May 2002 • Volume 8 • Number 5 |
Think you have a handle on your patients' self-prescribing habits? This might surprise you: More than 70 percent of American adults and about 50 percent of children take over-the-counter medications in any given week, according to a study in the Jan. 16 Journal of the American Medical Association.
If you're concerned, it's with good reason. Considerable evidence indicates that many patients do not read labels or heed warnings about possible drug interactions or side effects of OTC products. And because there is a general perception that these drugs are safe, patients may not seek the necessary information before making a selection. The danger is only increasing, says one FP.
"In the last five years, there's been an incredible burst of new pharmaceuticals, and with it an awareness among physicians of interaction problems," says Susan Montauk, M.D., who co-wrote a new AAFP monograph on the subject (see story "AAFP's OTC monograph can help").
In fact, more than 100,000 drugs are available without a prescription, according to recent data reported in JAMA. "There's no way you can know about 100,000 medicines, so you have to educate your patients on how to assess and use OTCs," says Montauk, professor of clinical family medicine at the University of Cincinnati College of Medicine.
To be sure, OTC medicines can be beneficial. Patients who study the choices can treat themselves appropriately for minor conditions without the inconvenience of visiting or calling their physicians.
But physicians should impress on patients the need to read labels carefully -- especially the small print -- and ask questions if they're uncertain of what's appropriate for their ailment. Assuming that all OTCs are benign can prove disastrous, especially if a patient already is taking another medicine or several others.
EASY TO OVERDOSE
Catherine Little, 67, of Cincinnati, used to pride herself on the fact that she never caught cold. Until February. Already taking blood pressure medicine and a nonsteroidal anti-inflammatory drug, Little was struggling with a cold when she started taking an OTC cold medicine. But a wracking cough persisted, so she also took a cough medicine she had on hand. She didn't have a measuring spoon handy, so she estimated her dose. "And that's about all I remember," she says. She woke up in the hospital.
At first, ER doctors weren't sure what was causing Little's dementia. Tests for stroke, masses and metabolic events were negative. Only after she became more lucid was she able to say what she had taken. Hospital workers determined that she overdosed on OTC medicines, says Montauk, her physician.
Montauk says it is common for medicine to have different effects in patients over age 65. Even if there is no concern about drug interactions, older patients should start with the OTC drug's dose.
Another common mistake patients make is to take OTC drugs for longer than recommended. This information is on the label, often in tiny print.
Polypharmacy presents another potential danger. For instance, naproxen and ibuprofen are safe and effective, but many patients experience problems if they take both at the same time, says Montauk. And these days, many people take an aspirin a day for cardiac benefits. However, aspirin mixed with non-steroidal anti-inflammatory drugs can increase the risk of gastrointestinal problems. Mixing caffeine or tobacco -- agents that already increase blood pressure -- with any medicine that raises blood pressure can cause disaster as well.
BRING THEM IN
It's not enough to ask patients what OTC medicines they are taking. "You must ask what they have in their cabinets," Montauk says. "Better yet, have them bring them in." Anything that's in their cabinet could be used when a patient is ill and perhaps not thinking clearly.
But the biggest danger may well be unfamiliarity.
Sometimes a patient doesn't know what they're taking, says Montauk. "It's not uncommon for people to tell me they're taking an antihistamine and then tell me that the 'antihistamine' they're taking is Sudafed.
"And when you hear, 'Oh I just take a vitamin,' you have to ask for more specifics; it could be a diet drug containing ephedra or an inappropriately high dose of a fat-soluble vitamin."
Because of the potential danger for patients who incorrectly use over-the-counter medicines, the AAFP recently published its first-ever guide to the medications, "Appropriate Use of Common OTC Analgesics and Cough and Cold Medications." The American Family Physician monograph, available online at http://www.aafp.org/afp/otcmonograph/, was written with financial support from a grant from McNeil Consumer Healthcare.
This guide integrates basic science with practical insights and guidance about patient management and counseling.
It contains patient education materials in English and Spanish that include a list of questions patients should ask doctors about medications; medicine dos and don'ts; and foods, drinks and activities to avoid when taking certain medications. It also explains the difference between generic and brand-name medicines, and gives tips for choosing medicines.
Physicians' Medicare payments could drop by nearly 20 percent during the next four years if nothing is done to remedy the sustainable growth rate-based formula the federal government uses to calculate those payments.
This year, physicians were hit with a 5.4 percent cut in the conversion factor used to update their payments for Medicare services. The Medicare Payment Advisory Commission has warned that next year's cut could be 5.7 percent. MedPAC released its projections during its March meeting. Another 5.7 percent cut is expected in 2004, followed by a 2.8 percent cut in 2005.That would push physician payments back to the 1993 level, despite rising practice costs.
"Those future cuts would be devastating to our doctors," said AAFP Executive Vice President Douglas Henley, M.D. "What's even more critical is the adverse effect these cuts would have on patients' access to Medicare services."
Academy President Warren Jones, M.D., of Ridgeland, Miss., took that message to Congress April 10 when he testified on the issue before the House Small Business Committee.
"The gap between cost inflation and Medicare's payment updates is already starting to take its toll," Jones testified. "In the last year or so, access problems have been reported in Atlanta, Phoenix, Albuquerque, Annapolis, Denver, Austin, Spokane, northern California and Idaho."
"AAFP data from last year reveal that 17 percent of family physicians who responded to our practice survey are not accepting new Medicare fee-for-service patients," Jones testified. "Given the recent and projected cuts in Medicare reimbursement, we have reason to expect that the number of physicians not accepting new Medicare patients will climb."
Back at the AAFP, Henley said most primary care practices are in effect small businesses, and many already are losing money due to Medicare payment cuts and inflation. "What the projected cuts don't take into account is the additional negativity of inflation on physician income. It's simple: You can't run a small business when you're losing money," he said.
Compounding physicians' financial problems this year is the aftermath of a national tragedy -- the Sept. 11, 2001, terrorist attacks, said AAFP Director Arlene Brown, M.D., of Ruidoso, N.M., and family physician Ronald Johnson, M.D., of Pittsfield, Ill. (see story "Lower payments force FPs to risk personal loss for their patients, practices").
Why? The processing of physician reimbursements by private health insurers slowed to a "snail's pace" after Sept. 11 because insurance companies were inundated with attack-related claims, they said. Physician payments normally processed within 30 days now are taking around 120 days to settle.
In his congressional testimony, Jones warned that if practices close because of these factors, some rural communities could face economic hardship. This is because the presence of a family physician in a community is an economic stimulus. He cited a study by the Center for Health Policy Research at the Oklahoma State University Health Sciences Center that found "on average, each family physician will generate (both direct and secondary) an estimated 50 full-time jobs, and these jobs will generate more than $1.1 million of income annually."
Continuing efforts in Congress to repeal the SGR-based physician payment formula advanced when Reps. Nancy Johnson, R-Conn., and Bill Thomas, R-Calif., included MedPAC's projected payment levels in a letter they sent in late March to Thomas Scully, administrator of the Centers for Medicare & Medicaid Services.
Earlier in March, Johnson introduced a bill, H.R. 3882, which would enact recommendations MedPAC released in December 2001.
Those recommendations would change the 2003 conversion factor to a positive 2.5 percent and eliminate the SGR-based formula beginning in 2004. The final recommendation would revise the productivity adjustment for physician services by using multiple factors -- including costs for office space, medical materials, supplies and equipment -- instead of labor only.
However, an estimated $126 billion would be needed to implement those changes during a 10-year period. Capitol analysts believe President George W. Bush is willing to fix the physician reimbursement problem but insists on a "budget-neutral" plan.
Henley said, "The Academy is working diligently and aggressively to convince Congress the SGR-based formula needs to be fixed -- even if it means the government must spend more money." AAFP leaders and members pressed the issue during April visits to legislators on Capitol Hill. And the Academy is working with a coalition of other medical organizations, including the AMA, in continued lobbying efforts, Henley said.
"Congress needs to understand how the current pay formula adversely affects the entire Medicare system and produces results opposite of what Medicare is all about," he said.
For a growing number of family physicians, Medicare payment cuts ultimately could break up the "families" dependent on them -- families composed of patients, employees and entire communities.
While some FPs have stopped accepting new Medicare patients, others are putting personal loss on the line to keep their "families" intact.
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| Ronald Johnson, M.D., stands astride the farmland he's mortgaged to save his practice. Inset: Leonard Guthrie, 91, of Pleasant Hill, Ill., who suffers from a heart ailment, visits Johnson for a check-up. | |
One rural doctor in Illinois who borrowed money to meet his payroll is now borrowing against his dream farm to repay those loans and protect his practice from financial failure.
Medicare patients make up one-third of the Pittsfield practice of Ronald Johnson, M.D, and the area's only hospital claims nearly 80 percent of its patients use Medicare. With an average age of 58 in the two counties Johnson serves, "we don't have the choice of not taking Medicare patients. That's our life here," he said in a recent telephone interview. "They are our neighbors; they are our friends. We have to take care of each other."
When he added the losses from Medicare reimbursements and accounts receivables that have doubled in the past six months, Johnson realized he needed to borrow an amount that nearly equaled the value of his farm.
"I got lucky," he said, "because the farm has been taking care of itself financially. Now, it's going to take care of us and our patients."
Johnson is finalizing a loan for two-thirds of his farm's value. It's an amount that realistically, he said, can sustain his practice for another year -- two at the most -- depending on factors including future Medicare reimbursement rates, the local economy and land values.
"I'd never thought I would spend this much of my time being a businessman," he said. "It's such a joy to sit down and see a patient. I thought that was what I was training for."
AAFP Director Arlene Brown, M.D., of Ruidoso, N.M., said she and her staff "saw the writing on the wall" when Medicare physician payments dropped and accounts receivables increased. Something had to happen to keep her "frontier medicine" practice open.
Brown serves 8,000 patients, some of whom must drive 50 miles on a dirt road to reach a paved road -- then must drive another 100 miles to her office. At least 30 percent rely on Medicare, she said, "and we can't stop accepting these patients."
So Brown took a pay cut and turned to her staff for help. The employees -- a close-knit "family" -- didn't want to see anyone lose his or her job, she said. Instead of eliminating a position and/or cutting patient services, all staff members agreed to cut their hours and pay by 15 to 18 percent.
"We must stay open," Brown said. "We know if my patients have to get their primary care 200 miles away from home, they won't go get it. They depend on me, and on us."
How long can her practice hold out for a permanent financial solution? Not long, Brown said. She's hoping efforts to get the federal government to rethink Medicare and correct the physician payment formula will succeed soon.
"If not, we'll be cutting some services we don't have to provide," she said. "The first to go will be flu shots." Next to go will be the free assistance older and low-income patients get when they need help to buy prescription drugs.
"It all makes for bad medicine," Brown said, "but it could help keep our doors open."
If her practice closes, the entire community -- her community -- could collapse, she said. "A majority of Americans eat, live, sleep and die in small communities. If we shut down the very things that help small communities survive, like medicine, then those communities will die."
In the words of folksinger Bob Dylan, "The times, they are a-changin'." And family physicians need to change right along with them, says the American Board of Family Practice.
Witness the way FPs take the certification and recertification exams. According to Robert Avant, M. D., ABFP's executive director, it's time to make optimal use of today's computer technology.
"What we want to do is move toward a computer-administered exam," said Avant. "This is where many different types of examinations are headed."
Avant and Terrence Leigh, Ed.D., ABFP assistant executive director, presented the concept April 7 at the Residency Assistance Program Workshop for Faculty and Staff of Family Practice Residencies in Kansas City, Mo.
Such a system, Avant said, would open up possibilities well beyond the capabilities of the current testing format.
"The graphics are better; our ability to monitor how someone is doing is better," he explained. "But the most exciting thing is that we've been able to develop patient-care simulations that allow us to move from presentation of a case to doing the history, developing a treatment plan and following up over time. That's something we haven't been able to do with the current exam."
So, the $64,000 question: When should FPs preparing to sit for their boards expect to be faced with a computer screen rather than paper and pencil?
"We're hoping to begin phasing this in during the 2003 calendar year," said Avant. Meeting that timetable, however, depends on the results of a just-completed pilot project. On April 12, the board offered its certificate of added qualifications in sports medicine exam in a computerized format at eight different sites around the country. Although ABFP has conducted previous pilots, he said, this was the first time the entire exam appeared in computerized format.
Understandably, there was a certain amount of opening-night jitters involved. "It's a critical issue for us," said Avant. "If the results are perfect, we can proceed with our scheduled timetable. If there are problems, they'll have to be addressed. Our concern is that it has to be perfect the first time, because it IS the exam."
What is the Academy's reaction to the change?
"It's just terrific," said Norman Kahn, M.D., vice president for science and education. "We asked ABFP to do two things, and they did both of them. It's a clear sign of the strong working relationship the AAFP has developed with ABFP."
Members have clamored for many years to have the exams administered more than once annually, Kahn explained, and the board is doing just that. "In 2003, physicians taking the certification or recertification exam in July will have the choice of taking it on paper or on the computer," he said. "And then there will be a second exam offered later in the year that will be given only by computer."
The same arrangement will hold for 2004. After that, put down your pencils, ladies and gentlemen. It's all keystrokes and mouse clicks from there on out. Although you'll still get two chances a year.
Regarding AAFP's second request, said Kahn, "This gives us two full years to prepare the nation's family physicians. We'll be providing training at the 2002 Assembly, as well as during the 2003 board review courses and the 2003 Assembly," and most likely beyond that.
As for the logistics of how and where the exams will be administered, Avant said, "We'll need to start out by using exam centers, but the goal on down the line is to be able to offer this via home computers. Of course, there'll be some confidentiality issues that will have to be addressed when we get to that point."
The eventual objective, he said, is to use this technology for performing other types of ongoing physician assessment.
"We really want to move ahead in ways to assess physicians over a lifetime, and this is the way to go," Avant said. "But we don't have a drop-dead date for that."
When the AAFP Congress of Delegates last fall adopted the plan Assuring Health Care Coverage for All, the delegates may well have had in mind their own uninsured or underinsured patients.
In this article, two women describe the consequences of being uninsured. Read their stories, and then take action to publicize AAFP's plan for insuring all Americans.
 Some faces of the uninsured: (Top photo) Sharon and Rich Schober, here with twins Kelsey, left, and Seth, have been uninsured for 13 months. (Lower photo) Mary Collins has been uninsured for seven years. |
UNINSURED WIDOW
Mary Collins of Mishawaka, Ind., and her husband used to have health insurance through his employer, UniRoyal. Then Polycast bought the UniRoyal factory, Collins' husband retired, Polycast went bankrupt and -- about seven years ago -- the insurance disappeared.
Collins, now a 63-year-old widow with diabetes and high blood pressure, struggles to keep up with her medical bills. "In the richest country in the world, everybody should be able to have affordable health care," she says. "In a little more than a year, I'll reach 65 and be on Medicare, and I can't wait."
She goes to the family practice center at St. Joseph Medical Center in South Bend, Ind., for her care and pays on a sliding scale. Recently, her office visit was listed as costing $52, adjusted to $39; the glucose test cost $15; her flu shot, $11; and her pneumonia vaccination, $17.
Routine costs, right?
Easily paid?
Not by Collins. She tops those costs with about $167 worth of medicine per month, plus $20 worth of test strips and lancets for checking her glucose levels.
"I've slacked up on checking my blood sugar because everything is so expensive," she says. "When I go to the grocery store to buy things I should be eating, like fresh fruits and vegetables, sometimes they're too high, so I buy a lot of beans and potatoes, and I'm not supposed to have too much of those foods."
Collins should call the center each week to report her blood pressure levels. "I kind of fudge on that," she says, "but I've been really conscientious about taking my medicine."
That makes her different from many of the uninsured, including Sharon Schober and her family.
FAMILY TEMPORARILY WITHOUT INSURANCE
The Schobers live in Sutton, Alaska, and expect by early this month to regain insurance after 13 months without it.
"Early last year, my husband thought he had a chance to change his part-time work in maintenance at a hospital to full-time work with insurance coverage. I worked then as a home health nurse for more than 20 hours a week, so we had insurance through my work," says Sharon Schober. "We took the risk of having me take fewer hours so I could home-school our twins until they reached third grade."
They expected to be without coverage for three weeks. However, Rich Schober's full-time job didn't materialize until this spring.
He has restless leg syndrome, requiring a new drug that costs about $205 a month. "He uses less than the prescribed amount of the drug to try to get by," says Sharon Schober.
After enjoying good health most of her life, she had a gall bladder attack in August. "I ended up in the emergency room and then in surgery three days later," she says. "The ER bills were scary enough, but the surgery bills are incredibly frightening. I haven't even thought about how long it'll take us to pay the $15,000 for the surgery."
For primary care, the Schobers see Cathy Baldwin-Johnson, M.D., of Wasilla, Alaska, the AAFP's 2002 Family Physician of the Year. She credits the Schobers: "They are faithful about making regular payments on their bill."
Baldwin-Johnson asks families just to keep paying something. "She's flexible," says Sharon Schober. "She doesn't require X amount by a set date."
Within four months of going without insurance, the Schober children were enrolled in Denali Kid Care, a State Children's Health Insurance Program. Sharon Schober says her nursing background led her to the program. "I was familiar with the health care system, knew Denali Kid Care existed, knew how to go about getting it," she says. "And I knew we needed it."
The Academy encourages you to talk with your colleagues and community about the difficulties the uninsured face. In your discussions, you can describe key points from the AAFP plan, Assuring Health Care Coverage for All.
Request the plan and other materials via "Quick Fax" in this issue, or print the materials online at http://www.aafp.org/unicov/. At that site, you can read vignettes about other uninsured and underinsured people. You can also link to a PowerPoint presentation you can use in discussing the plan.
You're a family physician. You're supposed to treat the whole person. But to do this, it may seem that you have to be all things -- doctor, educator, confidant, social worker -- to all people.
And in a society where minor conflicts too often escalate to violence -- how about referee? Because sometimes you might have to step between two patients and be the mediator, a role you might be reluctant to assume.
But if that's the case, consider this: You've been mediating conflict all along. In any practice, conflicts arise among staff members or between patients and staff.
How you deal with such stressors can serve as a lesson for those around you, says Kevin Sherin, M.D., director of the University of Illinois at Chicago's Christ Hospital Family Practice Residency Program. "We're role models for our patients," he says. "How do you deal with the angry patient? How do you deal with the angry staff person? How do you deal with conflicts between residents-in-training?"
Mediation skills gleaned from these situations can be used to help patients, says Sherin, who has written a monograph on intimate partner violence for the journal Hospital Physician.
The key is not to view conflict as a bad thing, says Deborah Taylor, Ph.D., associate director at the Central Maine Medical Center Family Practice Residency in Lewiston. Taylor, a speaker on resolving conflicts within residencies, says it is important to approach, not avoid, conflict.
"There are benefits to conflict," says Taylor. "It gives you an opportunity to solve problems and make improvements. It can help you identify and make necessary changes. It helps people to clarify what their goals and missions are, and it keeps people on the same page."
When handled appropriately, conflict can actually strengthen relationships, Taylor maintains.
Another FP's experience bears out Taylor's perspective. Christopher Gaynor, M.D., M.A., a staff physician at Community Health Center of Snohomish County in Lynnwood, Wash., says he jumped into the fray of a family controversy when he noticed strife between an 11-year-old patient and the patient's stepfather. Gaynor says he picked up on "vibes" between the two during a visit at which "the stepfather did nearly all the speaking, and the patient stared at the floor." The patient, recently diagnosed with type 1 diabetes, was struggling with depression.
"So when the mom brought him in at a subsequent visit, I asked about the relationship between the patient and his stepfather," says Gaynor. "The mom admitted that the stepfather had low tolerance for the patient's shenanigans, and that he easily lost his temper and yelled at the boy. The patient, when asked about physical mistreatment, revealed an instance of abuse. What ensued was a powerful expression of mother's dismay that this could have occurred in her home without her knowledge. The boy was ultimately able to hear his mother's commitment to preventing further physical violence against her son, but also a commitment to working things out with her spouse."
The revelation enabled healing to take place, says Gaynor. By the next visit, the patient's depression had improved and he had enrolled in counseling. Furthermore, the stepfather had agreed to leave limit-setting to the boy's mother and enrolled in anger management classes.
Positive outcomes such as this require that the physician be perceptive enough to recognize potential sources of conflict.
Sherin says conflict management needs to be better addressed by the medical school curriculum. "The whole issue of conflict resolution is certainly on the prevention side of the kinds of curricula that need to be out in the communities," he says.
To be effective, residents need awareness of intimate partner violence, child abuse and elder abuse, he says. But the larger issue for society to grapple with is how to prevent violence in the first place.
"How does your family handle conflict?" AAFP President Warren Jones, M.D., of Ridgeland, Miss., would like to see more FPs ask this as a patient screening question. As a goal of his presidential year, Jones wants to address the need for FPs to mediate conflicts.
"Family physicians ask: 'Do you have firearms in the home? Do you wear seat belts when you drive? Do you have medicines or toxins within the reach of children?' Asking about conflict in the family is the logical extension in the interest of practicing prevention," says Jones.
Jones is no stranger to this issue. As a teen-ager, he says, he had a "flash temper" and often got into fights. Eventually, his mother sent him away to live with an older sister and her husband, and the change in surroundings helped turn things around for him.
Often, the root of young people's conflict is grounded in self-esteem problems, said Jones. "We've got to get across to young people how to value themselves, how to value their family ties, how to value their communities and de-escalate conflict."
And while FPs may already feel overburdened, the fact is, no other specialist is in as strategic a position as the family doctor. FPs are trained in the workings of family systems, and they should know about community resources available for those entangled in conflict. "Family doctors have the tools -- they need to use them," says Jones.
"This is a part of what we do better than anyone else, because we know the family," he says. "If we don't ask the family, 'How do you resolve conflict?' no one will."
Is this you? Take a look -- you might see yourself in the description below. The description is based on information from the latest FP Report reader survey:
You're incredibly busy. You're a "skim" reader who quickly reads FP Report's front-page cover stories and the "issue highlights" bar at the top of page one. You also look at "special sections" on specific issues that appear from time to time in the paper. What we'll do: We'll continue to focus design and editorial efforts on page one, and to include special sections on issues critical to you.
You have issues. Specifically, you want to read news about family practice, legislation and regulations, and clinical issues, in that order. What we'll do: We'll continue to focus most coverage on these "top three" areas of interest.
You increasingly view FP Report as a catalyst to action, not just an information source. In the past several months, you were more likely than before to save an article, visit the Academy's Web site, call an article to a colleague's attention or answer an AAFP call to action. What we'll do: We'll keep striving to provide useful information you'll want to save, Web addresses for helpful resources and calls to action on issues that impact you.
You think the paper is getting better. You continue to perceive improvements in FP Report's timeliness and coverage of specific issues and in the paper's design. What we'll do: We'll keep striving for even more improvements!
Your needs shift over time. Right now, Medicare payments might be your hottest button. Tomorrow -- will it be privacy rules? Bioterrorism? Or something unforeseen? What we'll do: We'll keep beating the bushes, leaving no stone unturned to find and report on your next issues -- hopefully before they begin to concern you.
Finally, thank you for your support for what we do. We do it for the very best reason: You're "our Academy." You're the reason we're here.
Paula Haas Binder
Editor, FP
Report
Along the way to a smoother flow of electronic communications between physicians and insurers, a deadline is looming.
The Centers for Medicare & Medicaid Services wants medical practices to be in compliance with the transactions and code sets rules issued in 2000 to implement part of the Health Insurance Portability and Accountability Act of 1996. If you're already in compliance, you're ahead of the game. If not, CMS is asking you to complete a short, simple form by Oct. 15 outlining your plans to comply by Oct. 16, 2003.
The rules apply to electronic transactions containing patient-identifiable health information -- such as health care claims, payments and referrals. The regulations establish standard formats for these transactions and mandate the use of well-known codes, such as CPT codes, instead of the local codes some insurers require.
The CMS form asks -- in multiple-choice questions -- why your office will not be complying with the transactions and code sets rules by this October, what range of expense (less than $10,000?) you might incur to reach compliance, what phases of implementation you've completed and whether a vendor may assist you.
To download the form and instructions, go to http://www.cms.gov/hipaa/hipaa2/ascaform.asp. If your office has a compliance plan, you may be able to submit it instead of the CMS form.
Tip: Check out the Family Practice Management article this month on conforming with the HIPAA electronic transactions and code sets rules. More information is online at http://www.aafp.org/fpm/hipaa.html.
HHS recently proposed changes to several federal privacy rules implementing the Health Insurance Portability and Affordability Act, citing the need to protect patient privacy while removing obstacles to quality health care. One substantial revision would make the signing of patient consent forms no longer mandatory before care is given.
Physicians must make a "good-faith effort" to inform patients of their privacy rights under HHS Secretary Tommy Thompson's recommended revision, but they can treat patients without a signed consent form.
"The President believes strongly in the need for federal protections to ensure patient privacy, and the changes we are proposing today will allow us to deliver strong protections for personal medical information while improving access to care," Thompson said in a statement.
How will the new rule improve patients' access to care? As an example, Thompson said a sick patient could stay comfortable at home while a friend or relative picked up the patient's prescription at a pharmacy. Also, he said, "Doctors will be able to consult with nurses and others involved in a patient's care to ensure that they get the best care."
The revised patient consent form rule is a "big victory" for physicians, said AAFP Executive Vice President Douglas Henley, M.D., because doctors can explain or seek advice about a patient's care without fear of violating the patient's privacy rights.
For a patient involved in medical research, one proposed rule change would mandate the signing of a single consent form instead of the multiple forms required now. Thompson said the single form would keep patient privacy intact without impeding the effectiveness of research. Another revision would apply rules similar to the "Common Rule," which governs federally funded research, to ensure a patient's identification is protected while participating in privately or publicly funded research projects.
Other proposed revisions to the rules that implement HIPAA continue to seriously concern the Academy, such as a revision to the business associate contract requirement. HHS's proposed rule change provides some relief for physicians, however, by including model business associate contract provisions and giving physicians another year to change current contracts.
At press time, the Academy, using an analysis provided by AAFP legal consultants, was developing a comprehensive response to HHS concerning the proposed revisions.
The HHS proposal can be found in the March 27 Federal Register, or visit http://www.hhs.gov/ocr/hipaa/propmods.txt to read the document.
Note: AAFP's new HIPAA Privacy Manual provides sample forms and a step-by-step guide to implementing the privacy regulations. You may purchase the manual online at http://www.aafp.org/hipaa/ or by calling (800) 944-0000. As HIPAA publishes further final rules (not just proposed revisions), notices will be posted on the Web site, and purchasers will receive updates.
It's the moment you've awaited since you first hit the doors of medical school. You've trained for it, reveled in it, probably dreamed about it. And now, you're a first-year resident in family practice.
So what's with the butterflies?
Relax, says Mark Su, M.D., who's been there. He's in his second year of residency at Tufts University Family Practice Residency, Malden, Mass. That little bit of trepidation only proves you're human, he says.
Here's some advice to help quell those whispers of anxiety.
CARVE OUT YOUR NICHE
"Early on, get used to being called 'doctor,'" Su says. "Accept this position and entitlement -- you've earned it."
But don't overdo it, he adds. "There are many nonphysicians who have much more experience than you do and who can help you if you're humble and 'learnable.' Cop an attitude and you'll have trouble."
Nicholas Parkinson, M.D., a first-year resident with the Grant Medical Center Residency, Columbus, Ohio, has a similar take on the subject.
"Learn to be comfortable with your own ignorance," Parkinson says. "You'll rarely lose others' respect if you admit to the things you don't know and express eagerness to learn. But you will lose respect if you pretend to have complete knowledge or adopt an attitude of indifference about things you don't know."
Remember, says Su, "There will be times when you 'grow' and feel like you know a lot, and there will be times when you feel like you know nothing. It's all part of the process -- just keep going."
GET WITH THE PROGRAM
"Be proud of your program," Su urges. "Many people have worked hard to get it where it is now." Balance the problems and the strengths, and focus on and learn from the strengths.
That doesn't mean you should turn a blind eye to what goes on around you, especially when it comes to financial issues. "Nearly all programs are struggling in today's health care economic environment," Su says. "Learn what you can from discussions on this subject; don't blow it off."
Guard against naïveté on other "political" issues as well, he advises. Expect multiple pressures from all directions: nurses, faculty, peers, students and that nebulous entity known as "the system." But don't take it personally -- most of that pressure represents the proverbial "trickle-down effect."
Make a conscious effort to be thoughtful and compassionate despite exhaustion and the ubiquitous pressures, Su adds. Extend this courtesy not only to your patients, but also to peers and staff, he says, "Because believe me, they know what you're going through!"
GIVE IT YOUR BEST SHOT
"This is your only chance to practice and learn before going out into the 'real world,'" Su points out, "so give it your best shot."
Parkinson is right in step with this "go for it" attitude. "The huge range of medical knowledge that applies to our specialty is sometimes so overwhelming that we're tempted to give up on being detailed and persistent in our studying," he notes. "This can be dangerous and, needless to say, no fun.
"The tough thing about family practice is that there is no particular hill for us to be king of. For our patients' sake, we strive to gain competency in a variety of disciplines in which other doctors are always the 'experts.' This occasionally makes us vulnerable to the snubs of short-sighted professionals from other areas of medicine. Gaining the confidence in yourself and in your specialty to endure such nonsense is part of the training process."
Taking pride in the specialty is key, says Parkinson. "One of the most exciting and satisfying things about family practice is having the opportunity to use an obscure pearl of knowledge gleaned from some musty archive to make an impact on the health of a real patient."
If you've been itching to speak your mind about issues facing family medicine today, you'll have ample opportunity at this year's National Conference of Family Practice Residents and Medical Students July 31 Aug. 3 in Kansas City, Mo.
The conference theme, "Family Medicine: Today's Challenges, Tomorrow's Opportunities," will be explored in many offerings. Here's a sampling:
Other speakers on tap include Michael Magee, M.D., director of the Pfizer Medical Humanities Initiative and author of The Principles of Positive Leadership and The Best Medicine -- Doctors, Patients and the Covenant of Caring; Denise Rodgers, M.D., immediate past president of the Society of Teachers of Family Medicine and associate dean for community health at the University of Medicine and Dentistry, New Jersey-Robert Wood Johnson Medical School, New Brunswick; and AAFP's 2002 Family Physician of the Year Cathy Baldwin-Johnson, M.D., of Wasilla, Alaska.
During the conference, you can choose from a literal smorgasbord of educational offerings. Check out the myriad residency programs, career opportunities, medical information resources and more in the exhibit hall. And, of course, you can help shape AAFP policy by speaking your mind and voting your conscience at the National Congress of Family Practice Residents and National Congress of Student Members.
Early-bird registration ends June 14, so it's time to make travel plans. Grab the registration brochure you received in the mail a couple of weeks ago, and pick one of three ways to register:
Preregistration ends July 8; after this date, you must register on-site.
Questions? E-mail them to conference@aafp.org, or call (800) 926-6890, Ext. 6726.
To the editor:
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To the reader Write us a letter of 200 words or fewer (subject to editing). FP Report, 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672; fax them to (913) 906-6089; call (800) 274-2237, Ext. 5230; or contact fpreport@aafp.org via e-mail. |
I'm writing in regard to the March FP Report article "Future of Family Medicine Project Surges Forward." I serve as chief of minimally invasive surgery and endoscopy at our rural community hospital, and I am physically sickened by the huge discrepancy in the training for, and the actual skills needed by, rural family physicians, both old and new. But no postgraduate surgical training exists for family physicians in America. Everyone -- from physician's assistants and nurse practitioners to general surgeons -- has slowly taken away the tools of our trade.
I would beseech the individuals involved in the Future of Family Medicine project to think outside of the box and seize back the profession of rural family medicine with a vengeance. Don't let another resident go into rural American medicine surgically unprepared. Don't let another day go by without helping train and retrain existing rural physicians struggling to keep their community hospitals afloat. Don't allow another minute to go by where other specialties not only look down on family physicians in rural practice, but also have the audacity to tell us we can't perform the very procedures we need to exist. Please -- don't give away our profession.
Andrew Jones, D.O.
Cottonwood, Idaho
For more information on these programs, call (800) 274-2237 and ask for the extensions listed below, or access the other sources noted.
Tar Wars. Winning posters in the state Tar Wars poster contests must be received at AAFP headquarters by May 15 to be considered for the national competition. For more information, call (800) TAR WARS [827-9277] or visit http://www.tarwars.org/.
Research. If you'd like a research study grant from the AAFP Foundation Joint Grant Awards Program, apply by June 1. For an application and details, call Ext. 4470 or go to http://www.aafpfoundation.org/jgap/.
You may have creative ideas for beginning a family practice research project. Submit your proposal by Aug. 30 for a Practice-Based Research Network Stimulation Grant. For information, e-mail smorantz@aafp.org or call Ext. 4470.
Patient education. Note the July 1 deadline for awards to be presented at the 24th Annual Conference on Patient Education Nov. 21 24 in Fort Lauderdale, Fla. The Patient Care Award for Excellence in Patient Education Innovation will be given to a health professional or nonprofit organization. The H. Winter Griffith Award for Excellence in Patient Education Materials will be presented to an individual, practice or organization. For information and applications, call Ext. 5412 or visit http://www.stfm.org and click on "Society Information" and then "Awards."
Family practice residents are encouraged to apply for scholarships or grants to attend the patient education conference. Send AAFP the application with a letter of recommendation from your program director by July 12. Applications are available through your residency, at http://www.aafp.org/pec/ or by calling Ext. 3132.
The Academy would like to cast a wide net in encouraging members to serve on AAFP commissions and committees. Family physicians in these groups help draft policy statements, design programs to meet FPs' needs and often serve as Academy representatives to other organizations.
Take a moment to consider: Would you like to help shape AAFP policies and programs by taking a national leadership role? Or do you know someone you think should be nominated?
If so, talk with your chapter leaders to see whether the chapter might nominate you or your colleague for a commission or committee. The AAFP will accept nominations beginning July 1, and the deadline is Oct. 10 -- but now's the time to start considering your national leadership opportunities or those of your peers.
Family physicians serve in many roles -- as clinicians, educators, humanitarians, researchers and leaders -- yet all share the common goal of bridging the gap between individual and community health. So said AAFP Board Chair Richard Roberts, M.D., J.D., of Madison, Wis., April 8 when he delivered the Thomas L. Stern Lectureship during the 2002 Residency Assistance Program Workshop for Faculty and Staff of Family Practice Residencies in Kansas City, Mo.
One need only reflect on the specialty's history, said Roberts, and it's not difficult to understand why FPs are uniquely suited to the task. Specifically, with the birth of medical specialization right around the time of World War II, it started becoming apparent that something was going awry. The concept of the patient as a "whole person" was being subsumed by the concept of the patient as a set of potential disease management opportunities.
Enter family medicine. Enter continuity of care over a lifetime. From there, it became a series of short leaps to expand care for an individual to care for a family -- and then for a community -- and then for an entire population.
This is where FPs find themselves today, according to Roberts. Small wonder that "Americans depend on family doctors like no one else when it comes to health care," he said.
After all, "Who's the expert here?" asked Roberts, noting that, for example, FPs care for more patients with cardiovascular disease than any other specialists. "In my view, it's us," he said.
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Discussing a cancer diagnosis, failed treatment or a
shortened life expectancy with patients is a sensitive and difficult task.
"Cancer: Supporting Patients and Families" has tools and examples of how
to approach these conversations. This video/online CME program is part of
AAFP's Annual Clinical Focus 2002: Cancer. View the video at
http://www.aafp.org/videocme/. AAFP Prescribed credit
is available for $8.
Counseling tools can help you explain to patients the risks and benefits of breast and prostate cancer screening. Open http://www.aafp.org/clinical/tools/ for these guides, or call and request the free counseling tools: #R929 on prostate screening and #R930 on breast cancer screening.
Check out the updated AAFP Patient Stop Smoking Guide with revisions based on the U.S. Public Health Service clinical practice guidelines. The AAFP guide includes information on smoking cessation medications. A package of five brochures costs $10. Order online at https://secure.aafp.org/cgi-bin/catalog.pl?uid=cat100951, or call and request item #R915.
Proven value: Check your mailbox late this month for the Official Program and Registration Materials describing the best CME value for family physicians, the AAFP Scientific Assembly Oct. 16 20 in San Diego. Register by July 24 for the widest choice of courses and a $100 savings on your general registration fee.
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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.
