February 2002 • Volume 8 • Number 2 |
 Family physicians are answering patients' questions about anthrax and smallpox, AAFP President Warren Jones, M.D., tells a reporter with Conus Communications, a satellite news service. |
The National Press Club in Washington, D.C., came to the Academy with a request: Headline the club's "NewsMaker" press conference on bioterrorism Dec. 14. The Academy sent two FP experts -- AAFP President Warren Jones, M.D., of Ridgeland, Miss., and Jonathan Temte, M.D., Ph.D., associate professor in the family medicine department at the University of Wisconsin, Madison, an infectious disease researcher and clinician.
"We are educating ourselves and other health care professionals to calm our patients' fears and serve on the front lines of the war on bioterrorism," Jones told reporters at the event.
"As family physicians, we would be the first to have contact with patients who may be suffering from a nuclear, biological or chemical attack," he said. "We must be prepared to recognize, treat and report such attacks."
Referring to maps indicating how widespread family physicians are across the nation -- in rural and urban areas -- Jones explained, "We are where patients are. We need to be a one-stop shop for answers to questions our patients have about bioterrorism."
ANTHRAX
"What's the most likely tool for bioterrorists?" asked one reporter. "Anthrax is the largest concern out there," said Temte. "It can be delivered in such a way that it doesn't have the potential to spread back to whoever's starting the outbreak. And as we've seen, it's highly deadly."
The envelope delivered to the office of Senate Majority Leader Thomas Daschle, D-S.D., contained about 20 billion spores of anthrax -- 10 billion per gram, said Temte. "That was enough to kill 2 million people."
Noting that five out of 11 people contaminated with anthrax at various locations had died, he said, "That we have such a low level of disease and mortality is a testament to how well I think the public health containment and education system did progress, even though there were a lot of problems up front."
Temte stressed the difficulty of identifying anthrax contamination: "Inhalation anthrax includes symptoms of fever, cough and malaise. This looks like an awful lot of common disorders, including meningitis, congestive heart failure, pneumonia and gastroenteritis."
SMALLPOX
 "The real force multiplier in biological terrorism is panic, misinformation and paranoia," Jonathan Temte, M.D., Ph.D., tells reporters at the National Press Club. |
"Unfortunately, we are all unvaccinated for smallpox," said Temte. "Even for those of us with doughnuts on our arms from 30 years ago, immunity no longer really exists."
So why aren't Americans being immunized against smallpox? "The vaccine available here is from the 1970s and early 1980s," Temte explained. "It was made in a way that would be totally unacceptable today. We'd consider it a dirty vaccine."
A safer vaccine is being made, he said, but there is no indication now for mass immunization.
The day before the NewsMaker press conference, Jones had attended a Partnership Awareness meeting at the CDC in Atlanta to discuss preparing for a smallpox bioterrorism attack. He described the ring vaccination concept recommended in CDC's draft response plan: Identify those who have come in contact with each smallpox victim and vaccinate them to limit the spread of the disease.
Replying to a reporter, Jones said, "If you're asking, 'Should people have prescriptions for smallpox immunization in their pockets and go and activate them?' -- that would not necessarily be wise. There are risks, even death, associated with smallpox immunization."
USING TRUST TO COUNTER TERROR
"The real force multiplier in biological terrorism is panic, misinformation and paranoia," said Temte. "Misinformation can enhance the terror within bioterrorism."
The reduction of public panic will require relationships built on trust, he said.
Jones showed survey results indicating Americans trust doctors to tell the truth more than they trust the president, police officers or business leaders. "If we don't know the answers to our patients' questions, we need to find the answers and get back with the patients to maintain the high levels of trust they have in us," he said.
Jones noted AAFP's bioterrorism information Web site -- http://www.aafp.org/btresponse/ -- a resource base to help family physicians recognize terrorist threats and events, treat patients appropriately and help patients recognize such threats without overreacting.
For faxed copies of two patient handouts on the Web site, see "Quick Fax" .
After a 10-month campaign, the Academy claimed victory Dec. 20 when Congress allotted $93 million for primary care training programs in the government's 2002 budget -- a $2 million increase over 2001 funds.
The AAFP had led the fight for the funds since President George W. Bush released his 2002 budget last February. It allotted nothing for these programs. Title VII grants -- specifically those in the primary care and dentistry cluster under Section 747 -- were developed years ago to relieve a physician shortage that no longer exists, said Bush. He called for the funds to be redirected to relieve the nation's nursing shortage and improve diversity among health professions.
"Fighting for funds is something we've done every year," said President Warren Jones, M.D., of Ridgeland, Miss. "But this year, the Bush administration remarked that there's an excess of physicians. We know that's not true when it comes to primary care. So we decided this was something on which we had to take the lead."
The Robert Graham Center in Washington, D.C., developed maps in late spring that showed, across all U.S. counties, what would happen if family physicians weren't available to provide primary care.
"This evidence was very clear," Jones said. "The maps showed a dramatic increase nationwide in underserved counties when family physicians were eliminated. And we need the federal government's money to keep recruiting top medical students into primary care."
Family physicians in the Academy and the Organizations of Academic Family Medicine presented the maps and other evidence to key lawmakers to help convince them to fund the Section 747 programs.
The $93 million appropriated to the primary care and dentistry cluster is less than 25 percent of the $378 million package going to all health professions programs in HHS' annual budget. Last year, the programs were allotted $25 million less.
AHRQ, NHSC, RURAL PROGRAMS GAIN MORE FUNDS
Also within the HHS budget, the Agency for Healthcare Research and Quality was appropriated $299 million, an 11 percent increase over 2001 funds. Jones said, "AHRQ supplies research that improves the quality of health care and life for patients. AHRQ and AAFP are on the same page."
The National Health Service Corps is slated to receive $153.5 million -- $11 million more than in 2001. "We have gone to the mat for the NHSC, because we need to help preserve the programs that get young physicians to remote locations and grossly underserved regions," Jones said. "They are doctors who love to practice medicine where it's really needed."
Rural health and telemedicine programs were granted $160 million in the 2002 budget, which is 20 percent more than appropriated in 2001.
2003 BUDGET BATTLE LOOMS
The battle over the 2003 federal budget is expected to be more difficult because of the nation's disappearing budget surplus, said Kevin Burke, director of AAFP's Government Relations Division. At press time, the Bush administration was scheduled to release next year's budget proposal in late January or early this month.
 Family physicians are answering patienInadequate payment has forced Baretta Casey, M.D., to raid her personal savings to subsidize her Pikeville, Ky., family practice. See story, "Message to CMS: Low pay kills practices." |
The year 2002 could be financially draining for many family physicians and other primary care providers, especially those caring for many Medicare patients. The largest-ever annual cut in the conversion factor used to set the Medicare reimbursement rate -- a 5.4 percent cut -- went into effect Jan. 1.
And as the year progresses, health care costs will rise, said AAFP Board Chair Richard Roberts, M.D., J.D., of Madison, Wis., as new technology emerges and demand for services increases. "Combine that with the cut, and doctors will suffer financially first," he said, noting that 20 percent of the average FP's patients rely on Medicare.
"So physicians will have to choose between not providing Medicare service, not providing the medical technology or not getting adequate payment for the service," Roberts said. "And in some cases, it will get to the point where doctors can't make it financially."
Then the country's older population will be hit, he said, because fewer physicians will accept Medicare patients -- especially in underserved, rural regions. "CMS isn't going to see anything dramatic in the short term," said Roberts. "But all this will happen. Practices will close, and patients won't have health care."
On Nov. 1, CMS announced the 5.4 percent cut in the conversion factor, a multiplier that translates relative value units into Medicare fees. The RVUs pertain to practice expenses, the physician's work and liability insurance costs. As of Jan. 1, the final increase for resource-based practice expenses took effect. That increase will somewhat offset the drop in the conversion factor for most FPs. The Academy's prior victory in defending RBPE will soften the blow from the cut in the conversion factor, said Roberts.
The AAFP went into action in early November to try to fix the immediate problem -- the conversion factor decrease. "We were not able to turn back the tide on that. The legislation we were behind was in place, and the legislators' support was there. But Congress didn't act," said Roberts.
Using the AAFP's Speak Out: Legislative Action Center, more than 7,000 members urged lawmakers to vote for two bills (S. 1707 and H.R. 3351) that would have decreased the conversion factor by only 0.9 percent and insisted on a revised formula for determining payment shifts.
While efforts to stop the 5.4 percent cut in the conversion factor failed, Congress did order the Medicare Payment Advisory Commission to report to Congress by March 1 on revising the formula. The formula's major flaw, according to medical groups, is its reliance on the nation's gross domestic product to determine whether reimbursement rates will increase or decrease each year.
"I really appreciate members' efforts," Roberts said. "It's true: We did not win this battle. But the war is not over. Fair physician reimbursement is the war, and members' sustained efforts will help us win the war."
How? The Academy plans to work with MedPAC and CMS to get the formula quickly corrected, Roberts said.
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It's early January in Leawood, Kan., and some 30 people are sitting in a meeting room of a church basement. Those gathered for the noon meeting include men in business attire, homemakers in casual clothes and the unemployed wearing sweat suits.
"Remember, who you see here ... stays here," intones a sign hanging from the ceiling. The meeting starts. "I'm Kevin, and I'm an alcoholic," begins one man. "Hi, Kevin," the group replies in unison. Kevin continues, "I'm grateful for my sobriety, and I'm grateful for everyone around this table. It's just great to start a new year sober." So begins a session of Alcoholics Anonymous.
POWER OF PEER GROUPS
One by one, each person at the meeting takes a turn, describing daily joys such as driving without fear of being pulled over, not being an embarrassment to their families, not wondering what happened during a blackout.
A few people have struggled in recent days: One woman, choking back tears, tells her supporters that she was denied an auto loan but vows to somehow endure the crisis without resorting to drinking. Several in the group write their phone numbers on a card and pass it to the woman. When the meeting's over, they clasp hands and recite the Lord's Prayer. Alcoholics Anonymous is clearly benefiting people such as these.
But not everyone agrees with AA's 12-step approach.
"Although AA works well for many alcoholics, there are a few people who don't do well in that sort of group," says Sharon Sweede, M.D., chair of the Commission on Public Health's subcommittee on addiction. She should know: Sweede works at the Julian F. Keith Alcohol and Drug Abuse Treatment Center in Black Mountain, N.C. In particular, victims of abuse and people with a dual diagnosis -- addiction plus mental illness -- may not thrive in Alcoholics Anonymous, says Sweede.
And some people object to the religiosity of many AA groups. Indeed, groups such as Rational Recovery and the Secular Organization for Sobriety, or Save our Selves, were formed by former AA members who sought an alternative. These organizations are great -- if you can find them in your area, says Sweede.
In addition, some women may object to the paternalism of AA's tenets. Sweede says she has found a 16-step program, advocated by Charlotte Kasl in her book Many Roads, One Journey, to be a more feminist-friendly alternative. Kasl, in the introduction to her book, writes that the 12-step model can perpetuate the victimization of persons whose egos are already fragile. Herself a veteran of 12-step programs, Kasl says she modeled her steps on AA's but used more empowering language. For instance, AA's first step is to admit being powerless over alcohol; Kasl's first step is to affirm that the addict has the power to take charge and not be dependent on a substance or another person for self-esteem.
"COLD TURKEY" VS.
CONTROLLED DRINKING
Adding to the debate over quitting addictions is the controversy over whether it may be possible to moderate, not stop, drinking. Sweede dispels this notion when it comes to hard-core addicts. "The ones who have the disease really don't have the choice," she says.
Sometimes, she concedes, it's difficult to distinguish an abuser from an addict. "Problem drinkers can cut back, recreational drug users can cut back. It's worth a try," Sweede says. "But if they're addicted, then by definition, they'll find cutting down gradually is extremely difficult."
When trying to differentiate the abuser from the addict, Sweede looks for four things: impaired control over alcohol/drug use, compulsion to use, continued use despite harm and demonstrated craving when not using the substance.
She offers this caveat: "I think it's important for FPs to not feel they have to know for sure whether it's abuse or dependence. Their talking to patients about it is more powerful than they realize. Brief intervention does help."
By now, some of your patients may be struggling to keep their New Year's resolutions. For many patients, their goal may be to overcome addictions such as smoking.
But many people attempt quitting several times before they succeed.
So for those who have failed in their attempts at quitting, all is not lost.
Just having a conversation with their physician is motivating for patients, says FP Donald Pine, M.D. Helping patients quit smoking has become an area of interest for Pine, who practices at the Park Nicollet Clinic in Minneapolis.
Research indicates behavior change occurs in stages: precontemplation, contemplation, preparation, action and maintenance. The physician can facilitate the change process by modeling the patient encounter according to the patient's stage of change, says Pine.
Patients rarely come to him expressly to inquire about quitting smoking, he says; it emerges as an issue during the exam. That's why he keeps a flow sheet in the patient's record to detail what has transpired in regard to smoking cessation and what stage of readiness the patient is at.
Pine, whose practice has participated in trials of smoking cessation, offers this advice for patients who are ready: "The best strategy is to ask the patient to set a quit date; ordinarily we give the patient a week or so to get ready."
Pine also encourages patients to make a list of reasons to quit and work on strategies for dealing with cravings and withdrawal symptoms.
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Although studies show that patients who use nicotine replacement therapy have better outcomes, "It's surprising to me how many people choose not to use pharmacotherapy," says Pine. "They're thinking, 'Here I am trying to get rid of nicotine, and you're encouraging me to use it more.'"
But NRT helps lessen withdrawal symptoms, says Pine.
What about patients who try to gradually quit? The withdrawal symptoms will become difficult to deal with once the patient's nicotine usage significantly drops, Pine says.
"It's appealing to people to gradually reduce their use of tobacco," says Pine. "I would never discourage people from doing that, but the clinical trials show that that strategy does not seem to be effective. People need to set a date."
R-E-S-P-E-C-T. To paraphrase singer Aretha Franklin, that's what it's all about. And increasingly on campuses around the country, that's exactly what family practice is getting. As the specialty comes into its own, more and more FPs are ascending the heights of academe.
Not an easy road, to be sure. Time -- and timing -- have played a role. As has devotion to the precepts that define family medicine. But family physicians have proved themselves equal to the task.
"Family practice is a young specialty," says Richard Homan, M.D., dean of the Texas Tech University School of Medicine and the Graduate School of Biomedical Sciences, Lubbock. "We're now at the point where we're well enough developed in our careers to assume these positions of responsibility."
Homan sees FPs as well-suited to academic leadership. "We have a broad area of expertise, and we communicate well," he says. "We're able to bring a global perspective to our work."
As the former chair of the family and community medicine department at Texas Tech University Health Sciences Center, Homan was able to "build bridges and forge connections" with other departments, he says.
 Richard Homan, M.D. |
 Joseph Scherger, M.D. |
 Nancy Dickey, M.D. |
 Ann Jobe, M.D., M.S.N. |
 Michael Lewis, M.D., Ph.D. |
CREATING NEW LEADERS
That sort of broad-based support mimics the breadth of the specialty, according to Joseph Scherger, M.D., M.P.H., founding dean of the Florida State University College of Medicine, Tallahassee. "The generalist physician is an ideal leader," says Scherger. "We understand a broad dimension of medicine."
The progenitors of the discipline likewise understood that leadership required attentive nurturing. Nancy Dickey, M.D., of College Station, Texas, president of the Texas A&M University Health Science Center, points to AAFP's role in cultivating FP leaders.
"The Academy has spent a great deal of time and energy doing formal leadership training," says Dickey. She also cites the Society of Teachers of Family Medicine Foundation's Marion Bishop leadership training program as one recent example. "Growing" new leaders takes pairing family medicine's brightest and best with those who have already demonstrated their leadership skills. This active mentoring is then passed on to yet another generation of rising stars.
ROLE MODELS FOR FAMILY MEDICINE
"I think having visible role models who enjoy what they do is a critical element of increasing interest in family medicine," says Ann Jobe, M.D., M.S.N., dean of the Mercer University School of Medicine, Macon, Ga. "Although I have to be careful about promoting family practice over other specialties, that doesn't mean that I can't speak out about the contributions family physicians make and how much they are needed."
Dickey says she, too, recognizes the need for sensitivity to alternative career paths. "There's no doubt that as a dean of a medical school or as president of a university, you have to be a leader for all. But simply having family physicians in the extraordinarily visible position of dean or president says to people, 'Wow! These aren't just country bumpkins who treat splinters. These are real people with potential for real impact.'"
For Scherger, it's not so much about promoting the specialty as it is about promoting what the specialty does. "I'm not here to promote one specialty. I tell students, 'The purpose of this medical school is that you'll go out and meet unmet needs, that you'll serve society.' It's caring about communities and people in those communities that leads people to family practice."
SERVING PATIENTS, FAMILIES AND COMMUNITIES
In that sense, medical educators can best serve their students -- and their patients -- by modeling the values they wish to impart, says Michael Lewis, M.D., Ph.D., of Charleston, W.Va., vice chancellor for health sciences for the state of West Virginia.
"It's important for the medical education system to be able to respond to the needs of individuals, families and communities," says Lewis. "While the explosion of medical information will continue to drive the development of marvelous new treatments, we must remember that there is a person receiving the treatment and there is a concern to the family involved. Medical educators must continue to make vigorous efforts to preserve sensitivity and compassion toward the individual and the individual's family."
"Medical education needs to instill in the new generation of physicians the critical skills of caring, communication, collaboration, commitment to professionalism and continuous improvement," Jobe notes. "Academic medicine must be open to change -- not resistant to it. The curriculum in medical schools needs to be responsive to the changing health care environment so that we can educate future physicians to practice in new ways."
RE-ENGINEERING MEDICAL PRACTICE
Scherger takes pains to instill this attitude at Florida State. He advocates taking advantage of the tools that are out there to better serve patients. "I don't believe that patient-centered care for an aging population with more and more chronic illnesses can be done well in 10-minute office visits," says Scherger.
"The visit is the most precious thing we do," he says. "We need to use the office visit far more selectively so we can devote more time to it. The way we do that is to tend to the more routine needs in a more efficient way. That's where the Internet and e-mail and resource-sharing come into play."
Don't discount the value of relying on other health care professionals to expand the services your practice can provide, Scherger says. Nurse practitioners, physician assistants and other professionals have a valid place in health care.
"This is not a case of either/or; the beauty of these professionals is that they work with family physicians," he says. "Right now, the percentage of family docs working with NPs or PAs is very, very high. What the midlevel providers do is let doctors prioritize their time, focusing on more complex problems. This is what makes family medicine fun."
W ant to present your research or your scientific exhibit at the Scientific Assembly this fall? The meeting will be held Oct. 16 20 in San Diego, and the deadline for applications is April 12.
Go to http://www.aafp.org/assembly/x1948.xml to link to applications to make a family practice research presentation and to present a scientific exhibit.
In addition, Tar Wars has two deadlines looming. The program -- AAFP's tobacco-free education effort aimed at fourth- and fifth-graders -- will hold its annual meeting July 21 23 in Alexandria, Va., and Washington, D.C. (for information, see "Quick Fax," page 8).
Local, regional and state Tar Wars coordinators (including FPs, family practice residents and medical students) may request scholarships to attend the conference. For an application form, call (800) TAR WARS [827-9277]. Apply by March 11.
The Tar Wars Star Awards, honoring groups and individuals for contributing to Tar Wars, will be given during the conference. You may print the nomination form from http://www.tarwars.org/x812.xml or request a form by calling (800) TAR WARS. Submit your nomination by April 15.
 Baretta Casey, M.D., consults with Medicare patient Mary Jackson, 90, about a foot problem. |
Family physician Baretta Casey, M.D., has a message for the Centers for Medicare and Medicaid Services. It has to do with Medicare reimbursement -- especially the largest-ever conversion factor cut of 5.4 percent that took effect Jan. 1 (see story, page 1). And she sure hopes someone at CMS is listening.
Casey has done what the government wants many physicians to do: set up practice in an underserved area, taking care of many patients on Medicare and Medicaid. She came to medicine later in life than many do, as a wife with two children -- three by the time she graduated. She wanted to become an FP and practice in her Appalachian hometown of Pikeville, Ky.
Her business background stood her in good stead. She bought an office building at an auction, rented out the top floor to offset the cost of her first-floor office, computerized her practice from the start and opened her doors as a solo practitioner eight years ago.
"The first day of practice, I saw 17 patients," Casey recalled. "By the end of the week, I was seeing 30. And it hasn't slowed down one iota."
Thanks to the booming practice and conservative living, Casey paid off $145,000 in student loans her first full year. But that was as good as it got. Ensuing years didn't get better. They got worse.
"I have watched medical expenses continue to grow," Casey said. "As a solo practitioner, I pay for everything. And the increase hasn't been the measly little percentage you hear forecasted by the government. I've tracked it on my computer. It has gone up 10 to 15 percent every year."
Which wouldn't be such a problem if reimbursement rates kept up. But they haven't -- just the opposite. Casey knows: She's been tracking those on her computer, too.
"It took about six years, but at the six-year mark, they literally met in the middle," she said. "The past year, they crossed over. And now, I have to dip into my savings to cover the extra expense. I'm basically subsidizing my own practice."
Other physicians have told her they've borrowed at the bank two or three times already to cover salaries. "That's very scary," she said.
And now, in 2002, the worst blow of all -- the 5.4 percent cut in the Medicare conversion factor, which is tied to the plummeting gross domestic product. "I've had to make some decisions," Casey said. "I won't take any new Medicare patients or take new patients with any insurance company that follows suit and drops payment.
"I currently pay an employee one week of each month's salary just to fill out indigent medication forms, mostly for Medicare patients with no drug coverage. I may be forced to stop this free service to my patients."
And ultimately, she said, "If things don't change, I probably couldn't stay in practice any more than two more years."
Which brings this story to Baretta Casey's message for CMS:
"If our reimbursement rates continue to go down and our expenses continue to go up, you will see an exodus of physicians out of rural areas like Moses out of Egypt. It's not because doctors don't care about their patients. They do, tremendously.
"It's because nobody is going to continue in a field or in a business when they're losing 10 to 15 percent per year. Try to explain to Capitol Hill that the practice of medicine is like other businesses: The only way you can survive is to be able to pay your bills."
Casey is fighting for change, involved in organized medicine, doing what she can. She's vice speaker for the Kentucky AFP and an alternate delegate from Kentucky to the AMA House of Delegates.
Last December, during AAFP's luncheon at the AMA house interim meeting, Casey went to the mike to speak her mind. As she spoke, a ripple of recognition ran through the family physicians in the room. Here was someone telling it like it is -- telling their story with eloquence and passion.
CMS, are you listening?
With overwhelming support from members, the Academy thwarted an effort by chiropractors in the last half of 2001 to be designated as primary care providers in the Veterans Affairs health system.
The AAFP alerted members just days after the House Veterans Affairs Committee approved a bill that would have allowed veterans to designate a chiropractor as their primary care provider.
Nearly 7,800 AAFP members sent letters opposing the bill to lawmakers in Congress. Their message? Chiropractors are not qualified as primary care providers because their training does not include the breadth or depth of medical education required of a primary care physician.
"Many members were concerned that this measure could be seen as a foot in the door for other health care systems to allow chiropractors primary care status," said Roberts. "It wasn't only a bad decision for veterans' health care, but it was also an insult to veterans since they could then receive care of less quality." The final bill allows chiropractors to continue providing chiropractic services only. It was approved and sent to the White House for President George W. Bush's signature Dec. 20.
OTHER ISSUES
The Academy also addressed challenges in these areas:
"REMARKABLE" RECORD
All in all, the Academy enjoyed a remarkable track record in 2001 and the past few years in Washington, Roberts said.
Jerome Connolly, senior government relations specialist in the Government Relations Division, agreed. "We won the chiropractor issue. We were successful in gaining increases in Title VII and National Health Service Corps funds. We made strong strides on OxyContin and Medicare contractor reforms, and we are well-positioned to influence a better formula for determining Medicare payments."
"We learned much in 2001," Roberts said. "There was a lot happening in America, and then there was Sept. 11. Family physicians got more involved because of it, and I think we're going to see that more often now."
Family physicians are worried about their practices and the health care system, he said.
Roberts' message to members? "Don't get frustrated. Until we get this system working better, the Academy will work to increase its visibility and influence in Washington."
Health problems resulting from overweight and obesity could reverse many health gains achieved in the United States in recent decades, according to a report released Dec. 13 by Surgeon General David Satcher, M.D., Ph.D. The report calls for partnerships among health care providers, schools, faith-based groups and other community organizations to combat weight problems. It also calls for a dialogue to consider classifying obesity as a disease category for reimbursement coding.
"Overweight and obesity may soon cause as much preventable disease and death as cigarette smoking," Satcher, a family physician, said at the press conference marking the release of The Surgeon General's Call to Action to Prevent and Decrease Overweight and Obesity. About 300,000 U.S. deaths a year are associated with obesity and overweight, he said, compared to more than 400,000 deaths a year associated with smoking. The total direct and indirect costs attributed to overweight and obesity amounted to $117 billion in the year 2000.
"Overweight and obesity are among the most pressing new health challenges we face today," said HHS Secretary Tommy Thompson. "Our modern environment has allowed these conditions to increase at alarming rates and become a growing health problem for our nation. By confronting these conditions, we have tremendous opportunities to prevent the unnecessary disease and disability they portend for our future."
Statistics tell the story:
The surgeon general's report was dedicated in memory of FP Paul Ambrose, M.D., M.P.H., who was killed in the Sept. 11, 2001, terrorist attacks. Ambrose, senior editor of the report, served in the HHS Office of Disease Prevention and Health Promotion. "His spirit and his professionalism motivated this team. He truly made a difference," Thompson said.
The Surgeon General's Call to Action to Prevent and Decrease Overweight and Obesity is at http://www.surgeongeneral.gov/topics/obesity/. For more on dealing with obesity in your practice, go to http://www.aafp.org/fpr/ and access the November and December 2000 issues of FP Report for a two-part special section on this topic.
*About 30 pounds overweight
 Source: Behavioral Risk Factor Surveillance System, reported in The Surgeon General's Call to Action to Prevent and Decrease Overweight and Obesity |
It seems a simple concept: If you're trying to promote the specialty of family practice to medical students, bring them together with practicing FPs who love what they do.
But making that happen isn't always so easy. In fact, it can be downright hairy. Not to mention costly.
That's one reason why AAFP created the Chapter Student Interest Matching Grants in the late 1990s.
Administered by the Division of Medical Education under the direction of the Commission on Resident and Student Issues, the grant program supports constituent chapters' efforts to collaborate with family medicine interest groups, departments of family medicine, family practice residencies and others to develop innovative programming to further medical student interest in the specialty.
Two recipients of the 2001 grants -- the Maryland AFP and the New Hampshire AFP -- came up with ambitious ways of doing just that.
MARYLAND AFP
The Maryland AFP received $5,000 to help fund a comprehensive initiative targeting third-year medical students. Partners include the medical schools at Johns Hopkins University and the University of Maryland, both in Baltimore. Each school's family medicine interest group has been heavily involved in the project. MAFP's initiative is expected to reach more than 350 students through participation in community service projects and preceptorship programs, as well as via presentations by family medicine leaders, including AAFP Board Chair Richard Roberts, M.D., J.D., of Madison, Wis., who gave an introduction to the specialty in September.
"My experience with the students and residents was very positive," said Roberts, who spoke to gatherings at Johns Hopkins, the University of Maryland and Franklin Square Hospital Center, Baltimore. "We had probably in each instance 20 to 30 folks. The topic was well-received, and there were lots of good questions."
Other speakers have included Kevin Ferentz, M.D., director of the University of Maryland Family Practice Residency, and Sally Rixey, M.D., Franklin Square's family medicine residency director. FPs practicing in rural and urban settings are featured, and students are invited to participate in summer externships and community-based tobacco education programs.
NEW HAMPSHIRE AFP
The New Hampshire chapter, working with Dartmouth Medical School, Hanover, also received $5,000 toward its student interest programming. Mimi Emerson, M.S., associate project director with the Family Medicine Predoctoral Education Division at the medical school, characterized the initiative as a two-pronged approach "to promote both the community-medical school collaboration and also to promote family medicine among students."
"It's hard to know whether you're 'supporting' or 'promoting,'" Emerson added. "Because really, the students who are already fired up -- this just gives them more to fall back on. But I also think it tweaks the interest of some along the way."
Dartmouth had already begun assessing factors that influence students' career choices, thanks to a Health Resources and Services Administration Family Medicine Predoctoral Education Grant. Interactive panel discussions in September brought FPs, family medicine residents and medical students together in a no-holds-barred "infofest" that allowed students to get a bird's-eye view of the specialty from those who know it best.
"Overall, the students came out of that auditorium very jazzed up -- a lot of conversations both with faculty and with each other," said Emerson. "You could tell that that kind of opportunity helps to make the whole picture more real for them."
The AAFP grant allows expansion of this project, pairing students with practicing FPs for a series of hands-on clinical workstations highlighting patient care skills often used in family practice. New Hampshire Family Physician of the Year Douglas Keene, M.D., of Sullivan will deliver the keynote at this April 4 event.
Lisa Corum, M.D., of Louisville, Ky., was surprised by the blizzard of e-mails that ensued after she posed a simple question to an AAFP e-mail discussion group: "Has anyone heard of a grassroots effort to eliminate OB as part of the residency requirement?" The topic had generated lively discussion at the December meeting of the Jefferson County chapter of the Kentucky AFP.
"None of our local members seemed to think limiting our scope of practice was an issue," said Corum, an alternate delegate from the new physicians' constituency and a firm supporter of mandatory maternity training in residency.
Here's a sampling from that blizzard of e-mail responses.
MEMBERS SPEAK OUT
CALLS FOR CHANGE
While the e-mails generated by Corum's question all reflect similar sentiments, there is another side to the issue.
Daniel Hafendorfer, M.D., of Louisville, Ky., president of the Jefferson County chapter, said the number of unfilled family practice residencies nationwide is climbing. "We're seeing a significant number of young medical students going into internal medicine/pediatrics," said Hafendorfer, "and many of them have said to me, 'Well, I would have gone into family practice if I didn't have to do the extensive OB work.'"
Couple that with the shrinking number of FPs who actually do maternity care, said Hafendorfer, and the need for change becomes clear. (According to AAFP's 2001 edition of Facts About Family Practice, 30 percent of members include obstetrics in their practices.)
"Why are we spending all the time and training on maternity care, potentially alienating residents who might consider family practice, when the majority of FPs don't do OB?" asked Hafendorfer. Make OB training optional, not mandatory, for the specialty's residents, he suggested.
THE BOTTOM LINE
"OB care in family practice isn't going away," said Perry Pugno, M.D., director of the AAFP Division of Medical Education. "Both the Residency Review Committee for Family Practice and the Residency Assistance Program concur that training in maternity care is still a core curriculum element of family practice residency education."
AAFP President-elect James Martin, M.D., of San Antonio said the current dialogue about maternity care "has been very rewarding for those of us who see maternity care as an important part of the family physician education." Martin directs the Christus Santa Rosa Family Practice Residency Program in San Antonio.
"There are groups of people in family medicine who say we shouldn't be providing maternity care, and there are others who say it's an integral part of what we do," said Martin. "This issue is being pushed by some programs and will be discussed by the Future of Family Medicine committee -- a panel exploring options for the specialty and ways to involve many FPs in the ongoing discussion. As we work through the FOFM project, hopefully we'll be able to come to some conclusions, and that will influence the type of curriculum we include in our training."
 The Louisiana AFP announces the candidacy of Michael Fleming, M.D., of Shreveport for AAFP president-elect. |
 The Pennsylvania AFP announces the candidacy of Thomas Weida, M.D., of Hershey for AAFP vice speaker. |
 The Kansas AFP announces the candidacy of Rick Kellerman, M.D., of Wichita for AAFP director. |
 The Ohio AFP announces the candidacy of Mary Jo Welker, M.D., of Columbus for AAFP director. |
The Academy has released its 2002 Childhood Immunization Schedule, which is updated to include recommendations for high-risk children. The AAFP has issued two prioritization recommendations made in response to shortages of diphtheria toxoids and acellular pertussis and pneumococcal conjugate vaccines.
Regarding hepatitis B, all pregnant women should be screened for the surface antigen, HBsAg. Infants born to HBsAg-positive mothers should receive hepatitis B vaccine and 0.5 mL hepatitis B immune globulin at separate sites within 12 hours of birth. On the immunization schedule, the first dose of hepatitis B is shaded beyond birth to denote that it should be given at birth unless the mother's surface antigen status is negative, in which case the range from birth to 2 months is acceptable.
Because of vaccine shortages, the schedule recommends that physicians not vaccinate healthy children 2 years old and older against invasive pneumococcal disease until appropriate amounts of the vaccine are more widely available. However, physicians should continue vaccinating all infants younger than 12 months and older children who are at increased risk of developing pneumococcal disease.
Prioritization recommendations also apply to DTaP vaccine. The AAFP recommends that physicians with a low supply of the vaccine give priority to vaccinating infants with the initial three doses and defer the fourth dose. If this does not provide enough vaccine, then the fifth dose for other children over 12 months can be deferred.
The updated schedule, released annually in January, is developed by AAFP representatives who collaborate with the CDC's Advisory Committee on Immunization Practices and the American Academy of Pediatrics. Go to http://www.aafp.org/x7666.xml to download the immunization schedule. You can also request it via fax (see "Quick Fax").
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Are you involved in research in a family practice setting? Note the Feb. 22 submission deadline for grant applications for Practice-Based Research Network Stimulation Grants. Vie for a grant of up to $5,000. Contact Susie Morantz at smorantz@aafp.org for more information.
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Proven value: It's time to register for two spring conferences held annually in Kansas City, Mo. Go to http://www.aafp.org/leader/ to register for the National Conference of Special Constituencies April 25 27 and the Annual Leadership Forum April 26 27. The two conferences will come together to share a common program on Friday and Saturday mornings. Save $50 by meeting the Feb. 28 early-bird registration deadline. For details, use "Quick Fax" at right.
Proven value: The AAFP Scientific Assembly Oct. 16 20 in family-friendly, sunny San Diego offers FPs valuable CME, networking opportunities with colleagues, and an exhibition hall chock-full of products, services and representatives eager to answer questions. Registration packets will be mailed to AAFP members in May, with online registration at http://www.aafp.org/assembly/ beginning May 30. Check the Web site for updates.
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A shipping fee may apply; Kansas residents pay a 7 percent tax. |
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FP Report is published by the
AAFP News Department.
Copyright © 2002 by
American Academy of Family Physicians.
