October 2001 -- FP Report

October 2001 • Volume 7 • Number 10

Terrorist attacks kill two FPs; other FPs help victims

BY JODY McAULAY GLOOR

Early on Tuesday, Sept. 11, family physician Frederick Rimmele, M.D., left his home in Marblehead, Mass.; caught a flight in Boston; and headed for the central California coast for some much-anticipated bird-watching and an Academy CME course.

FP Paul Ambrose, M.D., M.P.H., boarded another flight that morning in Washington, D.C. His destination: Los Angeles and a conference on preventing youth obesity -- a topic on which he recently completed some research for HHS.

But neither made it. Terrorists hijacked Rimmele's United flight and crashed it into the south tower of the World Trade Center in New York City, killing all 65 people aboard and thousands more. And somewhere over Ohio, terrorists commandeered Ambrose's American airliner, headed back to Washington and slammed it into the Pentagon, killing all 64 people aboard and 125 others.

HONORING THE VITIMS

Frederick Rimmele, M.D., 32, was flying to Los Angeles and then on to Monterey, Calif., to attend an AAFP course, "Geriatric Medicine for the Family Physician," which was cancelled after the terrorist attacks. He practiced at the Hunt Center in Danvers, Mass., and taught at the family practice residency at Beverly Hospital in Danvers. His wife, Kimberly Trudel, and other family members ask that donations be made in Rimmele's name to the Nature Conservancy, 4245 North Fairfax Drive, Suite 100, Arlington, VA 22203. Please refer to account #2861662.

Paul Ambrose, M.D., also 32, was a fellow at HHS who worked on health care policy in Washington, D.C. His parents, with the Marshall University School of Medicine, have established a scholarship in his memory. Contributions can be mailed to Linda Holmes, Marshall University School of Medicine, 1600 Medicine Center Drive, Huntington, WV 25701. Please make checks payable to: School of Medicine -- Paul Ambrose Scholarship.

Almost immediately, FPs on the ground began answering the cries for help. They jammed New York City hospitals, waiting to treat victims. Some walked or ran to the attack sites and joined emergency response teams in assessing the injured crawling from the smoke and debris. Many more called disaster agencies, offering their services wherever they were needed.

Academy member Neil Calman, M.D., president and co-founder of The Institute for Urban Family Health in New York City, was working just one mile away from "ground zero" at the twin towers when disaster struck.

"We were in touch immediately with all the emergency authorities," Calman said. "At that time, expectations were very high that there would be thousands of injuries. Unfortunately, that was not the case. By late Tuesday night, all the emergency care was being handled by nearby hospitals."

Just across the river from the towers, at St. Mary Hospital in Hoboken, N.J., family physician Abbie Jacobs, M.D., watched the 110-story buildings burn and collapse. Jacobs is director of the family practice residency at the University of Medicine and Dentistry of New Jersey. The ensuing "mass exodus" from the city brought 158 victims to Hoboken's command central post.

"They came in on their own, kind of like the 'walking wounded,'" she said. "We had people who walked six miles to Queens to catch the ferry to get here. One woman with an Achilles tendon rupture had walked for miles. It was almost as if she wasn't aware of the injury."

No critical cases came to Hoboken, and many with minor injuries just wanted to talk about their experiences. One young woman who watched the terror unfold on her TV told how her husband called her from the south tower after the north building was struck. "Then that building was struck, and now he is presumed dead," Jacobs said. "She, like many others who have come in since, needs psychological help."

Soon after news of the attacks reached the AAFP's national headquarters, staff established a special hotline and e-mail address for members wanting to volunteer for rescue and relief efforts. During the next two days, more than 300 Academy members responded to the call. Several constituent chapters posted volunteer hotline numbers on their Web sites as well.

By Wednesday, physicians and Academy leaders turned their attention to the more serious emerging need -- counseling -- for victims, their families and friends, rescue workers, and all those who witnessed the attacks on-site or on TV.

Early that day, Calman and six other physicians walked the mile to ground zero. "It was clear that doctors had responded by the thousands," he said. "Rescue workers and firefighters were the only people getting treated there."

Calman later began counseling physicians and residents at the institute, he said, because they were "completely frustrated that their medical skills were of little or no help at that point." He e-mailed them expressing that their "regular" work still was very important.

The entire experience, he added, reminded him of the "incredibly critical role" family physicians have when tragedy strikes. "We can do it all. We can assess emergency needs. We can provide anesthesia. We can irrigate eyes, and we can treat burns and lacerations," he said. "And now we can counsel people."

On Thursday, Sept. 13, the Academy e-mailed a special bulletin to members and a letter to chapter executives, alerting them that many patients and their families will need counseling.

The Academy offered a list of resources, including clinical materials about diagnosing and treating post-traumatic stress disorder and materials to use when talking with patients of all ages, family members and colleagues. The list is posted online at http://www.aafp.org/resources/. For more FP involvement, go to http://www.aafp/org/publications/ and click on "AAFP News," then on "Directors' Newsletter," to read the Sept. 20 issue.

Researchers, ethicist ponder clinical trial safety issues

BY TONI LAPP

The recent death of a healthy 24-year-old volunteer in a Johns Hopkins University asthma trial has some family practice researchers re-evaluating safeguards and others fearing a backlash among potential study volunteers.

The aim of the trial was to study how normal lungs function when exposed to factors that constrict them. Lab technician Ellen Roche took hexamethonium, a chemical that causes asthma-like symptoms and is not approved by the FDA for use in humans. Roche, who was paid $365 for her participation, developed a cough within 24 hours of taking the drug and later lapsed into a coma. She died less than a month later. Those familiar with the case say the informed consent failed to tell patients about the risks of the drug, which was described as a "medicine."

Protecting your patients

With so many persons participating in clinical trials, it's likely there are patients within every family practice who are volunteers, whether their FPs know it or not. But if a patient asks for your opinion about participating in a trial, researchers say there are a few things to consider.

Ensure that an institutional review board has approved the trial.

Read over the informed consent document; make sure the patient under-stands the risks.

If the patient has a condition that could benefit from being in a clinical trial, know what the treatment arms are.

Does the patient have a mild condition so that receiving a placebo wouldn't pose a great risk?

In some cases, volunteers suffer from conditions for which there is no cure and therefore have nothing to lose by participating in trials. In this case, the advantage is that the patient is getting the very best of care in the control group -- and even better care if the intervention turns out.

But for the most part, studies today are safer than ever, many researchers say.

One physician who worries about repercussions is Barbara Yawn, M.D., M.Sc., of Rochester, Minn., a member of AAFP's Commission on Clinical Policies and Research. Not only was the death a tragedy, but it also "was a disaster for research," says Yawn.

"I think people are going to be very fearful," she says. "And that's why we need to get as much out and known about the Hopkins study as possible. Let people know about what type of safeguards are in place. There are a lot of people participating in studies, and the risk is low -- but with so many people participating, sometime, somewhere, someone will have a bad reaction."

By some counts, 2.2 million people are currently participating in clinical research trials in the United States. Institutional review boards have the responsibility of evaluating these trials for safety and adherence to ethical guidelines. These review boards ideally include laypersons and clinical experts.

Even though Johns Hopkins is a research-oriented institution, it is not immune from errors, says Yawn. Indeed, the sheer number of research projects conducted by such institutions make it more likely that one of them would have a tragedy, she says.

One researcher who was not surprised by the event at Johns Hopkins is Stephen Spann, M.D., of Houston, chair of the AAFP Task Force to Enhance Family Practice Research.

"Adverse reactions can happen anywhere," says Spann. "It's not necessarily a negative comment on the institution where it happened."

IRB PROBLEMS

However, one medical ethicist says institutional hubris could have played a role. "The more prominent the research institute, the bigger the problem," says Don Reynolds, a program associate with Midwest Bioethics Center in Kansas City, Mo.

"In theory, IRBs are supposed to be populated by community members to dilute the presence of institutional bias," he says. "But in truth, we've done a poor job of recruiting. Often (IRBs) don't represent the kind of distance that's needed."

A lawyer by training, Reynolds sits on several IRBs for the University of Missouri-Kansas City. He notes that the safeguards that are in place are fallible. In Johns Hopkins' case, he says, the institution streamlined the process by which its IRB worked, possibly circumventing a key safeguard in the review process. If investigators had done a complete review of the literature, they would have found reports of adverse events with hexamethonium, says Reynolds. But even when the boards adhere to the complete process, many are overworked by the sheer number of trials. In one case, an acquaintance on another review board told him her board had 12,000 adverse events to evaluate.

PLACEBO RISK

Spann notes that individuals in the placebo group may not be at risk of an adverse reaction from an experimental treatment, but they face another risk: not receiving treatment while participating in a placebo-controlled trial.

Just such a risk caused one physician to experience conflict between his role as a researcher and his role as a physician. Bernard Ewigman, M.D., director of the Center for Family Medicine Science at the Department of Family and Community Medicine, University of Missouri-Columbia, says that in one study, "the potential benefit did not justify the risk of going without treatment for the patients." He declined to work on the study.

TO PAY OR NOT TO PAY

In studies he has been involved with, Ewigman has paid volunteers for their time and effort. But patients should never be compensated for taking risks, he says.

Reynolds concurs. The woman in the Johns Hopkins trial received payment for her participation. "In studies like this one, where there is no benefit to the person, you want to be sure that the person understands the known risks and that they aren't being influenced (by money) to enter the study," he says.

That the volunteer was also an employee of Johns Hopkins is also a concern. "You want to be careful there's not a culture of everyone participating at an institution," Reynolds says.

And even though clinical trials pose a risk, they are an improvement over the days when drugs were tried experimentally without formal data collection or control groups, says Ewigman. They are the foundation of evidence-based medicine.

"It's important to emphasize the gold standard of evaluating a treatment is clinical trials," says Spann. "We must do everything we can to minimize the risks, but the trials must go on."

Vaccine at issue as FPs brace for flu season

BY TONI LAPP

"Order early and often" might have been the mantra of some health care professionals when they ordered the flu vaccine this season, says the CDC.

The CDC is concerned that some medical professionals might have placed double orders for fear there would be shortages again this flu season. The CDC is now asking providers to reassess their vaccine needs and alert their vaccine suppliers if their orders overstated their needs.

And those providing services in work sites are being asked to notify their vaccine suppliers and request that their shipments be deferred until November. That way, ample vaccine will be available for persons at high risk of complications from the virus.

Those who placed double orders of the vaccine just to ensure they'd have some may want to familiarize themselves with the return policy of the manufacturers. The two U.S. manufacturers, Wyeth Lederle and Aventis Pasteur, will not accept returns.

Both manufacturers call customers before shipping to confirm the order, said company spokespersons. Customers can revise their orders at that time.

Because delays are expected in the shipment of flu vaccine, the CDC is asking that physicians give their high-risk patients priority when administering the vaccine.

ETA FOR SHIPMENTS

Wyeth Lederle had not started shipping as of mid-September but expected to begin filling orders by early October, said spokeswoman Natalie deVane. Aventis Pasteur had started shipping and was on track to complete its goal of sending customers at least 25 percent of their orders by the end of September, said spokesman Len Lavenda.

The reason for sending partial shipments is to allow all vaccine providers to offer their high-risk patients the vaccine early in the season.

The message being repeated by the AAFP and other health organizations is this: If your healthy patients want to beat the rush to get their flu vaccine this fall, tell them to wait until December, when the vaccine supply will be plentiful. However, if your patients are at increased risk of influenza complications or are health care workers, go ahead and vaccinate in October and November.

The CDC projects that about 56 percent of the total vaccine supply will be distributed by the end of October, about 31 percent will be delivered in November and the final 13 percent in early December.

Information on influenza vaccine lots that are released by FDA and available for distribution by manufacturers can be found at http://www.fda.gov/cber/flu/flu.htm.

The AAFP has released a prioritization schedule for the vaccine; it can be found online at http://www.aafp.org/policy/camp/27.html.

State health department contingency plans are being added to the CDC influenza Web site at http://www.cdc.gov/nip/flu/.

CONCERNS VOICED OVER SUPPLY, COST

Clearly, family physicians are concerned about their ability to provide the vaccine: At press time, the AAFP Congress of Delegates was set to consider seven resolutions about vaccine supply or cost during the delegates' meeting Oct. 1 - 3 in Atlanta.

The cost of the vaccine went up from 22 percent to 67 percent compared with last year. Some reasons: One manufacturer withdrew from the flu vaccine market, the remaining manufacturers made improvements to their production facilities, and the cost of shipment increased because of the move to split orders. Reimbursement has been another concern. The Centers for Medicare and Medicaid Services reimburses 95 percent of the average wholesale price and then adds an additional amount for administration costs. Currently, the CMS reimbursement is $4.26 for the vaccine and an additional $4.59 for administration costs. The reimbursement for the vaccine is expected to go up to $6.29 on Oct. 1, said Kent Moore, manager of health care financing and delivery systems for AAFP.

For those physicians thinking ahead to the 2002 - 2003 flu season, the mantra could be "order early, but not often." This year, one manufacturer took orders only through May 15. Since then, customers have been advised to order through a distributor, which may cost more.

AAFP Foundation will collect relief funds

The AAFP Foundation will collect contributions for a Disaster Relief Fund to help people in New York City and the District of Columbia in the wake of the terrorist tragedies on Sept. 11. All of the collected funds will be sent to an appropriate agency in the two cities; the agency will be identified by the AAFP Foundation and the foundations of the New York State and District of Columbia chapters.

Send contributions, marked for the Disaster Relief Fund, to: AAFP Foundation, Attention: Disaster Relief Fund, P. O. Box 7388, Shawnee Mission, KS 66207. If you have questions, call the AAFP Foundation at (800) 274-2237, Ext. 4450.

AHRQ awards $750,000 in grants to Academy

The Academy's interest in improving patient care has been bolstered by two grants worth $750,000 from the Agency for Healthcare Research and Quality. The money will fund three projects of AAFP's National Network for Family Practice and Primary Care Research.

The first grant, worth about $200,000 per year for three years, will create a National Developmental Center for Evaluation and Research in Patient Safety in Primary Care. Through the national research network, the center will focus on identifying medical errors and near misses and will develop and test patient safety tools in actual practices. The network currently includes 117 clinical practices in 34 states and Canada.

The second grant, worth about $150,000, is a continuation grant that will develop two research projects. One will test two methods of data collection -- paper versus personal digital assistants -- to study pneumococcal immunization in elderly adults. The second research project will collect information about patient-physician encounters from network physicians using the National Ambulatory Medical Care Survey.

John Hickner, M.D., M.S., network director and a professor of family practice at Michigan State University, East Lansing, will be the principal investigator of the studies. James Galliher, Ph.D., research director will be the co-investigator.

New survey shows
Academy provides what members want

'TOP 10' MEMBER NEEDS IN 2001

Program/Service Mean rating

1. CME accreditation (ensure the quality of FP Prescribed credit) 5.91

2. American Family Physician journal 5.78

3. Representation of the specialty in Washington, D.C. 5.76

4. Public promotion of the FP's image 5.62

5. Representation of the specialty at the state level 5.54

6. Representation of family practice to other specialties and within organized medicine 5.46

7. Involvement with family practice residency programs to improve their training 5.45

8. Promotion of family practice in medical schools to ensure the continued supply of FPs 5.43

9. Programs for medical students to increase their awareness of and interest in family practice 5.37

10. Help for members in accurately coding services 5.34

Although the annual Member Attitude Survey is used to gauge members' opinions about the Academy's performance, AAFP leaders this year decided that they wanted to know more.

So a new questionnaire -- designed to give members an opportunity to say how the Academy should spend its energy -- was mailed to 1,500 randomly selected members. Now, the results of the 2001 Member Needs Assessment survey are in.

They show "there's really nothing the Academy is doing that members don't want," says Jan Carter, director of strategic planning and marketing and questionnaire author. "I think it's great that this lends validity to both the Member Attitude and the Needs Assessment surveys."

Members rated 53 major AAFP programs and services according to how much emphasis the Academy should place on them. A rating of 1 indicates "no emphasis," while the highest rating of 7 indicates "maximum emphasis."

Members said the top 10 programs and services that the Academy should emphasize range from CME and representation of the specialty in Washington, D.C., to programs for medical students and assistance with coding (see list at right). In fact, Carter says the list covers what AAFP leaders already consider to be key issues.

No significant response differences were found in the top 10 list when results were analyzed using different demographic characteristics. The demographic characteristics include: location (rural and urban), gender, age group (under 36, 36 - 45, 46 - 55, 56 - 65, and 66 and above), and practice arrangement (solo, two-person, group, multi-specialty group, not reported and other).

Because the results can help the Academy meet members' needs, the assessment survey will be conducted every two years.

FP accepts challenge as NFL head team physician

BY SHERI PORTER

(Above) Andrew Tucker, M.D., head team physician of the 2001 world champion Baltimore Ravens, conducts tests on defensive end Rob Burnett, during a midweek clinic. (Below) Tucker keeps watch on the sidelines during every Ravens game.

No one can confirm that Andrew Tucker, M.D., of Baltimore is the first FP to claim the title of head team physician in the NFL. But most agree that his accomplishment is unusual. "It's not been real common," says Tucker, who started the 2001 NFL football preseason as head team physician for the Baltimore Ravens. "Usually, in the NFL, the head of the medical team is an orthopedic surgeon."

Tucker, who's starting his 11th year with the organization (formerly the Cleveland Browns), previously was the team's primary care physician. He takes his new role in stride. "My day-to-day job hasn't changed much," he says. "The challenge is making good decisions, quick decisions, about whether someone can continue to play."

During football season, Tucker's NFL duties "take up about 20 percent of my time and 90 percent of my worries," he says. "The nature of the business is to keep guys healthy and on the field -- it's a high-stress kind of environment."

Tucker also is director of the University of Maryland's Primary Care Sports Medicine Fellowship. In addition, he serves as team physician for two Baltimore colleges and sees private patients.

FPs are uniquely qualified to position themselves at the forefront of sports medicine because of their ability to treat orthopedic as well as medical problems, says Tucker. In July, the latter was spotlighted when Minnesota Vikings tackle Korey Stringer died after collapsing from heat stroke. "Tragedies are fortunately pretty rare, but when they do occur, shock waves reverberate throughout the whole country," says Tucker. After Stringer's death, NFL Commissioner Paul Tagliabue ordered all NFL teams to evaluate policies and procedures relating to the diagnosis and treatment of heat injury. "It's certainly got a lot of us working to figure out -- quite simply -- are there things we could do better," says Tucker.

He's also concerned about head injuries. "Concussions are a common injury in football, whether you're talking about high school, college or professional," he says. "The issue of chronic deficits in athletes as a result of repeated concussions is a major concern." Tucker says standard neuropsychological testing has only recently been tapped as a resource to help evaluate when an athlete can safely return to play (see related story below).

Also commanding the attention of team physicians is the proliferation of supplements and performance-enhancing agents. "There are health issues related to supplements and ethical issues about taking performance-enhancing agents," says Tucker. Manufacturers' claims regarding enhanced performance are seldom substantiated by scientific data. "Do these substances work, and more importantly, are they safe?" he says.

The summer of 2001 saw a rash of deaths on the playing field, including high school, college and professional football players. The tragedies have physicians such as Tucker wondering if there is a connection between some of those deaths and the escalation of unregulated supplements and performance-enhancing agents among players. "We're trying to find out how much is being used -- which is probably considerable -- by athletes at all different levels," says Tucker. "We need some good research in this area."

Neuropsychological testing a boon to team physicians

Family Physician Cindy Chang, M.D., head team physician at the University of California, Berkeley, understands the angst of college athletes awaiting medical clearance before returning to play after an injury. She oversees 27 Division I varsity sports and 900 college-level athletes. And Chang is pleased with a tool now available to her -- neuropsychological testing -- that helps assess athletes who have suffered head injuries. "It gives us objective data to say 'Yes, you're OK to play' or 'No, you're not OK to play,'" says Chang.

Here's how it works at Berkeley.

During the preseason, all intercollegiate football, rugby, and men's and women's basketball and soccer players are asked to participate in a research study that involves testing of the effects of multiple sports-related traumas on the brain. All athletes with a past history of head injury are also asked to take the brief battery of standard neuropsychological tests to establish a baseline.

The 30-minute computerized test measures memory and speed of mental processing. For example, to test short-term memory, several common words are displayed on the computer screen. They are displayed a second time, in the same order. The words appear a third time assimilated into a larger list, and the athlete's task is to choose the original words.

During the season, if the athlete receives a head injury, a post-concussion test is given. Then the results are compared to the athlete's baseline. "We can actually show the results to the student athlete," says Chang. "'This is how you tested when you came in preseason, and this is how you're testing now. Your memory is off. You were slow at processing these symbols during the second test. Your brain has not fully recovered from your head injury.'"

Sometimes, the test allows Chang to clear athletes for play earlier than current concussion guidelines recommend.

Chang says she wants to protect her athletes from a condition called second impact syndrome. If an athlete returns to play before a head injury is resolved and receives another head injury, brain function can rapidly deteriorate. "It's life-threatening," says Chang, "and it's something we warn our students about."

FP works to keep female athletes healthy

"The female athlete has different needs, unique medical concerns, and we need to screen them differently from male athletes," says Aurelia Nattiv, M.D., of Los Angeles.

Runners on UCLA's 2001 women's cross country team benefit from health screenings targeting female athletes.

Nattiv, associate professor at the University of California, Los Angeles, Department of Family Medicine, Division of Sports Medicine and Department of Orthopedic Surgery, knows all too well the injuries and health issues that plague UCLA's female athletes --including nutrition problems that can affect a woman's menstrual cycle and bone health.

"We want to be sure that our female athletes get enough calcium and that their menstrual periods are regular," says Nattiv. She screens athletes for irregular menses and encourages a calcium intake of 1,200 - 1,500 milligrams daily because "disordered eating and menstrual problems are significant risk factors for stress fractures and low bone density."

Nattiv also encourages her female athletes to maintain a positive energy balance -- taking in enough calories to fuel the amount of energy expended. "A long-distance runner expends an incredible amount of calories per day," says Nattiv. This athlete needs to consume more calories than an average person just to stay in that positive energy balance. "We look at her energy expenditure and her intake and then educate her on appropriate dietary intake and nutrition to fuel her body throughout the day," she says.

When a negative energy balance has been corrected, the menstrual cycle may be restored. "We're less apt to go immediately to the oral contraceptive pill to normalize menses," says Nattiv. "Instead, we try to focus on the underlying problem -- the energy deficit -- and work on that through lifestyle changes."

Researchers are focusing on maximizing peak bone density to prevent bone loss and future osteoporosis. "A window of opportunity exists to increase bone density during childhood and adolescence," says Nattiv. Researchers are therefore currently studying the effect of jumping exercises on bone density in elementary-school children. "Being proactive is the wave of the future," says Nattiv. "As researchers identify risk factors, new interventions will be put into place to try and minimize these risks."

Put me in, Coach
AAFP releases new sports medicine consensus statement

BY CINDY McCANSE

"The Team Physician and Conditioning of Athletes for Sports: A Consensus Statement" -- the third in a series of sports medicine policy statements developed by the Academy and other groups -- is ready to take the field.

This latest statement represents the fruits of an ongoing collaboration of the AAFP, American Academy of Orthopaedic Surgeons, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports and American Osteopathic Academy of Sports.

The statement addresses general conditioning principles, including sport-specific conditioning and modification of the conditioning program as indicated; pre-season issues; in-season issues; and off-season issues.

Robert Pallay, M.D., of Belle Mead, N.J., a member of the Commission on Public Health, and David Glover, M.D., of Warrensburg, Mo., team physician for Central Missouri State University and a Missouri AFP past president, represented the AAFP on the consensus panel.

According to Glover, the consensus group's original intention was that the statements would primarily target the team physician -- the physician who's dealing with athletes. "But as we encourage our patients to become more and more active," he added, "we should probably identify 'athletes' as all of us."

Previous consensus statements developed by the groups are "Team Physician" and "Sideline Preparedness for the Team Physician." They cover guide-lines for choosing a team physician, an outline of the duties expected of that physician and sideline preparedness at sporting events, including a medical services plan.

To access the first two consensus statements, go to http://www.aafp.org and click on "Clinical Information." Next, click on "Clinical Policies" and then on "Public Health" to find links to each statement. The third statement will go online soon.

No shortage of sports medicine fellowships

A quick online jog to http://www.aafp.org/fellowships/sports.html shows just how popular this area of medicine is among primary care physicians. Nearly 50 programs are listed on the site, many offering more than one position and some culminating in a graduate degree.

Most fellowships last for 12 months, although there are a number of two-year programs available. All but two of the programs listed offer annual stipends, with amounts ranging from $34,000 to $50,300. Various types of insurance and other benefits are also offered.

Depending on program location, fellows may provide hands-on care for high-school, college or professional athletes engaging in activities ranging from local track and field sports to international Olympic events. In addition, activities such as didactic sessions, roundtable discussions, teaching rotations and monthly journal club meetings form the academic backbone of these programs.

Completion of at least a one-year sports medicine fellowship program accredited by the Accreditation Council for Graduate Medical Education confers eligibility to sit for the exam leading to a certificate of added qualifications in sports medicine. The exam is offered by the American Board of Family Practice and other medical specialty boards.

October 2001 • Volume 7 • Number 10

Members of the U.S. ice sledge hockey team rest during a break in practice at the 1998 paralympics in Nagano, Japan. Cindy Chang, M.D. (see previous story), a member of the U.S. medical team, said athletes "were very, very thankful for our medical care."

Treating disabled athletes is part of the game plan

Disabled athletes face many of the same ailments and injuries as able-bodied athletes, says FP Brian Halpern, M.D., of Marlboro, N.J.

Halpern is medical director of the Disabled Athlete's Clinic that opened a few months ago at the Hospital for Special Surgery in New York City. He says disabled athletes show up with a variety of medical needs. "We take care of soup to nuts -- they have prosthetic issues, exercise issues, skin issues, tendonitis, bone density issues. We really take care of the whole athlete."

The clinic's goal is to empower the disabled athlete to return to his or her sport or exercise program following evaluation and treatment. A multidisciplinary team approach offers the expertise of sports medicine physicians, physical and occupational therapists, prosthetic and orthotic technicians, nutritionists, nurses and social workers. The focus on treating the sports injury at hand remains the same, whether the patient is a professional or recreational athlete.

"I think in the past, we've focused too much on the athlete's disabilities, instead of the sports performance within that disability," Halpern says.

From passion to patience -- seven steps to a thriving FMIG

BY CINDY McCANSE

"Outlast, outplay, outwit." That's the catchphrase from the hit TV show Survivor.

But what does the phrase have to do with growing a successful family medicine interest group?

Everything, said Michael Sevilla, M.D., during a session, "Effective FMIG Leadership: You Have To Start Meeting Like This," at the recent National Conference of Family Practice Residents and Medical Students in Kansas City, Mo. Sevilla is a resident delegate to the AAFP Congress of Delegates and a member of the Commission on Resident and Student Issues.

He opened the discussion by outlining seven steps students can use to fashion a top-notch campus FMIG. Participants then broke up into small groups led by FMIG regional coordinators to brainstorm about specific issues faced by FMIGs.

Michael Sevilla, M.D., of Salem, Ohio, instructed medical students at the National Conference in the proper care and feeding of a campus family medicine interest group.
Regional FMIG coordinator Lauren Giammar of Canton, Ohio, encouraged students at the session to focus on one quality of a successful FMIG at a time.

Here's some of what Sevilla had to say:

Passion. You gotta have heart. "Great leaders are not just 'out there,'" he explained. "Great leaders are ordinary people -- like you and me -- who do extraordinary things."

Preparation. Basically, you need to do your homework, Sevilla said. "Ask yourself, 'What are M1s and M4s looking for?' Brainstorm about what future FMIG sessions should cover, then create an outline of events you want to see happen in the coming months." And don't forget to anticipate problems and devise solutions ahead of time to overcome them.

People. Take full advantage of knowledge held by the folks who remain involved with the FMIG over the long haul, Sevilla urged. Officers change every year, he noted, but people such as the program's faculty adviser, resident adviser, and staff at your state and national academies "bring a history to the organization."

Empower. "Encourage leadership at all levels," said Sevilla. "Great leaders take the time to train those who'll come after them." For example, it's a good idea for outgoing officers and FMIG advisers to sit down annually with folks coming on board and take a long, hard look at the program and the preceding year's activities. "Look at what worked and what didn't," Sevilla said. "That way, (new) people can hit the ground running; they don't have to keep reinventing the wheel every year."

Persistence. "Don't fall prey to false expectations," Sevilla warned. The "high" of a particularly successful meeting or event won't last forever. "You have to find creative ways to keep the excitement up," he noted, "and that can be tough." One way to do that, he added, is to celebrate ...

Party. "Reward your successes!" said Sevilla. Throw a party to celebrate some major milestone achieved. And remember, "it's important to thank everybody," said Sevilla. Whether you use e-mail, write a personal note or verbally recognize someone during a meeting, do it "and you'll be surprised by the number of people you'll have back," he said.

Patience. Remember, Sevilla urged, "Leadership is a learned skill, and you'll make mistakes along the way." Just learn from them and go on, he said. Never letting yourself forget what family medicine is all about can help you keep the day-to-day issues you deal with in the proper perspective.

"Great leaders are focused on the patient," said Sevilla. "That's really why we're all here (at the National Conference), isn't it?" It's not to go to this procedures course or visit that residency program booth, he said, "It's because we want to help people."

Ready to think residency?

BY JANE STOEVER

If you're a medical student who's wading into the residency application and interview process, here's some advice for you.

Six family practice residency directors answered a battery of questions from medical students during a workshop at the recent National Conference of Family Practice Residents and Medical Students in Kansas City, Mo. Below is a sampling of the directors' advice.

Q. What type of information should I share in my personal statement?

Medical students listen up at the National Conference workshop "What Inquiring Minds Want to Know From Program Directors."

A. Let your true self emerge. Have your friends proof your statement and ask them, "Is this me?" Tell us your passion; run the risk we won't like you. If you offend one of us by telling us who you are, you may not be happy in our residency anyway.

One thing that can jump you up in our evaluation is how well you understand family practice and its lifestyle; community involvement is extremely important.

Q. Do I really need a letter of recommendation from my department chair?

A. How well does the department chair know you? It may be better to have a letter of recommendation from a junior faculty member who's been important in your training than from a chair who barely knows you.

Q. What are the pros and cons of a program in a health system with multiple residencies versus a program that's the sole residency in the institution?

A. Way too much is made of the distinction. Don't assume that all stand-alones are similar or that all affiliated programs have too much competition. Look at both types.

At the affiliated programs, ask the family practice residents whether they learn from the OB-Gyn residents. Ask whether the internal medicine residents always get the first call when an IM patient comes to the ER or whether family practice residents get called first. The residents are the ones in the trenches; they'll tell you the situation.

Q. How many programs should I interview with?

A. Between eight and nine is typical. Residents say the best way to cut down on the interviews is to invest lots of effort in planning ahead, studying programs' materials, making contacts.

Q. When should I schedule interviews?

A. Some schools ask you to wait till January; we start seeing applicants in October. When we see early candidates keeping in touch with our team, we know they may be a good match with our program.

Don't cram five interviews into one week; they'll all flow together in your mind. Don't do more than three a week; two is better.

Finally, you may feel more comfortable if your first interview is at a program that's not on the top of your list. You can go through the first interview and find that it can be interesting, that we will enjoy getting to know you. That will help you get over the sweaty palms and anxiety.

AAFP, industry in agreement

Principles for cooperation on gifts, CME guidelines developed

BY CINDY McCANSE

PRINCIPLES FOR COOPERATION

We the undersigned organizations share a common commitment to the primacy of the patient-physician relationship, to patient advocacy, to unimpeded access to health care for all, and to improved lives and better treatment through scientific advances. The relationship between physicians and industry serves to implement state-of-the-art scientific information and technological advances to enable physicians to better care for their patients.

We hereby pledge our full support to the following principles:

Above all, we put the health and well-being of the patient first.

We will assist physicians in their efforts to educate their patients in all aspects of health care -- including wellness, prevention and treatment -- by providing timely, accurate and balanced information based on scientific evidence.

We will adhere to the guidelines established by the American Medical Association on gifts to physicians from industry and by the Accreditation Council for Continuing Medical Education on standards for commercial support of continuing medical education.

We will work proactively and continually to inform physicians and industry representatives of these ethical standards.
© 2001 American Academy of Family Physicians

American Academy of Family Physicians
AstraZeneca
Aventis Pharmaceuticals
Eli Lilly and Company
Endo Pharmaceuticals, Inc.
Forest Laboratories Inc. and its subsidiary,
Forest Pharmaceuticals Inc.
GlaxoSmithKline
Janssen Pharmaceutica
McNeil Consumer Healthcare
Ortho Dermatological
Ortho-McNeil Pharmaceutical Inc.
Pfizer Inc.
Pharmacia Corporation
Procter & Gamble Pharmaceuticals
Welch Allyn, Inc.
Wyeth-Ayerst Laboratories

In an unprecedented move to ensure adherence to ethical guidelines governing interactions between physicians, CME providers and the pharmaceutical industry, the Academy and 15 pharmaceutical firms have individually elected to sign onto a joint statement of principles.

The spark for the initiative arose during this summer's AAFP/AAFP Foundation/Industry Executive Leadership Forum, according to AAFP Executive Vice President Douglas Henley, M.D. The meeting is an annual feedback session among members of the executive committee of the AAFP and the AAFP Foundation and industry leaders. This year, it was held June 11 - 13 in Philadelphia.

"The Academy believes very strongly in the intent, purpose and application of the AMA ethical guidelines relating to the interaction between individual physicians and the pharmaceutical industry," said Henley. "AAFP has the same commitment to upholding the Accreditation Council for Continuing Medical Education guidelines relating to the interaction between CME providers, such as the Academy, and industry.

"This issue was discussed at great length during the meeting, and industry leaders asked the Academy to take the lead, develop the principles and challenge industry representatives to sign on. And they have."

"We have received an enthusiastic response from industry," concurred Sandra Panther, executive vice president of the AAFP Foundation. "Overall, companies welcome the idea of partnering with the Academy to convey the message that ethical practices are in place to which they adhere both at the corporate and at the local level."

The agreement consists of a set of four principles, to which all signatories have pledged their support. The text of that agreement is shown in the box at right, as are the names of the companies that had joined the initiative as of Sept. 20.

The opening statement, principles and signatories appear on the front of a pocket-sized card that will be distributed to attendees at the AAFP Annual Assembly Oct. 1 - 7 in Atlanta. On the inside of this folded piece appear summaries of the gifts to physicians from industry guidelines developed by the AMA Council on Ethical and Judicial Affairs and the standards on commercial support of CME developed by the ACCME.

This information is also available on the AAFP Web site at http://www.aafp.org/cooperation.

All costs involved in developing and distributing information about the initiative have been funded entirely by the AAFP.

Gifts from industry

To the editor:

To the reader: Write us letters of 200 words or fewer (subject to editing), using the FP Report addresses at the bottom of page 2.

I had mixed feelings reading the September FP Report article about the AMA initiative on ethical gift-giving by the pharmaceutical industry. On the one hand, any action on this front should be welcome. On the other hand, the AMA has, in my view, already tarnished itself in this effort by the manner in which it first accepted industry funding for the project, and then engaged in some rather unbecoming bluster when challenged on this by the media. I would hope that the AAFP could approach this topic in a way that illustrates a higher level of organizational integrity and will, hopefully, produce guidelines with more teeth in them.

In a letter in the same issue, Rocky Khosla, M.D., dismisses concerns for the ethics of interacting with pharmaceutical representatives as "baloney." However, a large and growing body of evidence indicates that those physicians who are most heavily influenced by the drug companies are (1) least aware of their being influenced and (2) most liable to get angry when accused of being influenced. An excellent source of information on this topic is at www.nofreelunch.org online.

Howard Brody, M.D.
East Lansing, Mich.

Editor's note: See story above for AAFP's approach to this topic.

Lewis to oversee West Virginia's academic health affairs

Michael Lewis, M.D., Ph.D.

Michael Lewis, M.D., Ph.D., of Charleston, W.Va., joins the elite ranks of academic leadership. Lewis, a member of AAFP's Commission on Finance and Insurance, has been named vice chancellor for health sciences for the state of West Virginia.

Lewis, who represents his home state in the AAFP Congress of Delegates, was previously associate vice president and associate dean for health sciences at West Virginia University Health Sciences Center -- Charleston Division.

As vice chancellor, Lewis will be responsible for advancing the mission of the health sciences centers run by the state's public higher education institutions. This system comprises three medical schools, one dental school, one school of pharmacy and a number of other health and allied health programs. Lewis will also oversee strategic planning for the centers.

One of Lewis' first challenges will be working with health care facilities across the state to train more nurses. Like many areas of the country, West Virginia is experiencing a nursing shortage. "Another major goal is strengthening the state's rural health care system," Lewis said. This effort will include "enhancing training and practice opportunities for family physicians and other providers crucial to rural health care delivery."

Order from AAFP at (800) 944-0000 unless otherwise noted.

A redesigned Web site for AAFP's Tar Wars^® program is filled with new information, colorful designs and winning posters from the 2001 National Poster Contest. The site for the tobacco-free education program went live in September. The home page provides quick links to the program's 2001-2002 curriculum, newsletters, National Poster Contest information for 2002 and tobacco education-related resources. Visit http://www.tarwars.org/.

Are you looking for more resources on mental health care? Order your free CD-ROM on the Annual Clinical Focus: Mental Health 2000 now. This CD contains video programs, American Family Physician monographs, patient education handouts and more. Request it by sending an e-mail to orders@aafp.org, calling the AAFP order department or faxing your order to (913) 906-6075. Ask for item #588. Have your AAFP ID number available.

Proven value: Health messages about smoking, drinking, stress, eating disorders, sex and STDs fill six brochures targeting teens. Display them in your reception room, and distribute them to teen patients during office visits or at youth gatherings. Go to https://secure.aafp.org/cgi-bin/catalog.pl?uid=cat100953 and have your AAFP ID number ready to order a package of 100 brochures for $28.

A shipping fee may apply; Kansas residents pay a 7 percent tax.

Available on AAFP Express

Call the AAFP Express toll-free number -- (800) AAFP EXP [223-7397] -- and supply your AAFP ID number to have selected materials sent almost immediately to your fax machine for free. Some documents available:

Description of document Doc. no.

2001 Recommended Childhood Immunization Schedule 7001

Proposal on health care coverage for all 8007

Press release on board certification/recertification 1010

Title VII press materials 1003

Information on the 2001 conferences

Emergency and Urgent Care for the Family Physician

Oct. 29 - Nov. 1, Paradise Valley, Ariz.

2009

23rd Annual Conference on Patient Education

Nov. 15 - 18, Seattle

7004

State Legislative Conference

Nov. 15 - Nov. 17, Bernalillo, N.M.

8006

Sports Medicine Review

Feb. 6 - 10, 2002, St. Louis

2000

National Network Convocation of Practices

March 13 - 16, 2002, Kansas City, Mo.

7015

FP Report is published by the AAFP News Department.
Copyright © 2001 by American Academy of Family Physicians.

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