only lead to more efficient service, but also to safer delivery of medicine, said Scherger.
As things stand now, "we are writing lethal orders by hand," said Scherger, citing the 1999 Institute of Medicine report on medical errors.
Training tomorrow's information masters
Scherger, who will become founding dean of Florida State University College of Medicine in Tallahassee on July 1, knows all about innovation.
The medical college, the first allopathic school to be established in the United States in almost 20 years, began training its first class of students last month. They will spend their first two years in Tallahassee and then will be dispatched to clinical training sites across Florida.
The Internet will be used to link clinical training sites and facilitate interactions among students, faculty, community physicians and patients. The school will provide students with laptops, and each student will receive a personal data assistant loaded with search information.
"These students will be trained to be information masters using new technology," said Scherger. "We expect them to not only learn from their community mentors, but to teach them. They will be trained to be 21st- century physicians, using the power of information technology to provide high-quality care consistently."
Transforming your practice
His advice to practicing FPs wanting to start the change now? First, begin e-mail communication with patients. Second, implement an electronic patient record system.
That advice caused somewhat of a stir among NCSC audience members, some of whom cited concerns over legal liability, confidentiality and reimbursement for e-mail communication.
But Scherger said that physicians who begin to use technology will soon realize the advantages. He said he's received fewer e-mails than expected, and, furthermore, patients tell him things in e-mails that they are too embarrassed to discuss during office visits.
It comes down to improving service delivery in what is, after all, a consumer-driven environment. "How we deliver health care isn't satisfying for people," said Scherger.
"Family practice is at a place where it needs to make a fundamental transition in order to have its proper place in medicine in the 21st century," he said. "We will not succeed if we continue the way we have been."
Rx for drug abuse?
Director Karla Birkholz, M.D., answers reporters' questions at the National Press Club.The National Institute on Drug Abuse, the Academy and six other organizations launched a campaign this spring, the National Initiative on Prescription Drug Misuse and Abuse.
AAFP Director Karla Birkholz, M.D., of Phoenix was the only practicing physician helping kick off the campaign at a press conference in Washington.
When asked how to distinguish between abuse and proper use of drugs, she said, "Here's what I tell my patients. 'If you're using your medicine properly, you'll be more effective and productive in your life. If you're using it to get high or escape your life, that's abuse.'"
In a later interview, Birkholz said misuse can include not taking medicine for fear of addiction, taking it in wrong dosages and taking it for reasons other than those intended. And she said some patients coordinate their own care, going to different specialists and taking multiple medications with serious repercussions.
Birkholz noted a further problem: underprescription.
"With our pain patients, we should be treating their pain and their depression and anxiety," said Birkholz. "Some physicians are afraid of using high-powered drugs, but those drugs may be what our patients need."
Sometimes, combining medications at lower doses may yield fewer harmful side effects in patients with problems such as hypertension, diabetes and depression, said Birkholz.
Birkholz told of a psychiatrist who once advised her, "If you have a patient needing more than one antidepressant, you should refer the patient to a psychiatrist." Birkholz replied, "Do you know what I do for a living? I have to manage multiple medications. That's my job."
Collaborating partners in the national prescription drug initiative are the AAFP, National Institute on Drug Abuse, AARP, American Pharmaceutical Association, National Association of Chain Drug Stores, National Community Pharmacists Association, National Council on Patient Information and Education, and Pharmaceutical Research and Manufacturers of America.
Info from NIDA
The National Institute on Drug Abuse reports:
- Some 46.6 percent of physicians find it difficult to discuss prescription drug abuse with their patients, according to a survey of primary care physicians and patients.
- An estimated nine million Americans used prescription drugs for nonmedical reasons in 1999.
- The most commonly misused or abused prescription drugs are opioids, central nervous system depressants and stimulants. Those drugs, when not taken as prescribed, can alter the brain's activity and lead to dependence and, possibly, addiction.
- Up to 17 percent of adults 60 or older may be affected by prescription drug abuse or misuse.
A new publication to help health care professionals discuss prescription drug abuse with patients is online at http://www.drugabuse.gov/ResearchReports/Prescription/Prescription.html and may be ordered by calling NIDA at (800) 729-6686 and requesting the research report on prescription drugs.
Constituencies tackle tough issues
BY SHERI PORTER & JANE STOEVER
Jacquline Perry, M.D., of Huntsville, Ala., listens intently before sharing her views at the National Conference of Special Constituencies.
Mary Gayle Armstrong, M.D., of McComb, Miss., makes sure her vote is counted during the women physicians' hearing.
Newly elected IMG delegate Ashok Kumar, M.D., of Tyler, Texas, takes a turn at the NCSC microphone.The corridors and conference rooms of the Hyatt Regency Crown Center filled with family physicians, chapter executives and other Academy friends April 26 - 28. Nearly 400 registrants participated in the Annual Leadership Forum and National Conference of Special Constituencies, held in conjunction each year.
Resolutions passed at NCSC are referred to either the AAFP Board of Directors or the Congress of Delegates for further action. Here's a sampling of work from the five constituencies.
Women FPs
Discussion on four resolutions pertaining to emergency contraception kept women physician constituency members literally on their toes as they lined up at the microphones.
Three resolutions, two of which passed, asked for more education and training on the subject for both practicing physicians and residents.
The debate heated up when attention turned to the resolution calling for the Academy to oppose over-the-counter availability of hormonal emergency contraceptives.
"There are 1.5 million abortions a year in the United States. If this (use of over-the-counter hormonal contraceptives) were widely available, it could cut that number in half," said Linda Prine, M.D., of New York, who spoke against the resolution. Prine called emergency contraception a compelling public health issue and an option for people who can't access a doctor.
Deborah Green, M.D., of Fort Lupton, Colo., voiced concerns about the patient/doctor relationship and said that birth control should be discussed in the physician's office, not the pharmacy. "I'm afraid teens will misuse this as a form of birth control, which it is not," said Green.
There were voice votes, hand counts and several mandatory recounts with one-vote margins.
In the end, the resolution failed late Saturday afternoon by a final hand vote of 17 - 15.
International medical graduates
IMGs, meeting for the second year, passed a resolution aimed at eliminating inequities in the resident selection process. Ashok Kumar, M.D., of Tyler, Texas, was elected at the meeting as one of the first IMG delegates to the AAFP Congress. He hopes to be seated there this fall pending adoption of a Bylaws amendment by the COD. Kumar said IMGs take the same examinations as American graduates, plus a clinical assessment test and an English language skills test.
"We want to make people aware that IMGs are equally qualified for residency slots," he said. IMGs consistently fulfill important health care needs in the United States by serving in rural and underserved areas, he added.
New physicians
During most years since 1995, the new physicians have sought a position on the AAFP Board. They chalked up their first success last fall. The Congress of Delegates asked the Committee on Bylaws to draft an amendment reserving a Board seat for new physicians, those in practice fewer than seven years. The Congress will vote on the amendment this fall.
The new physicians at NCSC adopted a resolution on the election process for the new physician. "When the Committee on Bylaws meets this June, we hope it will add this process to the final amendment," said new physician Julie Wood, M.D., of Macon, Mo., who helped write the resolution. The process calls for candidates to be nominated by constituent chapters, elected by new physicians at NCSC and voted on by the Congress.
Among the concerns of new physicians are licensure and credentialing problems. "The Federation of State Medical Boards has made it harder to get licensed quickly, and many insurance plans and HMOs may not credential you for six or nine months, so you can't see patients in those plans," said Wood. "You're at the whim of the insurance plan."
She adds, "The new physician on the Board could provide our perspective on all issues, not just new physician issues."
GLBT constituency
The gay, lesbian, bisexual and transgender constituency, meeting for the first time, sent a resolution to the joint constituency (a meeting of all the constituencies), which approved it. The measure asked AAFP to introduce a resolution in the AMA House of Delegates calling for a change in federal immigration and naturalization laws to extend resident alien status to those meeting the AAFP definition of family.
The AAFP defines family as "a group of individuals with a continuing legal, genetic and/or emotional relationship." Currently, immigrants' spouses (not lesbian or gay partners) may receive resident alien status.
Minority constituency
The minority constituency asked the Academy to support legislation that would help fund culturally sensitive interpretive services for health care and to develop and promote to members both written and electronic materials on cultural competency and special populations.
The constituency called for health promotion efforts, including the prevention of substance abuse, on behalf of prisoners and former prisoners. The minority physicians also resolved that the Academy should encourage HCFA to provide reimbursement, if needed, for transportation of Medicare patients for up to 12 health care visits.
Just do it: Involve residents in family practice research
BY SHARON DICKINSON DENT
After three years of speaking at the annual AAFP Residency Program Directors' Workshop on how to introduce research into residencies, FP Jon Temte, M.D., Ph.D., and Mark DeHaven, Ph.D., weren't sure their efforts were being translated into research.
"We realized that the best way for residents to learn about research would be for them to 'just do it,' and we would provide tools and resources," said DeHaven, a faculty member at the University of Texas Southwestern Medical Center at Dallas.
Want to join the second project?
The "Just Do It" team's second project is scheduled to kick off this month at the 2001 program directors' workshop. To join the project, call Jonathan Temte, M.D., Ph.D., at (608) 263-3111.
Also this month, an interactive Web site should open with the "Just Do It" curriculum, covering these topics:
- identifying the role of research in family medicine training,
- asking the research question,
- searching and critically appraising the literature,
- establishing the research design,
- implementing the research project and collecting data,
- using and understanding statistics,
- interpreting and synthesizing, and
- reporting, writing and presenting the research.
So he and Temte, a faculty member at the University of Wisconsin Medical School in Madison, launched "Just Do It: A Networked, Participatory Research Experience" at the 2000 program directors' workshop. They recruited family practice residencies to gather data on initial management of the febrile child 5 years old or younger.
Temte explained that the study involved residents, fellows, faculty physicians, physician assistants and nurse practitioners at 10 residencies across the country. Data collection took place over 13 weeks, wrapping up in March. Participants at the clinics entered data on pocket cards, which were returned to the project coordinators.
What emerged was the largest data set on febrile children ever to come out of family practice settings, said Temte at the AAFP research network convocation in March.
Initial returns (one residency had not yet submitted data) showed that 546 febrile children were treated in the clinics during the study period. "We have a very rich representation in terms of ethnicity," Temte said, noting that the group was about 46 percent white, 12 percent black, 37 percent Hispanic and 5 percent Asian.
The most compelling finding so far, Temte said, was the number of children treated with antibiotics. "Fifty-four percent who came in with a fever or a reported fever got an antibiotic," he said. "If you go back and add up everything that you might consider an antibiotic for -- for example, otitis media or strep throat -- if you add up all of those, it still doesn't add up to 295 kids. We're giving antibiotics to kids with upper respiratory infections, kids with bronchiolitis and respiratory syncytial virus; we're giving them to kids who probably shouldn't be on them. If you look at the literature, we probably should be way, way, way, way down from that."
Some other results:
- Eighty percent of children received no diagnostic tests. When tests were ordered, the most common one was a white blood cell count.
- The most common diagnosis by far was upper respiratory infection (about 252 cases), followed by otitis media (175 cases) and sinusitus (30 cases).
- Five percent of children were admitted to the hospital, but most children, 66 percent, were told to come back for follow-up after three days or as needed.
- Children with higher temperatures were more likely to receive antibiotics and more tests than were children with temperatures at or below 101.2 degrees Fahrenheit.
Resident researcher: 'I enjoy it!'
Q&A
Damon Schanz, D.O., a third-year family practice resident at the University of North Texas Health Science Center in Fort Worth, served as his site's principal investigator for the first "Just Do It" study (see "Just do it: Involve residents in family practice research"). Here are some of his thoughts.
Did the study provide you with any insights about research?
I have always been interested in research. I worked with several researchers at UT Southwestern and Texas A&M Medical School prior to entering medical school. I guess they stimulated my interest in research. This project, however, gave me direct insight into the workings of the internal review board.
Do you think it's important for residents to do research?
It's at the discretion of the resident. Some may not like the academia of research; others may enjoy it. I think it is good for the practice of medicine to ensure that residents can understand how research is performed and be able to sift through the countless journals and decide what is and what is not good research. I think the only way this can be achieved is with participation.
You say you want to continue doing research. Why?
I enjoy it! There is so much information yet to be gathered on how, why, when and if patients respond to certain drugs or treatments. It is not difficult information to obtain, and it can be beneficial in the future to other practicing physicians and the public.
Are you planning to write a paper on the "Just Do It" study results?
Yes, the results are too good not to publish. I think the main point is that not every patient needs an antibiotic. This can be proved by the overwhelmingly large amount of antibiotics that were prescribed.
Did the study results make you think about the way you treat febrile children? Will you do anything differently now?
I will definitely think about my prescribing habits when it comes to children. However, each child and physician encounter is different. If I believe they need an antibiotic, the study will not dissuade me.
More on GLBT issues
To the editor:
The responses to the March FP Report article on sexual identity (letters printed in the May FP Report) are ample evidence that these types of articles and education are badly needed.
All physicians should be aware that the American Psychiatric Association regards therapy to change sexual orientation as harmful and unethical. Physicians who believe that they don't have gay, lesbian, bisexual or transgender patients in their practice probably haven't asked the right questions in order to find out. Without an atmosphere of acceptance and an openness to discuss GLBT issues, most patients will keep information about their sexual orientation to themselves rather than be subjected to rejection, harassment or referral to change their orientation. The GLBT community is as diverse as the rest of society and mainly invisible. Unless physicians are taught ways to address the sensitive issue of sexual orientation, these patients will remain unidentified and inadequately cared for.
Stephen Adams, M.D.
Springfield, Mo.To the editor:
I'm writing in response to (the May FP Report letters from) doctors who are outraged by your special section on sexual orientation issues.
Straight physicians and staff take for granted their heterosexual privilege. If we value diversity, we must constantly ask ourselves what our prejudices are and challenge those prejudices. If I had a different sexual orientation, I would not want to be seen by a physician who could not overcome that prejudice any more than I would want to see a racist physician if I were nonwhite. This assumes that there is an adequate supply of enlightened physicians.
It amazed me that people continue to be prejudiced about sexual orientation. It has taken us decades to get equal protection for all races, creeds and colors. What will it take to provide gays, lesbians, bisexuals and transgender people with basic civil rights? Laws!
Susan Schmitt, M.D.
St. George, W.Va.To the editor:
I was saddened to read some of my colleagues' letters to the editor in the May edition of FP Report regarding the earlier articles about sexual orientation (March FP Report).
I believe, as a family physician, my job is to support and nurture all of my patients and to make them feel welcome. My practice has lesbian, bisexual and transgender patients. I treat each with respect and caring, and they have felt welcomed and have become loyal patients. We do not need to "agree" with our patients' lifestyle to care for them and respect them. I happen to be Jewish, but I care for patients of all religions. I also care for patients who smoke, who are alcoholics, who overeat, etc.
Aren't we supposed to be healers? A patient's race, religion or sexual orientation should not change that. Perhaps if we treated our patients as people without trying to categorize them first, we would be most effective as physicians.
Wayne Strouse, M.D.
Penn Yan, N.Y.To the editor:
The three members objecting to the report on sexual orientation (March FP Report) all seem to lack sensitivity to the fear of many gay or lesbian patients that they will not be accepted by their physician if they discuss their sexual orientation.
Many physicians have strong prejudices against homosexuality and may either embarrass a patient or imply that the patient is "sick" and should change. Some may even try to suggest a referral for change (as one letter- writer did) even if the patient is not seeking a change in sexual orientation.
If a GLBT patient hears a doctor speaking nonjudgmentally about gay people or sees some statement or sign that assures him or her that he or she will be treated with acceptance and understanding, the patient is more likely to confide in the physician. If there is no such hint or sign that this is a safe place to discuss sexual orientation, the patient will be silent and will not reveal what might be an important part of the history.
Joseph Norquist, M.D.
St. Paul, Minn.Do what's right
To the editor:
Recently, there was an AAFP mailing that basically asked, "What do you want AAFP to be?" It is almost as if we are willing to become whatever people seem to want for motives that remain unstated. Is profit the motive? Human pride? Desire to be the biggest and best on the block? Physician recruitment?
We should do what is right rather than what is popular. We should look to our heritage.
It is right to be honest. It is right to be compassionate. It is right to practice preventive medicine. It is right to be the advocate of the patient -- who works and sacrifices to pay the bill -- rather than to cave to a marketing program in the choice of a medication. It is right to help patients weigh their options and make the best choice. It is right to guide patients to the best specialist when this is necessary.
There are primary care docs out there whose sole purpose is to make the biggest profit. We need not attack them, but at the same time, we need not lower our standards to lure them into membership.
Your advertising campaign does justice to the high ideals of AAFP. Let us do our best to make sure that the people get what they need and what we promise to deliver.
Daniel Siemer, M.D.
Hammond, Ind.Tailoring residency training
Fellow (fel'o) n.
1. A distinguished member of a learned society.Beyond this simple definition is an abundance of experience, service, and education. The Degree of Fellow recognizes American Academy of Family Physicians members who have distinguished themselves among their colleagues and communities.
For more information on the American Academy of Family Physicians' Degree of Fellow, go to our Web site at www.aafp.org/fellow, or call 1-800-274-2237 ext. 6812.
If you plan to attend the Fellowship Convocation on October 5, 2001, in Atlanta, you must submit your completed application no later than August 1, 2001, for your name to appear in the program book.
To the editor:
It was exciting to read "Changes in the Pipeline?" and "Join in: Reassessment of the Specialty Expands to Include All Stakeholders" in the April FP Report. It is refreshing to hear that the residency curriculum may become more adaptable.
As a chief resident and family physician, I have been frustrated by the curriculum limits that stifle the opportunity for individualized training.
For example, I have at times asked myself why I am obligated to do several months of obstetrics training even though I do not plan to practice obstetrics after graduation. My time would be better spent mastering other skill sets that I would more frequently use.
Many internal medicine residencies offer a "traditional" track that is more hospital-based and a "primary care" track that is more outpatient-based. Obviously, our specialty is diverse, with family physicians operating in a multitude of geographic locations and practice settings. The residency curriculum should reflect this. Thus, on graduation, each individual may have expertise in specific subject areas while maintaining the core competencies. It is unclear to me whether this future flexibility in training requirements will need to be on an individual basis or on an interresidency basis. Either way, our specialty must change to reflect the reality of today's world and modernize residency training by emphasizing the core strengths of family practice based on an individual's future practice expectations.
Paul Lewis, M.D.
Indian Rocks Beach, Fla.
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.
Web watch: Members give aafp.org a thumbs-up
The votes are in, and AAFP's Web site has garnered rave reviews from members.
In an e-mail survey that was sent to 22,500 active members in March, a strong majority of respondents -- 89.5 percent -- rated the Web site as "good" or "excellent." About 3,600 members answered the 32-item questionnaire, yielding a response rate of 16 percent.
The information gathered will be used to improve AAFP's Web site, says Gordon Schmittling, director of the AAFP Research and Information Services Division. Schmittling adds that he is pleased with the feedback and wishes to thank the respondents because members' input is critical to the ongoing development of the site.
Several features of AAFP's Web site received special kudos. The "Daily Question," "Practice Pearls," and the state and national Web lobbying interface "Speak Out!" were all lauded for quality of information and ease of use.
One added note: 43 percent of respondents indicated that they have their own Web site, with 12 percent of respondents saying they used the Academy's free service to create a Web site on familydoctor.org for their patients.
Order from AAFP at (800) 944-0000 unless otherwise noted.
Online Video CME? That's right, three of Video CME programs are now only a mouse-click away. These offerings use streaming video, an online syllabus and an interactive posttest. Go to http://www.aafp.org/videocme to choose a program. To earn CME credit, pay $8.
Coming soon: Q-Care, a CME program of quality improvement self-assessment modules. The first module -- on migraine headache -- is being developed this summer. For information and to preregister, call (800) 274-2237, Ext. 5298. Cost for each module is $50; $25 for Home Study subscribers.
Check it out: The May 15 Family Circle features "Healthy Living," supplement produced in cooperation with the AAFP. The section covers topics such as allergies, cancer prevention and diabetes. Free copies of the magazine (#R021) are available in bulk for your reception room.
Proven value: Thinking about seeking staff membership and privileges at a local hospital? Or considering joining a new managed care organization? Either way, the book Family Practice in Health Care Organizations: Strategies for Strength (#R701, $10) is sure to be of benefit.
Proven value: If you're looking for a practice or an FP to recruit, log on to http://www.aafp.org/placement, the AAFP Placement Services Program. This free service to members lists clinical and faculty employment opportunities worldwide. Employers seeking to fill positions pay a nominal fee. Questions? Call (800) 274-2237, Ext. 6814.
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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