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September 2002 • Volume 8 • Number 9 |
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"This is a massive health care crisis in the making," AAFP President Warren Jones, M.D., of Ridgeland, Miss., said in the July 25 USA Today regarding a key finding of the AAFP's latest practice profile survey. Results of the study, released July 24, show a 28 percent hike in the number of family physicians who no longer take new Medicare patients, compared with the number the previous year.
Bloomberg Newswire ran a story about the survey the same day the results were announced. The following day, USA Today noted the survey findings on the cover of its "Money" section.
The survey, conducted in June 2002, found that 21.7 percent of FPs reported they could no longer take new Medicare patients, a significant increase from the previous year's figure of 17 percent.
The blame lies with low Medicare reimbursement, says Jones. "I've talked to many physicians who tell me that this year's Medicare payment cuts mean they just can't afford to keep their doors open and take more Medicare patients."
Deborah Haynes, M.D., of Wichita, Kan., a past AAFP director, is one FP who had to stop taking new Medicare patients. "The costs associated with treating them are increasing, while our reimbursement continues to go down," she says. "It's sad because these are the patients who need us the most."
The formula used to calculate the physician fee schedule dictated a 5.4 percent reduction in the Medicare conversion rate for physicians in January, and some previous years had cuts as well. The Academy has urged Congress to repeal the formula. It also has called on the Bush administration to make the administrative changes the law gives it the authority to make, to ensure that no senior goes without needed health care.
There's cause for concern, yes, but by keeping patients informed, you can minimize the public health threat posed by the West Nile virus, say health officials.
FPs should work with their local health departments to stay ahead of the epidemic, says family physician Kathleen Toomey, M.D., M.P.H., director of the Georgia Division of Public Health.
"Education is our best approach," she says. "The more we have a fully informed public, the better off we'll be."
The potentially deadly mosquito-borne pathogen can now be found in 36 states and the District of Columbia. Figures compiled at press time by state health departments cite 251 laboratory-positive human cases of West Nile virus-related illness this year alone, including 11 deaths.
Public health authorities warn that the virus is spreading more rapidly than in past years: From 1999 through 2001, 149 cases of virus-related illness in humans were reported, with 18 deaths.
CDC officials and other infectious disease specialists discussed these and other concerns Aug. 8 in a live satellite broadcast, "CD C Responds: Update on West Nile Virus for Clinicians and Labora-torians." The archived Webcast is available for viewing at http://www.phppo.cdc.gov/PHTN/webcast/westnile/.
Faculty for the program included newly named CDC Director Julie Gerberding, M.D., M.P.H., a former acting deputy director of CDC's National Center for Infectious Diseases. Gerberding was joined by other NCID officials and the state health officer of Mississippi, a state where human viral infection has been documented.
The broadcast addressed disease pathogenesis, epidemiology, and clinical and laboratory diagnosis. What's important, CDC officials urge, is to get the message out to patients to use common-sense precautions to avoid mosquito bites, especially during peak activity hours between dusk and dawn. A thorough history is indispensable during office visits from patients concerned about possible exposure, as are reassurances about the rarity of serious illness.
What can physicians do to head off the disease in their own communities?
Plenty, says Toomey.
Physicians can work with their local health departments to ensure that DEET-containing insect repellent is available to persons who can't afford to buy it, says Toomey. Also, she says, physicians can lobby to have public areas kept free of standing water, where the mosquitoes breed. One's own property shouldn't be overlooked either, she adds. Persons who become infected are usually infected by mosquitoes in close proximity to their homes, she adds.
Spraying is the least effective means of controlling West Nile virus, Toomey says, for a number of reasons. It's expensive, it kills beneficial insects, it's ineffective in wooded and foliated areas, and even if spraying kills adults, new mosquitoes will emerge within days, she says.
CDC maintains a comprehensive Web site devoted to the West Nile virus -- go to http://www.cdc.gov/ncidod/dvbid/westnile/ for the latest surveillance, prevention and control information, as well as for answers to frequently asked questions about the virus.
If White House officials don't get it regarding key family practice issues, including Medicare payment, it's not from a lack of effort on the Academy's part.
On July 11, several AAFP officers and staff members met for almost an hour at the White House complex with Rex Cowdry, M.D., consultant to President George W. Bush's Council of Economic Advisers and former acting director of the National Institute of Mental Health.
Title VII. "As I began to talk about the need for consistent funding for Title VII, it became obvious Dr. Cowdry didn't know what Title VII was, so I explained the funding for family practice training," said AAFP President-elect James Martin, M.D., of San Antonio. Cowdry took notes and asked about types of Title VII grants, Martin said.
"I emphasized that Title VII was zeroed out year after year in the president's budget, and Congress always puts it back into the budget," said Martin. "I said I was frustrated we had to spend time and effort each year to encourage Congress to maintain the funding. I suggested the Office of Management and Budget may not understand the need for Title VII. Dr. Cowdry seemed very interested."
AHRQ. AAFP Board Chair Richard Roberts, M.D., J.D., of Madison, Wis., discussed the need for increased funds for the Agency for Healthcare Research and Quality. "Dr. Cowdry found it compelling that the president's budget proposal would cut in half the funds for existing AHRQ grants," said Roberts.
He told Cowdry that a family medicine department with a $1 million grant for a three-year study could hire from 12 to 20 employees. "If your funds were cut in half, you'd dump your data analyst, dump your statistician, hope to complete data collection and then wouldn't have the means to analyze the data," Roberts told Cowdry. "If you did get it analyzed eventually, your conclusions might come too late to have an impact." Roberts said Cowdry understood the devastating effect the proposed drop in funds could have on ongoing research.
The Academy is seeking a 2003 funding level of $390 million for AHRQ, compared with the current $299 million and the president's proposal of $251 million (with about $50 million reserved for patient safety studies).
Medicare fee schedule. Discussing cuts in the conversion factor affecting the Medicare fee schedule, AAFP President Warren Jones, M.D., of Ridgeland, Miss., said to Cowdry, "The U.S. population is dependent on family physicians to meet their primary care needs. If our Medicare reimbursement keeps being cut and we can't accept new patients, who will take care of them?"
Jones said Cowdry, an economist and physician, got the picture about family physicians being distributed across the country -- in rural, urban and suburban areas -- from Robert Graham Center charts.
He encouraged Cowdry to ask the administration to separate evaluation and management services from procedural services when volume controls kick in, penalizing physicians for adding more services in an attempt to gain more reimbursement. "E/M services should not be subject to the same volume controls as other services," Jones suggested to Cowdry. "All physicians do E/M. Most family doctors can't add more E/M; most of us can't add any more patients during our day. But if it's colonoscopies or exercise stress testing, you can add more of those."
The AAFP leaders also said about one in five FPs are not accepting new Medicare patients (see "Crisis builds: More FPs stop taking new Medicare patients"). "Dr. Cowdry's eyebrows went up when we said that," Jones noted.
Other topics. The AAFP contingent also discussed the need to solve the medical liability insurance crisis. "In Mississippi, there's no neurosurgeon north of Jackson, and no family physician delivering babies at the hospital where my wife and I wanted to have our baby delivered," Jones told Cowdry. The consultant to the Council of Economic Advisers commented, "It's in the hands of the states," but Jones countered, "We need uniform standards, so the situation doesn't differ from one state to the next."
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As the meeting was coming to a close, the Academy contingent mentioned that the way to get care to the uninsured is spelled out in the AAFP plan, "Assuring Health Care Coverage for All." Cowdry had read the document last year and asked the group to stay awhile longer to discuss it.
"We were planting seeds," said Roberts of the meeting. "We were having a meaningful discussion about what concerns the administration should address.
"You reach as high as you can reach. This meeting was one step in developing a consultative dialogue that can be critical in shaping policy."
Sure, you could wait until afterward to learn what happened at the AAFP Annual Assembly Oct. 14 20 in San Diego. But why be patient?
Beginning Oct. 17, visit http://www.aafp.org/assembly.xml and click on "FP Report, Assembly Editions" to get the latest news right after it happens. Coverage from the on-site FP Report, Assembly Editions will be posted online the same day the papers are distributed in San Diego. Coverage will include news from the Congress of Delegates and the Scientific Assembly.
Back in the "glory days" of family medicine -- the 1970s -- Michael Worzniak, M.D., of Ann Arbor, Mich., often worked 18-hour days and was on call most weekends in his solo family practice. The schedule was grueling, but the payoff was great: He came to regard his patients as friends and vice versa, he told a lecture audience Aug. 2 at the National Conference of Family Practice Residents and Medical Students in Kansas City, Mo.
FP Susan Jurasek, M.D., of Lincoln Park, Mich., presented herself as the next generation of FPs to attendees at the lecture, titled "Family Physicians in the New Millennium."
In an effort to regain balance in their lives, an increasing number of physicians of Jurasek's generation are refusing to work extended days, carry a pager every weekend, visit inpatients or make house calls, she said. However, the result is an interruption in continuity of care and a breakdown in the doctor-patient relationship, said Jurasek.
Some of these physicians may have self-imposed limits on the scope of their practices during their child-bearing years, intending to resume services such as maternity care later in their careers. The problem with that, said Jurasek, is that skills not used regularly are soon lost.
| The idea is to take advantage of the low overhead afforded by practicing outside an office. |
Margit Chadwell, M.D., of Grosse Pointe Park, Mich., stood by nodding knowingly. She then took the podium to represent the generation of the future and presented a new model for practice, dubbed the "circle of care" model, that makes it easier for physicians to attain the hoped-for balance in their lives. Practices incorporating this design make use of job sharing and mixing part-time and full-time physicians.
The lecture was aimed at students and residents who may be coming to grips with what their careers will look like. However, it had significance for practicing physicians as well. It also offered a sneak preview of Worzniak's and Chadwell's article on the circle of care model in the September Family Practice Management at http://www.aafp.org/fpm/20020900/ .
The idea is to take advantage of the low overhead afforded by practicing outside an office, said Chadwell. A physician has no overhead at all when he or she walks into a hospital or nursing home. A practice that sees patients only in the office spends 60 percent of its income on overhead, while a circle of care practice can reduce its overhead because it won't need as many exam rooms or support staff, Jurasek contended.
In fact, practices that successfully embrace the circle of care model are more profitable than office-limited practices, the lecturers told their audience.
Those in attendance were receptive to the idea. "It's really exciting to hear this. We've struggled with these issues in my practice," said FP Erik Gundersen, M.D., who has a practice in Onalaska, Wis. While he saw potential for the model, he also saw one drawback: "Doctors want that 9-to-5 (schedule)."
Chadwell presented three practice versions that incorporate the circle of care model. They use varying numbers of part- and full-time physicians, but the concept remains the same: While one or more physicians are staffing the office, another physician is in the field visiting that practice's patients in nursing homes, at hospitals or on home visits. The physician in the field rotates regularly to practice in the office. Ideally, more than half of the income is generated outside of the office, said Jurasek.
"This model is more profitable because office-based visits generate the least income," said Chadwell. "Fixed overhead (costs) shift to 47 percent for the low-range model and 40 percent for the high-range model."
"I sound like an economist, not a doctor," she then quipped.
"But it's important," Worzniak replied.
"There is a misunderstanding about how to generate revenue," he said. "Physicians don't always understand the economics of it."
Hormone replacement therapy garnered blistering headlines recently when a major study comparing estrogen/progestin with placebo was halted early because the therapy's risks outweighed and outnumbered its benefits.
Principal findings for this portion of the Women's Health Initiative appeared in the July 17 Journal of the American Medical Association. Immediately, media coverage created a gigantic hot flash for HRT. FPs couldn't help but notice.
What was your experience like that day?
"It must have been on one of the morning talk shows today," wrote Michael Sevilla, M.D., of Salem, Ohio, in a July 16 e-mail to an Academy online discussion group. "I had about five people ask to be taken off of their HRT 'because that stuff kills people.'"
In a follow-up phone interview, Sevilla said he and his office staff always know when the press picks up a health-related story because the patient phone calls start rolling in. "I appreciate the fact that the media create enough interest in a topic to get people into the office to ask questions," said Sevilla. "But it's difficult for physicians to know what patients have seen and heard. Sometimes the media don't report the full story -- or the public picks up on the negative aspect and runs with it."
How is he handling the latest bombardment? The five FPs in Sevilla's medical group concentrate on patient education. "We directed staff to schedule appointments for patients calling in with HRT questions," said Sevilla. "Then we can discuss the issue in depth during the office visit."
FP Mary Elizabeth Roth, M.D., is in a management and teaching position at Sacred Heart Hospital in Allentown, Pa. She said colleagues have asked her opinion about the WHI results. "It's really the physicians who need the reassurance right now," said Roth. "They need to feel secure and knowledgeable about this topic."
| Women should consider which health risks concern them the most. |
In addition, said Roth, FPs are spending more time on HRT during patient visits, time for which they may -- or may not -- receive reimbursement. "You've got to stop in your tracks and try to explain what the headlines mean to your patient," she said.
"FPs are stymied," she added. "All of a sudden, women who automatically renewed their prescriptions every year are hesitating."
How does Roth respond to her colleagues' inquiries? Roth said she emphasizes separating "her" from the "herd."
"A family doc has to focus on the woman sitting in the office," she said, "but the physician also has to know the data about the herd" -- the large population upon which the study was based.
FP Melissa Behringer, M.D., of Huntsville, Ala., agrees. "This new study is important, and it probably should change our way of addressing this issue," Behringer said, "but it is clearly not an all-or-nothing decision."
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Behringer illustrated the importance of considering a patient's family history and unique risk factors. "One of my patients called in a panic, wanting off her estradiol patch," she said. Behringer and the patient went over the patient's history: six breast-fed children, a total abdominal hysterectomy and bilateral salpingo-oophorectomy, a favorable lipid profile, and no family history of vascular disease. However, the patient did have a strong family history of Alzheimer's dementia, colon cancer and osteoporosis. After discussing her options, the woman decided to stay on the patch.
"The increase in deaths in the WHI study were all in areas in which this patient had significant protective factors to begin with," said Behringer.
Sensational headlines can misconstrue the evidence in a study, she continued. "Yes, this kind of patient education is our job, but I don't like having to defend myself and my clinical advice from screaming headlines."
Several FPs said they use absolute numbers when explaining the risks and benefits to patients. "I've told my patients that with the new study, there's an increased risk of about 10 to 20 significant health problems developing in every 10,000 women taking the drugs for a year," said AAFP Director Daniel Van Durme, M.D., of Tampa, Fla. "Keep these risks in perspective."
AAFP Board Chair Richard Roberts, M.D., J.D., of Madison, Wis., counsels women to consider which health risks concern them the most. "If she has seen many close relatives endure colon cancers and colostomies, she may fear that more than she fears the risk of breast cancer," said Roberts.
Editor's note: At press time, two new reviews of research on HRT supported the findings of the halted WHI clinical trial. Go to http://www.ahrq.gov/clinic/3rduspstf/hrt/ to read the reviews on the AHRQ Web site.
There is no single, simple answer for all women regarding HRT," said Barbara Yawn, M.D., of Rochester, Minn., chair of the AAFP's Commission on Clinical Policies and Research. "The Women's Health Initiative study provides important new information that must be added to the existing data." And while the Academy recognizes that FPs need guidance, "we will not rush the process," said Yawn. "Compiling and analyzing this quantity of information takes time."
Over the next few weeks, said Yawn, the commission will review all available information, including the yet-to-be-released evidence report being developed by the U.S. Preventive Services Task Force.
The American College of Obstetricians and Gynecologists is also fielding questions, said Isaac Schiff, M.D., chair of ACOG's HRT task force. The task force was set up in May after the release of preliminary study results, said Schiff. An "urgent" meeting followed on July 25.
Their first goal, said Schiff, is "almost immediate." By Sept. 1, he said, ACOG will issue a statement to its members telling them "under what circumstances it is reasonable to continue to prescribe hormones, and under what circumstances one should consider other medications."
"The second goal is to put the whole subject in perspective," said Schiff. "And that, of course, will have a much longer timeline."
• Resident & Student News •
Providing the best possible health care is all about making the right connections. And it's not always in medical school that you learn to do that.
 America Bracho, M.D., M.P.H. |
So said America Bracho, M.D., M.P.H., Aug. 2 at the National Conference of Family Practice Residents and Medical Students here. Bracho delivered this year's Stephen J. Jackson, M.D., Memorial Lecture.
"Medical schools train us only to use this brain," Bracho said, pointing to where one would normally expect to find said organ. But if that's as far as you take it, she added, "You are blocking your ability to connect, because you don't connect with your brain. You need to connect inside -- you need to connect with the patient and you need to connect with the community."
It's only by using your emotional brain -- your heart -- said Bracho, that you come to understand that there's more to practicing medicine than simply treating patients' health problems. "For you, it might be just that medical condition," she said, "but not for them."
The trick, Bracho said, is interacting with patients in the context of their families and their communities. And to do that, she added, "You have to step out of your box. Go into the neighborhood to see what's going on." Once you have a handle on that part of the picture, you open yourself up to ways to engage patients in their own care.
Bracho has had ample opportunity to practice what she preaches. After years of rural practice in her native Venezuela, she earned her master's degree in public health from the University of Michigan, Detroit, specializing in health education and health behavior. Those experiences formed the backdrop for her founding Latino Health Access, an award-winning, nonprofit community health organization, in 1996.
Santa Ana, Calif.-based LHA uses a "client-driven" approach emphasizing collaboration among physicians, other public health profes- sionals and trained community health workers, or "promotores," who act as catalysts and role models. It's up to the clients to identify community-wide health problems -- alcohol and drug abuse, teenage pregnancy or other issues -- and follow through with meaningful, results-oriented projects often centered on making lifestyle changes.
In this setting, the physician's role is that of coach, team partner and advocate. While this approach may not reflect the proverbial wisdom you learned in medical school, said Bracho, it's what gets the job done. And it only happens when you make the decision to work with patients rather than on them.
"The only reason we don't make that connection is because we feel like we don't have control -- and if there's one thing they teach you in medical school, it's that you have to control," she said. "Let me bring you this truth today: You are not in control."
• Resident & Student News •
How do you coax family practice residents and medical students to learn what they should do in case of a bioterrorist attack? You make it personal.
That's exactly what the presenters of "Bioterrorism: Are You Prepared for Your Role?" did July 31 at the National Conference of Family Practice Residents and Medical Students.
Stephen Markovich, M.D., assistant director at the Riverside Family Practice Residency, Columbus, Ohio, and a former chem/biowarfare specialist for the U.S. Air Force, briefly recapped last fall's anthrax attacks.
"This was real," Markovich said. "This was serious. This affected every hospital in the country and every practicing physician."
Since last October, he said, physicians' interest in bioterrorism preparedness seems to be waning. "I want you to understand the essential importance of bioterrorism," Markovich said. "I want you to have a fundamental understanding of bioterrorism and your role as a family physician."
Part of filling that role is learning to view apparently mundane medical details in a new light, explained co-presenter Mrunal Shah, M.D., also assistant director at the residency program. Shah reviewed the biological agents considered by the CDC as the most likely candidates for weaponization.
FPs must be vigilant for signs and symptoms of the illnesses caused by these pathogens, Shah said, and they must be able to differentiate relatively benign from more sinister disease profiles. "It requires awareness on our part because we're out in the trenches," he said. "We're the ones who are going to see it."
Finally, it was Riverside Family Practice Residency Director Edward Bope, M.D., who "put the pedal to the metal," setting up bioterrorism scenarios both at home and abroad. In each instance, attendees had to consider several topics: patient care, general hospital/clinic operations, communication strategies, security and safety issues, and education and training opportunities.
Group members came up with exhaustive plans to address these areas. Specifics included creating patient triage schemes, establishing communications systems capable of reaching and reassuring the public, instigating measures to safeguard facilities' power supplies and other resources, and developing methods to measure the effectiveness of care teams' response.
Above all, warned Markovich, don't make the mistake of perceiving this as merely an intellectual exercise with no basis in reality.
"We think this is an extremely important workshop," he said. "In fact, if something like this were to happen tomorrow, this might be the most important workshop you ever attend."
• Resident & Student News •
The influence of pop culture on today's medical students and residents was surely on her mind as Denise Rodgers, M.D., delivered the lecture "From Marcus Welby to Beverly Crusher and Beyond" Aug. 3 at the National Conference of Family Practice Residents and Medical Students here.
The talk began with a slide show depicting warm images of residents and patients visiting family practice residencies, with "We Are Family" playing in the background.
But the lecture was about the future. And the past. Because as any history teacher would attest, studying the past is imperative to understanding the future.
And so, Rodgers, associate dean for community health at the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, delved into the infancy of family practice to talk about issues of importance to FPs.
Attendees laughed as she cited the treatment for duodenal ulcers suggested by the March 1970 American Family Physician: a dietary regimen of bland foods and liberal use of antacids. No mention of antibiotic therapy for Helicobacter pylori, the mainstay of ulcer treatment today.
But the mood became serious again. "How do we learn from the mistakes of our past?" she asked.
"We can be sure that 30 years from now, another speaker will give a talk like this, outlining the mistakes we make daily in our practices," she said, reminding the audience of the equivocal findings on hormone replacement therapy that currently dominate headlines.
She touched on other issues of importance to family physicians, such as health disparities and lack of a plan for national health care coverage for all.
Regarding racial health disparities, she again employed humor to make her point: Health disparities in the future will look like this, she said, showing a slide of otherworldly creatures from Star Trek.
But poignancy pervaded the discussion. African-Americans are less likely than whites to get heart and kidney transplants, coronary artery bypass grafts and coronary angiography, adequate pain control and curative cancer surgery, she said.
And no discussion on disparities would be complete without looking at the context in which they occur, she said, citing that 40 million Americans are uninsured.
"We must remember that good health is the foundation upon which we build good lives," she said.
• Resident & Student News •
 Beverly Aist, M.D., of the CHRISTUS Santa Rosa Family Practice Residency in San Antonio talks with AAFP Board Chair Richard Roberts, M.D., J.D., during resident congress proceedings. |
 Paul Watts, D.O., of the John Peter Smith Residency in Fort Worth, Texas, testifies at a resident reference committee hearing about extending benefits to residents' domestic partners. |
 Nearly 50 National Conference attendees get a jump on the day with an early morning yoga session. |
• Resident & Student News •
On Aug. 3, delegates to the National Congress of Family Practice Residents and National Congress of Student Members elected the following representatives for the coming year:
 Coffey |
 Carey |
 Carter |
 Sinar |
Nearly 60 resolutions were considered in the congresses this year. Here are a few of those actions, with the source listed for each.
The congresses asked AAFP to do the following:
For AAFP's first patient safety study in 2000, 42 family physicians in AAFP's national research network agreed to record 10 errors they observed in their practices during a three-month period. What they gave was information on practice mistakes. But what they got in return was invaluable: the knowledge of where change was needed.
"I remember being horrified that I had the 10 errors within about two days' time," recalls Diane Madlon-Kay, M.D., of Minneapolis. "Almost all the mistakes had to do with lab errors -- reports came back to me quite late, and some lab results were abnormal."
The study asked FPs to report errors that made them think, "That should not happen in my practice," even if the patients were not harmed by the errors. No patients were injured by the mistakes Madlon-Kay reported. But patients could have been harmed from the delays. "I knew the late reports were something I had to do something about. Sometimes the reports were coming to me a month late," she says.
Now the lab makes it a priority to get reports back to physicians soon, says Madlon-Kay. If reports stack up, staff are pulled from other projects to handle the work or overtime is paid. Also, lab analyses are recorded on the computer. "Safety will increase as we rely less on pieces of paper," says Madlon-Kay.
Another family physician in the U.S. study agrees. "I tend to print out most of my prescriptions now, and they're readable!" says Wayne Reynolds, D.O., of Gloucester Point, Va. The shift toward electronic medical records was already under way in his practice when he participated in the patient safety study.
"The EMR lets us easily track the use of substances people might be taking advantage of, such as sleeping aids -- controlled drugs," adds Reynolds. "The electronic record allows us to track refills. Also, at each patient visit, I can call up the patient's medicine on the screen and ask, 'Do you need a refill?' The system reinforces compliance."
Not that the EMR system is foolproof. "I also keep a paper copy of each patient record," says Reynolds. "The EMR system occasionally goes down, and some correspondence still comes to us from labs or other facilities that are not yet linked to us electronically."
Since 2000, besides implementing an EMR system and checking medications at every patient visit, Reynolds' practice has taken two other steps on behalf of patient safety: watching X-ray and lab reports more closely and tracking phone messages carefully.
A third FP who participated in the 2000 study, Kim Krohn, M.D., of Minot, N.D., says she is more aware of errors and other patient safety issues as a result of participating in the study. "I am also more aware that patient safety is not an interest of many people," she says. "They prefer the bury-the-head-in-the-sand approach."
| Consider joining AAFP's national research network and participating in future projects of the new AAFP Center for Evaluation and Research in Patient Safety in Primary Care. To learn about the network and the center, contact Debbie Graham, M.S.P.H., at dgraham@aafp.org or (800) 274-2237, Ext. 3176. |
Krohn noticed that the 300-resident nursing home in Minot had changed its medication lists in such a way that the lists were, she says, impossible to interpret. When physicians made rounds, they checked the lists and made mistakes changing dosages -- simply because the lists were hard to understand.
Krohn wrote the director of nursing about the problem, sent a copy to the administrator and medical director, and got the format of the lists changed.
"Had I not been interested in patient safety as a system problem, I would have accepted the situation and tried to deal with it," says Krohn.
"At least 30 physicians have patients in this nursing home, and I was the only one who pressed the administration to make the change," she says. "Physicians get frustrated because many things are out of their control. The medication lists are a good example of physicians accepting a bad situation without trying to fix it."
To help boost the patient safety quotient in your office, check out the resources listed below.
Resources
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Tiffany Sever from Westland, Mich., poses with her winning poster. Officials of the Academy's Tar Wars® program, which discourages tobacco use among youth, honored Sever and other poster artists during an awards ceremony July 23 in Washington, D.C. |
Should there be national immunization registries so that patients' immunization records could easily be tapped by health professionals across the country? Should drug companies standardize their applications for discounted pharmaceuticals for low-income patients? Should co-parent or second-parent adoption be allowed in families of same-sex couples? Should the Academy oppose unfunded mandates for translators for patients with limited English proficiency?
These are just some of the issues the Congress of Delegates will consider Oct. 14 16 in San Diego.
Go to http://members.aafp.org/members/x10518.xml to see the resolutions already submitted to the Congress. In addition, the Congress will take action on reports and recommendations from the Board of Directors, AAFP officers, and commissions and committees.
Family doctors in six countries agree: Most medical mistakes are process errors. In the first international study of patient safety in primary care, only about one-fifth of the errors come from a lack of knowledge and skills.
And those failures, all reported by FPs and GPs, are attributable to physicians, nurses, pharmacists, receptionists -- almost anyone in health care.
"The results of the international study were very similar to those of the U.S. study done in 2000," says Susan Dovey, analyst at the Robert Graham Center in Washington. Dovey coordinated both studies.
"Some people have asked us not to focus on the 21 percent of errors related to knowledge and skill, because that might feed into the 'name/blame/shame' culture we want to get away from. That culture prevents physicians from being willing to report errors," says Dovey. "But the physicians' own reports indicate a mix of process errors and shortfalls in knowledge and skills. If we were politically correct and just concentrated on systems errors, we wouldn't be right."
Besides, she adds, the knowledge and skills mistakes have implications for education, including CME and education for administrative staff. Dovey suggests health professionals need to learn they can make changes -- things they know are wrong can be reversed. One physician in the international study commented on "overcoming learned helplessness."
See the graph below for the types and numbers of errors 80 physicians reported from the United States, Australia, Canada, England, the Netherlands and New Zealand -- developed countries with similar primary health care systems.
Some reflections from U.S. physicians in the international study:
"Big problems grow from small-acorn errors."
"Errors in communication frequently set the scene for more complex errors."
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Examples of mistakes the physicians from the six countries reported:
Flow charts for vaccinations sometimes have more spaces for vaccination dates to be recorded than the vaccination recommendations call for. In several instances, a child received an extra vaccination because of the flow chart error. "Immunization guidelines change frequently," says Dovey. "This area needs attention."
Physicians said different doctors had prescribed contraindicated drugs for a given patient. "Continuity of care is emerging as a really important issue in protecting patients from harm," says Dovey.
The physical structures of doctors' offices may threaten patient safety. Two physicians reported that patients fell and suffered injuries from the hard tile floor. "We're dealing with vulnerable patients, many of them elderly, in these environments," says Dovey, noting that a carpet might have minimized the injury.
Mistakes in diagnostic test reports were mentioned by many physicians. Sometimes lab tests that should have been done with fresh blood were done late, often after a weekend. The physicians realized the lab results were skewed, and the patients were not harmed by the faulty reports. Another problem was incorrect transcription. For instance, a pathologist might dictate the report on the biopsy of a mole as "Margins unclear." The transcriber might hear, "Margins clear." "Several physicians in the study said they rely too much on tests," says Dovey. "They recognized their instincts are also valid!"
In country after country, physicians said they needed more linguists. "People who get into medical school in most of these countries speak English," says Dovey, noting that Australia, the United States and England have many immigrants who do not speak English. There are not enough health care workers from other countries. Physicians also often commented on needing more nurses.
The physicians said they needed "more time, more staff, more computers," says Dovey.
She credits error-reporting systems with giving physicians a means of self-reflection. "Our studies offer head space for doctors to think about improving systems -- we offer thinking room," she says.
See the resources box for the citation of the international study, as well as other patient safety materials.
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The Annals of Family Medicine, a peer-reviewed journal set to debut in 2003, is two steps closer to becoming a publishing reality: It is now accepting manuscripts and soliciting reviewers.
The journal will publish original research, methodology, theory and essays. Annals' goal is to support a learning community for those interested in generalist health care. The journal will seek to identify and address important questions in health and the provision of patient-centered, prioritized, high-quality health care.
And, because the quality of the journal is dependent upon having highly qualified reviewers, the editorial team is also encouraging those wishing to serve as reviewers to register now.
All materials should be submitted electronically to the journal's Web site, http://www.annfammed.org/ . Prospective writers can find instructions for authors at this site.
On its Web site, Annals declares its mission statement: "To mirror the opportunities, complexities and paradoxes of generalist practice, the Annals will reflect breadth and depth, process and outcomes, the general and the personal, the practical and the theoretical."
The Annals, which will be published six times a year, is a collaborative effort of the AAFP and five other organizations. It is managed by an independent board of directors with representation from each of the six organizations.
With a letter addressed to members of "the Family Medicine Community," Journal of Family Practice Editor Mark Ebell, M.D., M.S., in July announced that starting in January, JFP will no longer publish original research.
Ebell said that flat readership and an increasingly competitive market for advertising were among several factors that led to the publisher's decision.
"While personally disappointing to me, this was a business decision by the publisher," said Ebell, associate professor of family practice at Michigan State University, East Lansing. "To some extent, it is a reflection of a broader problem in our specialty: As researchers, we have to do a better job of addressing the needs of the clinicians in our field, and as clinicians, we have to learn to place a higher value on original research done by fellow family physicians and family practice researchers. Unfortunately, we were unable to increase readership to an extent satisfactory to the publisher with research as our predominant theme."
Ebell said he would dedicate himself to repurposing the journal with an emphasis on an evidence-based approach to primary care. As such, to fill the void left by the absence of articles on original research, JFP will publish more POEMs (Patient-Oriented Evidence that Matters), Clinical Inquiries, Applied Evidence review articles and other features.
Despite the setback, this development does not sound a death knell for research articles in primary care journals: The Annals of Family Medicine, set to begin publishing in Spring 2003, began accepting research manuscripts last month (see story "Annals seeks manuscripts, reviewers").
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A new tool to help you select practice management software is now available. Go to http://www.aafp.org/techguide.xml to check out the AAFP/Microsoft Technology Guide: Practice Management Software. Practice management systems available from nine vendors were evaluated over a two-year period in this collaborative effort of the AAFP and Microsoft®Corp. A link to install the free Adobe®Acrobat® Reader®, required to view the guide, is available at the site. |
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The Academy's Management of Maternity Care program has new additions, including a Spanish addendum (#R1703) available later this month. Check out the updated patient education resource list, which now features direct Internet links, some with Spanish translations. Go to http://www.aafp.org/momcare.xml to download the program guide (including a list of patient education resources) and to order prenatal documentation forms (#R704), $49 for a pack of 25. |
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Check out these new AAFP Proficiency Testing program products: a "urine sediment only" photo package for $99, CO LA's Lab Facts to aid in the interpretation of regulatory information for $75 and COLA's Laboratory Director On-Line Program for $450. Visit http://www.aafp.org/pt.xml to order online or call (800) 274-7911 for more information. |
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A shipping fee may apply; Kansas residents pay a 7.275 percent tax. |
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FP Report is published by the
AAFP News Department.
Copyright © 2002 by
American Academy of Family Physicians.
