 July 2002 • Volume 8 • Number 7 |
 The Missouri AFP fully supports AAFP's policy on smallpox vaccination, says FP Mark Mengel, M.D., of Clayton, Mo. |
The good news is that the threat level is probably minimal. The bad news is that there's a threat at all. That was the word coming out of one of four community forums the CDC recently hosted on smallpox and its bioterrorism potential. The June 8 forum here saw ample discussion about the disease, its possible use as a biological weapon, and the appropriate public health response to a probable or confirmed outbreak.
"We want to reiterate that the threat level at this time is not known, but it is thought to be small," said Joel Kuritsky, M.D., director of preparedness and response activity for the CDC's National Immunization Program. "We've talked about a lot of threat scenarios, however, including a self-infected terrorist walking amongst us. One of the big things you consider with bioterrorism is aerosolization of the agent and spread in a high population-density locale, like a subway."
The CDC sponsored the community forums to solicit feedback from health professionals, emergency responders, public health officials and others on the following questions:
Mark Mengel, M.D., chair of the family medicine department at Saint Louis University School of Medicine, highlighted the family physician's role in recognizing, reporting and responding to bioterrorism. Mengel spoke as the representative from the Missouri AFP, giving testimony in line with AAFP's policy on smallpox immunization, issued last month.
"The Missouri Academy will work with state bioterrorism and public health authorities in the identification of potential response team physician members in their role as sentinel physicians, especially in underserved and rural areas," Mengel said.
The Missouri AFP, he said, fully supports the AAFP stance, which embraces the strategy outlined in the 2001 CDC Interim Smallpox Response Plan and Guidelines (available at http://www.cdc.gov/nip/smallpox/). The AAFP policy further advocates "immunization of a limited number of persons predesignated by the appropriate bioterrorism and public health authorities" as "the next step in preparedness."
Go to http://www.aafp.org/immunization/smallpox.html for the full text of the Academy's policy statement.
Views aired at the forum varied widely, with some advocating little or no change from the 2001 CDC recommendations, others pressing for a more liberalized immunization policy, and still others taking a firm stance against universal vaccination. St. Louis resident Elizabeth Boone was definitive in her statement against mass immunization.
"I will not take the vaccine," said Boone. "You'd have to shoot me to get me to take it." What it boils down to, she added, is sharing complete information and allowing people to make their own decisions.
Universal smallpox vaccination is probably not a prudent course at this time, said Richard Clover, M.D., of Louisville, Ky., in a later interview. Clover, a member of the AAFP Commission on Clinical Policies and Research, is one of two AAFP liaisons to the CDC's Advisory Committee on Immunization Practices and has worked with that group to help formulate an appropriate national response plan to the specter of smallpox.
"Given what we know about possible complications associated with administering the vaccine," Clover said, "even with careful screening of candidates, the risks of mass vaccination appear to outweigh the potential benefits for a significant segment of the population. "Especially in the absence of a defined threat," he added.
Additional forums occurred June 6 in San Francisco and New York and June 11 in San Antonio.
The ACIP-National Vaccine Advisory Committee Smallpox Working Group, which advises the CDC, has reviewed feedback from these forums and from other meetings in which the AAFP has participated. At press time, no updates to the CDC guidelines had been announced. Go to http://www.cdc.gov/nip/smallpox/ for the latest information on those guidelines.
 D Ann Travis, M.D., of Fairburn, Ga., checks Bradly Foster's tummy during a routine physical. About 45 percent of Travis' patients, including Bradley, are on Medicaid. |
States facing budget shortfalls, for the most part, have not cut Medicaid programs or limited eligibility. Instead, they have expanded eligibility, eliminated some benefits for patients, and reduced or frozen physician reimbursement rates to cut Medicaid costs. So says a new study from the Urban Institute, a Washington-based policy analysis group.
What does that mean for you?
Most likely you're struggling to care for an increasing number of Medicaid patients, facing declining payments, and spending more and more time documenting patient care rather than treating your patients.
All of the above holds true for D Ann Travis, M.D., a Fairburn, Ga., family physician and member of the AAFP Commission on Education. If a patient visit lasts 15 minutes, she may spend up to an hour filling out diagnostic documents to make sure Medicaid reimburses her properly, she said. She now sees far fewer patients per day than she did only a few years ago.
In Fulton County, where Travis practices, 21 percent of the population receives Medicaid benefits. However, 45 percent of Travis' patients are on Medicaid. The area in which she practices has two distinct income brackets, she said. "There are the rich farmers, and then there are the poor people. There's not much middle ground here, economically." Travis fears that soon she won't have enough time to care for all her Medicaid patients.
Documentation doldrums
"Meticulous documentation slows the day considerably," Travis said. "It's very time-consuming and mentally challenging. The level of explanation required by nonmedical experts who decide the payments makes me feel as though my years of medical training are being ignored."
For example, Travis said a physician begins diagnosing patients when they walk through the door. Recently, after listening to a patient's complaints, checking her throat and confirming her fever, Travis found it obvious that the patient was suffering from strep throat.
"But you can't simply note that on the chart," she said. "You must be extremely detailed. Otherwise, it could adversely affect your reimbursement."
Medication concerns
Physicians are concerned about the future of Medicaid, Travis said, and some patients are concerned about program changes as well. She said her patients complain that Medicaid won't pay for medications they believe they need. Most are brand-name prescription drugs used to treat allergies, coughs, colds and similar conditions.
"Plus, Medicaid tends not to pay for the formulations of a medication that are easier for patients to take," she said. "And since private insurers are following the leads of Medicaid and Medicare, these changes end up affecting your entire patient population."
In Wisconsin, some Medicaid patients are assigned to an HMO for managed care, said Kevin Izard, M.D., a family physician practicing at the Capitol Drive Health Care Center in Milwaukee and a clinical professor at the Medical College of Wisconsin. The HMOs constantly change their lists of covered medications, he said, making it difficult to prescribe. More than 85 percent of Izard's patients receive Medicaid, and many are assigned to HMOs.
"These patients often wait to come in until they are really very sick," he said. "They come in sicker because they are living day to day. And this won't change. For them, medications often are a lower priority than, say, paying the rent."
Variation among states
To date, Georgia's Medicaid program reports that reimbursement rates
have remained steady even though the state's Medicaid budget is declining.
Elsewhere, Medicaid dollars are being stretched thin
to cover new programs
as well as rising enrollment.
Nationwide, Medicaid enrollment is up, according to the Urban Institute's study, "Health Policy for Low-Income People: States' Responses to New Challenges." The declining economy, rising unemployment rates and decreasing family income are cited as reasons for the increase, as well as continued outreach programs designed to expand Medicaid enrollment.
Yet some states have maintained their Medicaid budgets, the study shows. If states reduce Medicaid spending, they lose federal matching funds. For each $1 spent on Medicaid, the federal government gives the state anywhere from $1 to $3.18, depending on that state's matching rate. States also find it difficult to cut elements of their Medicaid programs because of the federal minimum requirements to receive the matching funds.
Examples from three states indicate the extent of the threat to Medicaid.
Most AAFP chapters have listed Medicaid reimbursement in their top three legislative priorities for this year, reports the AAFP Government Relations Division.
Doors still open
Despite the ever-increasing financial burdens caused by compliance with federal and state health care regulations, rising practice costs and the recent decline in Medicare payment rates, Travis said she won't close her practice's doors -- yet.
"No, I'm not going to stop seeing my patients," Travis said. "But when my income stops short of paying my mortgage, then I'll have to look at doing something else."
Medicaid faces "serious problems that will extend well into the future," the Urban Institute's study shows (see story above). So, what could happen? The report says:
When a state's budget shortfall becomes serious enough, the incentive to cut overall spending could outpace the need to maintain all Medicaid programs.
Reduced spending on services for the aging and disabled populations would yield savings but would adversely affect a vulnerable population.
Higher federal matching rates would ease states' financial burdens and increase their incentive to expand coverage to more uninsured people, but the federal budget deficit makes this option a long shot.
With the aging of the population, long-term care costs are projected to increase as well.
In the face of multiple pressures, states could have a hard time maintaining current eligibility levels for Medicaid. Additional initiatives, perhaps at the federal level, may be required to reduce the number of uninsured persons.
An analysis of the Urban Institute's study, posted online May 22 by the journal Health Affairs, is at http://www.healthaffairs.org/WebExclusives/Holahan_Web_Excl_052202.htm.
 Children's toys are commonplace at the Stanley Jackson Clinic, which takes a multidisciplinary approach to treating patients with HIV, as well as their families. |
Sometimes when a person becomes chronically ill, the family gets lost in the health care equation. One clinic is challenging this unfortunate happenstance, though, when it comes to treating families with HIV.
That's right, families.
HIV and AIDS do not affect one person in isolation, says FP Steven Bromer, M.D., director of the Stanley Jackson Clinic at San Francisco General Hospital. The treatment should reflect that, he says. Families are torn apart by news of HIV infection and the realities of living with the disease.
Thought to be the first of its kind, the clinic is named for a longtime patient of Bromer's and "long-term survivor" of HIV who died in 1998. Jackson, Bromer recalls, was a construction worker who helped build the new San Francisco General Hospital and, as a patient, helped train several generations of family practice residents.
A different perspective
The National HIV/AIDS Clinicians' Consultation Center, run by the University of California, San Francisco-Community Health Network Family Practice Residency, started the family clinic a year ago to better meet the needs of those who are shortchanged by the traditional delivery of HIV care. This is not to say that subspecialists are eschewed.
"There will always be a role for (other) specialists because HIV treatment gets complicated," says Bromer. "But a young family has many issues."
One of these issues is disclosure. Here's a typical scenario that brings people to the clinic: A woman, newly pregnant, learns that she is HIV-positive. Suddenly she is struggling with the prospect of disclosing the news to the rest of her family -- and her partner. She's also worried about the potential for peripartum exposure of her newborn. These patients are in need of social help as well as medical expertise.
"We try to counsel patients about if, when and how to disclose," says Bromer. "The ramifications of disclosure may rever- berate through relationships for months or years."
The clinic's multidisciplinary approach to care has much to offer families such as these. The clinic provides nursing; case management; substance use counseling; family therapy; and support from HIV specialists in adult, child and maternity care.
"It's an innovative approach to HIV care," says second-year family practice resident Matt Symkowick, M.D., of the UCSF-CHN Family Practice Residency. And above and beyond the multidisciplinary benefits, the clinic offers a drop-in opportunity for patients on Friday mornings, which has helped Symkowick in managing one of his patients who was referred from San Francisco General Hospital's Family Health Center.
"Subtle" clinic
You won't find any obvious signs that the Stanley Jackson facility is an HIV clinic. "These patients are in the early stages of identifying with being HIV-positive," says Bromer. "They're trying to normalize the experience."
Being able to bring their families to the clinic is part of making the visit as "normal" as possible.
 Staff at the Stanley Jackson Clinic check lab results on a new patient with HIV. Clockwise from top: clinic director Steve Bromer, M.D.; Kirsten Day-Thomas, M.D.; Matt Symkowick, M.D.; and Pat Mitchnick, R.N. |
At the clinic, one physician is assigned to a family, and a concerted effort is made to bring in the whole family. Caregivers' needs are addressed alongside those of the patient with HIV, alongside those of any children.
Another typical care scenario: A parent is diagnosed with HIV, and a grandmother steps in to hold a family together. However, the grandmother herself may be grappling with diabetes or hypertension and may neglect her own care.
Having one physician follow a family is an asset when it comes to ensuring caregivers' health needs are addressed and patients are adhering to antiviral medication regimens, says Bromer.
FP's role in HIV care
In starting this family clinic, Bromer is going against a trend toward subspecialization in the treatment of HIV and AIDS. He would like to see more family physicians think about what role they can play in HIV care.
The family physician can strengthen HIV care by developing a comprehensive family assessment from a family systems perspective, says Bromer. This will help identify the family's strengths and challenges that impact disease management and self-care.
"I had a number of patients whose daughters or sons died of HIV, and I saw the continuing ramifications," said Bromer. "I wanted to better address their needs. I have a strong belief that family physicians are well-suited to take care of families with HIV."
The National HIV/AIDS Clinicians' Consultation Center, which founded the Stanley Jackson Clinic for treating families affected by HIV, has long offered help in the way of HIV/AIDS counseling. The center operates the AAFP-supported National HIV/AIDS Telephone Consultation Service, known as the Warmline, at (800) 933-3413, as well as the National Clinicians' Post-Exposure Prophylaxis Hotline, known as the PEPline, at (888) 448-4911.
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With all the splashy media coverage in recent months about "boutique medicine" -- pricey but personalized care that offers patients 24-hour access to their physicians -- it might come as a surprise to some that plenty of FPs already share their e-mail addresses with patients at no extra charge.
These physicians say the efficiency of e-mail communication holds real advantages for both patient and physician. And those who use it don't want to lose it, despite growing security concerns and federal regulations brought to bear by the Health Insurance Portability and Accountability Act.
Haven't tried e-mailing your patients yet? Note the high marks some AAFP members give this 21st-century mode of communication -- but heed their cautions as well.
"E-mail is a wonderful way to cut down on the extra visits of
capitation patients, and it is a perk for the fee-for-service patient," said
Darlene Lawrence, M.D., of Washington. "I offer all my patients two e-mail
communications a month at no charge." Additional
e-mails are charged at
the same rate as an extended phone call, Lawrence said.
Lawrence built a disclosure statement into the automatic signature line of her office e-mail that addresses the confidentiality, time sensitivity and appropriateness of information that can be discussed electronically. "We tell patients that our e-mail has a 72-hour turnaround time -- and it's not for emergencies," said Lawrence. "My patients know up front that it is not Dr. Lawrence who is opening the e-mail, just as I am not the one to open 'snail mail' in my office."
Sometimes special circumstances make e-mail the best choice. Maj. Leslie Knight, M.D., of Lakenheath, England, has about 15 patients who e-mail her regularly. One patient's disability keeps her voice at a whisper. "I can barely hear the woman on the telephone," said Knight. But via e-mail, "we talk about symptoms, side effects of her medications and changes in dosing."
The key to e-mail communication is to stick to simple questions, said Knight. "We don't get into heavy 'Should I, or shouldn't I?' issues by e-mail, but a question like 'Where do I get a vasectomy?' can be answered in about 30 seconds, and it saves my nurse time on the phone."
Phone time is also an issue with Linda Siy, M.D., of Fort Worth, Texas. Siy practices at a community health center funded by the county, and she and some of her patients prefer e-mail because "it's easier than trying to snake through the county's automated phone system."
A recent example made believers of Siy's office staff. When new parents missed an appointment for a well-baby visit and immunization, the staff tried to contact them, as required by Medicaid. "They (the parents) were in India visiting family," said Siy. "We weren't able to reach them by phone, but they did read their e-mail."
Regardless of exceptional e-mail encounters, serious concerns exist about the security of protected health information and how HIPAA's privacy rule and security rule will affect the use of e-mail in the medical setting.
Jonathan Snider, M.D., of Hopkinton, Mass., understands the security issues and said he is awaiting the final word on HIPAA regulations that "may force me to use encrypted e-mail." For now, he said, "I tell my patients, 'If you're e-mailing from work, don't send me anything you wouldn't want to see in the company newsletter. If you're e-mailing from home, don't send anything you wouldn't want to see in the local newspaper.'"
David Kibbe, M.D., director of health information technology in the AAFP Socioeconomics Division, said physicians using nonsecure e-mail that contains personally identifiable patient information are taking a risk. "There is a risk that the e-mail contents will arrive somewhere and in front of some audience for whom they were not intended," he said."Physicians who engage in e-mail exchanges with patients should exercise caution and follow common-sense policies and procedures that limit the sensitivity of the information and its likelihood of disclosure."
Kibbe added it's going to take some time for medical organizations like the Academy to "provide protocols, policies and guidelines, and set standards we can all live with." (Go to http://www.aafp.org/policy/x134.xml, and scroll down to "Confidentiality" to read the Academy's policy statements on confidentiality issues.)
It's important for the Academy to be proactive regarding this complicated and evolving issue, said Kibbe. "Our status gives us lots of opportunity to define what is reasonable and appropriate, and if we don't, those definitions will be provided by security folks rather than physicians."
Documentation. Jonathan Snider, M.D., of Hopkinton, Mass., sends himself a blind carbon copy of every patient e-mail, prints out what needs to go in the patient record and regularly backs up his e-mail system to guard against computer crashes. "This is the beauty of e-mail. You have a typed verbatim transcription of what actually transpired," he said.
Time. You can easily forward e-mail messages to the appropriate office staff, be it for billing or scheduling. "Those pink slips for messages fall through the cracks," said Snider. Another timesaver is sharing Web resources with patients. "I can e-mail a patient with borderline high cholesterol medically sound and appropriate online links in less than 15 seconds," said Snider.
Patient appeal. E-mail makes patients feel connected with him, said Snider. "They tell me over and over that they feel like I'm always there for them because they can write a note to me, even at three in the morning."
Learn more from these resources about the medicolegal issues associated with e-mail communication between physicians and patients:
Read "Getting a Lock on Patient Confidentiality With E-mail Encryption" at http://www.aafp.org/ fpm/20001000/37gett.html in the online version of the Oct. 2000 Family Practice Management.
Order "Guidelines for Communication With Patients by E-mail" for $5 from the AAFP online catalog at https://secure.aafp.org/cgi-bin/catalog.pl?uid=cat100987 -- or call (800)944-0000 and ask for item # R711.
Think back to last year's flu season. Were you one of the thousands of physicians who had trouble obtaining influenza vaccine early in the season because of widespread vaccine shortages? Well, then it might surprise you to hear that 20 million doses of vaccine went unused during the 2001 2002 flu season. But that's exactly what happened, health officials learned at the National Influenza Vaccine Summit May 22 23 in Atlanta.
Particularly frustrating for health officials, says Herbert Young, M.D., director of the AAFP Scientific Activities Division, is the fact that only about half of persons 65 and older were immunized against flu last year. Young represented the AAFP at the meeting, which was convened by the CDC and AMA to address problems health professionals have faced in acquiring influenza vaccine in a timely manner and at an affordable price.
AAFP's position is that efforts should be strengthened to ensure flu vaccine is available for high-risk patients such as those in nursing homes or with comorbidities, says Young. However, many patients at increased risk do not see themselves as such, according to CDC research presented at the meeting. In particular, the well elderly do not realize the importance of being immunized.
At the meeting, manufacturers presented their plans to ship vaccine to physicians and health care facilities as soon as it is available. Full or partial orders would be shipped at different times, depending on the quantity initially ordered. Manufacturers told meeting participants that their production processes no longer allow vaccine delivery as far in advance as physicians have been accustomed to.
Other key points from the meeting included:
The CDC Advisory Committee on Immunization Practices and the AAFP continue to recommend that high-risk persons and their caregivers be immunized no later than October. All other persons should be immunized in November or later in the flu season.
Additional efforts are needed to urge these persons to get immunized even after October and November. The vaccine is effective two weeks after being given.
The vaccination reimbursement level should be set early on, and this information should be forwarded to intermediaries as soon as it becomes available. The Centers for Medicare & Medicaid Services is working with the CDC and FDA on this issue.
Groups represented at the meeting included medical professional organizations, vaccine manufacturers and distributors, mass immunization providers, occupational health programs, and government agencies.
Chalk up 2001 as
another successful year for AAFP's Annual Clinical Focus program. Results from
pre- and post-intervention surveys gauging the effect of ACF 2001: Asthma,
Allergy and Respiratory Infections indicate that, once again, Academy members
believe they've benefited from the program.
"It would appear from these surveys that family physicians increased their comfort and confidence in managing patients with asthma, allergy and respiratory infections," said ACF Medical Director Stephen Spann, M.D., of Houston.
In April 2001, an initial survey was sent to 2,000 active members, asking them to rate themselves on numerous patient care skills related to the three topics and on their knowledge and application of relevant technical innovations in the clinical setting. Of the 2,000 members, 214 responded. In March 2002, those 214 members were again asked to rate themselves in these areas.
Improvements in knowledge, skills and performance were noted across the board. Members reported, for example, that they gained confidence in their ability to overcome barriers to managing patients with asthma. They also reported improvement in knowing when spirometric testing should be administered. Some respondents noted, in fact, that they now perform this service more frequently in clinical practice.
Surveyed members reported increased confidence in knowing when and how to apply various allergy testing modalities. Likewise, they said enhanced knowledge about environmental allergens allowed them to more effectively counsel patients about minimizing exposure.
Respondents noted increased knowledge of indications for the use of antibiotics for respiratory infections and greater comfort in educating patients about emerging antimicrobial resistance. In their comments, respondents singled out focusing more energy on their overall patient education efforts as a significant area of practice change.
The findings from assessment of 2001's ACF activities are heartening, Spann said, and those activities stand to benefit patients with asthma, allergic disease or respiratory ailments. "Hopefully," he said, "this initiative will result in improvements in the processes of care for patients with these conditions."
AAFP members can now
order the CD-ROM wrap-up of the Academy's Annual Clinical Focus 2001: Asthma,
Allergy and Respiratory Infections -- at no charge!
Call the AAFP order department at (800) 944-0000, supply your member ID number, and ask for item #R591 to receive this compilation of ACF 2001 products and programs. Nonmembers can order the CD-ROM at a cost of $25.
Worried about bringing your practice into compliance with the transactions and code sets standards of the Health Insurance Portability and Accountability Act by the Oct. 16 deadline? You can extend the deadline for a full year, until Oct. 16, 2003. (The deadline for complying with the HIPAA privacy regulations remains April 14, 2003.)
To receive the automatic extension, just submit a form outlining your compliance plan to the Centers for Medicare & Medicaid Services. For more details on filing for an extension and a copy of the form, go to the online version of the May Family Practice Management at http://www.aafp.org/fpm/20020500/52hipa.html and read "HIPAA Compliance: How to Get an Extension," written by David Kibbe, M.D., director of health information technology in the AAFP Socioeconomics Division.
You also can submit your information to CMS using the agency's Web-based form at http://www.cms.gov/hipaa/hipaa2/ascaform.asp -- or you can devise your own format, making sure that the document contains equivalent information. Extension requests must be received electronically or be postmarked by Oct. 15.
If you've been searching the AAFP Web site looking for help understanding the Health Insurance Portability and Accountability Act, check out http://www.aafp.org/hipaa/ -- the Academy's brand-new HIPAA online information site.
The HIPAA home page guides the reader to materials that include sources of basic background information, an implementation section, a list of expert resources and answers to frequently asked questions about HIPAA regulations.
Information on the site is edited by David Kibbe, M.D., director of health information technology in the AAFP Socioeconomics Division.
The Institute of Medicine blew the whistle on medical errors in 1999 in its report, To Err Is Human. Agencies, consumer groups and legislators began asking health care professionals to share information on medical mistakes, a first step to preventing similar errors.
Immediately, physicians began saying yes to fostering patient safety -- but no to revealing errors that might be used against them in court.
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Federal protections would prevent disclosure of
information in civil, criminal or administrative |
Now, Sens. James Jeffords, I-Vt.; Bill Frist, R-Tenn.; John Breaux, D-La.; and Judd Gregg, R-N.H., have honed a patient safety bill that wins on two counts. It would encourage patient safety reporting systems and, at the same time, go far to protect physicians from prosecution based on the information they report.
The Academy has pledged its support for the new Senate bill -- S. 2590, the Patient Safety and Quality Improvement Act. The legislation supports collection of patient safety data, information that does not identify the patient or health professional.
"This legislation would create a system for reporting nonidentified patient safety information that focuses on preventing and correcting system failures and not on assigning individual or organizational blame," AAFP Board Chair Richard Roberts, M.D., J.D., of Madison, Wis., wrote to Jeffords and Frist.
A similar bill, the Patient Safety Improvement Act, H.R. 4889, has been introduced in the House of Representatives by Nancy Johnson, R-Conn. However, H.R. 4889 calls for the protections against disclosure of the patient safety data in court to be coordinated through Medicare, a proposal the Academy opposes. The Senate bill would have the Agency for Healthcare Research and Quality coordinate federal patient safety work, which the AAFP favors.
Nuts and bolts of new system
How would the new reporting system work? Both the Senate and House bills call for the following processes that the AAFP supports:
Information -- classified as privileged and confidential, data not identifying the patient or health professional -- would be voluntarily submitted to patient safety reporting systems.
Federal protections would prevent disclosure of the information in civil, criminal or administrative proceedings unless a judge found that the information met all three of the following criteria: It was material to a case; it was not available from any other source; and releasing the information would be in the public interest.
Patient safety organizations would set up a feedback loop so that those submitting information could learn from mistakes others reported.
"We need to encourage a learning culture to reach the greatest number of patients with improved safety measures," Roberts wrote.
Comments on House bill
In a letter to Johnson, Roberts advised, "The Academy is concerned that the (House) bill amends the Social Security Act and places these protections (against disclosure in court) under Medicare, instead of through AHRQ."
He explained, "Under the (House) bill, primary care physicians without Medicare billing numbers need to go through the Medicare physician billing application process solely for the purpose of obtaining a billing number in order to claim federal protections for reported data. This provision alone is likely to have a chilling effect on reported data."
Roberts added, "The Academy believes that existing error reporting systems have research connections to AHRQ and see this national center for primary care research as the most appropriate place to house patient safety efforts."
If you're reading
this after July 8, you've missed it: preregistration for the National
Conference of Family Practice Residents and Medical Students July 31
Aug. 3 in Kansas City, Mo.
But fear not: You can still register on-site. Slightly more hassle perhaps, but worth it nonetheless. This year's conference promises the usual cadre of educational and networking opportunities, as well as fun and the chance to shape AAFP policy.
And, in a first for the conference, three town hall meetings will focus on issues impacting family medicine and those involved in the discipline. The issues are resident work hours, the addition of a clinical skills exam to the United States Medical Licensing Examination (see stories below) and the Future of Family Medicine project. So firm up those travel plans, and come share your views with your colleagues.
It's 3 a.m.,
you're not even halfway through this shift, and you're already well on your way
to what you and your fellow residents have dubbed a "major exhaustive
episode."
That ratty old couch in the docs' lounge is looking mighty tempting, but -- *%##@! -- there goes your pager. Car meets bridge abutment. Car loses. And you're on your way to the ER.
Been there? Done that? Then perhaps you'd like to share your views on long duty hours with your colleagues at this year's National Conference of Family Practice Residents and Medical Students. You'll have that chance during an Aug. 1 town hall meeting on the topic.
Arguments on each side of the ideological fence have merit and command attention.
Clinical research has shown that lack of sleep impairs both cognitive function and motor skills. A recent study in the journal Nature reported that staying awake for 24 hours results in cognitive deterioration equivalent to that associated with a blood alcohol level of 0.1 percent -- the level at which operating a motor vehicle would be illegal.
At potential risk are not only the patients exhausted residents care for, but also the residents themselves, say members of a coalition lobbying for adoption of H.R. 3236, introduced late last year by Rep. John Conyers, D-Mich. The resolution calls for shorter resident work hours and other work environment changes and is supported by the American Medical Student Association, the Committee of Interns and Residents/Service Employees International Union, and the consumer watchdog group Public Citizen.
But, say others, learning to provide safe and effective patient care despite long hours is a key part of the training experience, and the issue certainly doesn't merit federal intervention.
In a recent e-mail discussion group posting, Robert Bowman, M.D., of the family practice residency at the University of Nebraska, Omaha, pointed out that in light of present fears of domestic terrorism, physicians must be capable of responding to stress with skill and surety. "Disaster drills are good preparation," Bowman said, "but they do not train the body. Call is what trains the body."
And for call to succeed as a training tool, certain factors need to be taken into account, he added. "All of these components need to be present: long hours, responsibility for patients, ability to do things and excellent available supervision.
"We want physicians who can serve. We need training programs that balance hours and training and quality. We need leaders to lead and direct programs. We need residents to be direct and communicate with program directors about conditions."
News flash: The Accreditation Council for Graduate Medical Education's directors last month OK'd proposed requirements on resident duty hours. Your comments are invited; go to http://www.acgme.org to find out how to access the report of the ACGME resident duty hours work group and enter your input by Aug. 1.
If the prospect of adding an additional six or seven hours to the already arduous United States Medical Licensing Examination somehow fails to bring tears of joy and thanksgiving to your eyes, you'll soon have a perfect opportunity to mount your soapbox and say so.
Just don't fool yourself: This thing IS going to happen. It's simply a matter of when, where and how much.
This topic will be addressed at one of three town hall meetings to be held Aug. 1 at the 2002 National Conference of Family Practice Residents and Medical Students in Kansas City, Mo.
Peter Scoles, M.D., NBME senior vice president of assessment, gave a brief recap of the issue:
"A clinical skills exam using hospitalized patients was part of the NBME examination program until 1964, when it was dropped -- with regret -- because of concerns about reliability," said Scoles. Recognizing the value of the clinical skills portion of the exam, the governance of NBME directed staff members to continue to pursue reliable methods of clinical examination.
The 1985 NBME Task Force on Licensure recommendations that led to the current USMLE called for inclusion of a clinical skills examination in the USMLE when such an exam could be shown to be valid and reliable. Since then, the NBME has worked with more than 50 medical schools on clinical skills exams that have been administered to tens of thousands of U.S. medical students.
"We are satisfied with the psychometric characteristics of the examination," said Scoles. "Our current round of field trials is specifically designed to test the logistics of administration of a standardized exam at two fixed test centers."
The exam will most likely consist of a minimum of 10 scored cases, with testing centers designed to permit administration of 12 to 14 cases should continuing research indicate a longer test is preferable. Each "patient encounter" will last about 20 minutes.
Cost for the added testing? Estimates based on costs for similar exams used by the Medical Council of Canada and the Educational Commission for Foreign Medical Graduates run from $750 to $1,200. And that's without travel costs.
Pilot testing in Philadelphia will be wrapped up later this summer, and an Atlanta pilot will begin in the fall. Assuming all goes as planned, the testing program is scheduled to launch in fall 2004.
Taking two hassles by the horns last month, the Academy asked the federal government to ditch the documentation guidelines for evaluation and management services and to lighten the paperwork burden for certifying patients' needs for durable medical equipment.
"Few things frustrate and discourage family physicians more than the E/M documentation guidelines," said AAFP Board Chair Richard Roberts, M.D., J.D., of Madison, Wis., in a June 4 letter to HHS Secretary Tommy Thompson.
The HHS Advisory Committee on Regulatory Reform voted 20 1 May 16 to eliminate the E/M guidelines. Roberts encouraged Thompson to accept the committee's recommendation. The best solution, said Roberts, "would be to develop more clearly defined E/M codes so that documentation guidelines would not be necessary."
HHS -- particularly through the Centers for Medicare & Medicaid Services -- has been studying ways to make it easier for physicians to comply with federal regulations. A new director has been named for the Physicians' Regulatory Issues Team, and Roberts wrote him June 3, targeting the time-consuming completion of certificates of medical necessity for durable medical equipment.
"Historically, CMS allowed DME suppliers to complete the CMN and then forward it to the physician for review and signature," wrote Roberts. "However, in recent years, CMS has increased the burden on physicians who order DME by requiring that they, rather than suppliers, complete most of the CMN."
Roberts noted that having the physician review and sign the CMN, which has always been part of the process, is enough to indicate the physician's responsibility for the document's contents. He called completing the CMN "a pure hassle in that it makes the physician responsible for doing someone else's paperwork."
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