 November 2002 • Volume 8 • Number 11 |
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Mosquitoes can kill. Ted Epperly, M.D., chair and program director of the Family Practice Residency of Idaho in Boise, wants people to know this.
Just as events of Sept. 11 have alerted people to the possibility of bioterrorism, the recent outbreaks of West Nile virus should be waking people up to the dangers of mosquitoes.
Many people attending Epperly's lecture during the AAFP Scientific Assembly Oct. 16 20 in San Diego were keenly aware of this. By a show of hands, about 25 attendees had already seen a case of this rapidly spreading disease in their own practices.
"The point is, this has become a permanent problem. This is here to stay," said Epperly.
Epperly noted that West Nile virus is a disease of birds; human beings are merely incidental targets. The disease is spread by mosquitoes that prey on birds as well as people. A spill-off to humans occurs after vast numbers of birds in a given area are infected, explaining why human infection peaks in late summer and early fall.
From whence did it come?
 Ted Epperly, M.D. |
It's found widely in the Eastern Hemisphere, having been first identified along the West Nile of Uganda in 1937, said Epperly.
No one knows for sure how West Nile virus came to the Western Hemisphere. Veterinarians in 1999 were the first to notice a mysterious illness that was afflicting crows in New York City. Not long after, five elderly persons, all living within a two-mile radius, became ill with profound muscle weakness and aseptic meningitis, and physicians were confounded. Serum from the afflicted birds was tested on the patients to confirm the virus.
Since then, it has spread rapidly, and now the most common states for human cases are Illinois, Michigan, Ohio, Louisiana and Mississippi. This geographical trend proves the pattern of the disease, said Epperly: It follows the migratory traffic of birds. These states are along what is known as the Mississippi Flyway, although East Coast states along the Atlantic Flyway are not spared.
More bad news: Despite dormancy, overwintering mosquitoes maintain the virus until spring. We can expect the trend to pick up where it left off as soon as the vectors become active again, said Epperly.
Things to know
West Nile is from the Flaviviridae family of viruses, which includes hepatitis C virus, and is of the same genus as dengue and yellow fever. Epperly predicted that West Nile will soon have the dubious distinction of being the most common viral encephalitis in the United States.
Risk factors include advanced age and immunosuppression. Up to 80 percent of those with the virus are asymptomatic. A high index of suspicion should be maintained regarding the patient presenting with muscle weakness, fever and headache in late summer or early fall.
Diagnosis is made by ELISA of serum or cerebrospinal fluid. State health departments will run the tests free of charge, said Epperly.
Treatment has included empiric treatment with ceftriaxone, ampicillin and acyclovir for culture-negative meningitis. Other drugs have shown no clear evidence of improvement, Epperly noted. Thus, prevention makes most sense.
The fact that the initial victims in New York lived in close proximity bears out the theory that the vectors of West Nile virus don't fly far, said Epperly. People should be vigilant to keep their property clear of standing water, where eggs are laid, and to wear long sleeves and long pants at dusk and dawn.
Epperly encourages physicians to stay current on West Nile developments. The CDC maintains a site, http://www.cdc.gov/ncidod/dvbid/westnile/index.htm, that is an excellent resource, said Epperly.
No holds barred. The AAFP Congress of Delegates wrestled with the nation's medical liability insurance crisis during the delegates' meeting Oct. 14 16 in San Diego.
What's it mean to have high jury awards and high liability insurance premiums? For answers, try these comments to a reference committee Tuesday:
Grassroots action
Some testifying to the reference committee swapped ideas on steps to take to overcome the liability insurance crisis:
Resolutions
The delegates considered asking the Academy to form its own national program for liability coverage.
"I don't think the Academy's role is to be an insurance company," said Pamela Kushner, M.D., of Long Beach, Calif., a member of the Commission on Membership and Member Services. "In the 1980s, I was on the AAFP Professional Liability Committee, and the same issue came up, and we decided against it."
On Wednesday, the delegates voted against having the AAFP provide liability coverage. They did ask the Academy to:
 "It's exciting to hear the energy in this room!" says resident Jay Lee, M.D., at a meeting on the Future of Family Medicine project. |
Family physicians peppered AAFP leaders with questions and comments at the town hall meeting on the Future of Family Medicine project during the Assembly. The project, begun in 2000 by seven family practice organizations, aims to develop a strategy to transform and renew the specialty.
"We want to make it a joy again to practice family medicine," said (then) AAFP President-elect James Martin, M.D., of San Antonio. "Still trying to do my coding at 8:30 at night is not joy."
He boiled down the project's questions to three: What's the role of the family doctor today? What can we do different in the future to meet the needs of people and society? How do we grow the discipline?
Martin breezed through early survey results, mining focus group discussions and partial data from more than 1,000 interviews with, for example, family physicians, general internists, subspecialists, third-party payers and patients.
"Contrary to most family physicians' beliefs, most subspecialists believe in the importance of family practice," Martin said.
Another result: Seventy-four percent of the general population surveyed said they were extremely or very familiar with family physicians' work. Only 32 percent said they were that familiar with internists' work.
"There's strong correlation between what family physicians do and what patients want," said Martin. "The survey data indicate that if you have a real serious problem, internal medicine might be better. But if you have a bunch of serious problems, see a family doctor."
"I can outdo the endocrinologists with my data," said Linda Stogner, M.D., of Estancia, N.M. "Our clinic maintains a diabetic patient registry, and I can pull up aggregate data at any moment for the hemoglobin A1c, blood pressure and lipid levels for our 130 diabetic patients. I know if I'm making a difference in the HgA1c in my community."
"You go, girl!" said (then) Board Chair Richard Roberts, M.D., J.D., of Madison, Wis. "You're going to teach us how to do this!"
Five FFM task forces will analyze the survey results and study the value of the specialty's core values in a changing environment: continuity, comprehensiveness, being patients' first contact in the health care system, and caring for patients in the context of family and community.
Resident Jay Lee, M.D., of Long Beach, Calif., commented, "The core attributes you're talking about -- they're why I went to medical school, but I didn't hear about them in medical school. I fell on them accidentally, at meetings with student leaders from other parts of the country. There needs to be more outreach to medical students."
(Then) AAFP President Warren Jones, M.D., of Ridgeland, Miss., replied, "Ssssh! Don't tell anyone we're here! We're America's best-kept secret! In our residencies, we're building total-potential cells -- you can go into a rural area or a city and do the work. We've got to come up with ways to make some changes and also address financial issues for our family doctors."
Check FFM's Web site, http://www.futurefamilymed.org, for updates on the project, and next spring, when more materials will be posted, submit your comments.
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The label "growing pains" is commonly used to explain many musculoskeletal aches in children, but it might mistakenly be applied to far more significant problems. Children with joint infection, structural abnormalities, neuromuscular disease and even neoplasia might first be seen by a family physician for vague bone-pain complaints that don't respond to over-the-counter painkillers.
"Conditions such as developmental dysplasia of the hip are often missed, chalked up to growing pains or muscle pain from fever associated with influenza," said Kenneth Taylor, M.D., co-presenter in the clinical seminar "Children's Potpourri: Commonly Missed Musculoskeletal Problems in Children" on Oct. 16, during the Assembly. Taylor is clinical instructor of family medicine at the University of California, San Diego, and co-director of sports medicine there.
A missed diagnosis of developmental dysplasia of the hip is the fourth-leading cause of malpractice suits in the care of children, said co-presenter Suraj Achar, M.D., clinical instructor of family medicine at UCSD and assistant director of sports medicine.
In his presentation, Achar said children with musculoskeletal complaints are often seen by family physicians rather in than the emergency department if there is no acute or traumatic injury.
"A child with osteochondritis dissecans might come into the office with mild pain in the knee, a little bit of limping, minimal effusion or swelling," Achar said.
Achar's take-home points were:
The primary differential is pain, Achar said. In musculoskeletal complaints, it might be due to infection, inflammatory disorders, trauma, neoplasia or hip disease.
And don't forget child abuse, he advised.
Onset of pain might be delayed, so that is not always helpful, Achar said, and a history of trauma can be misleading if child abuse is involved.
Location of pain can also be misleading since this type of pain can be referred.
"Knee and thigh pain is often from the hip," Achar said.
A plain X-ray series is suitable for diagnosing most cases of limp or trauma, Achar said, though he recommended getting at least two views, 90 degrees apart.
Achar said a positive joint exam, which finds swelling, limited range of motion, warmth, tenderness or erythema, will help rule out growing pains.
"Tylenol® takes care of growing pains," Achar said. "And growing pains are bilateral or symmetrical, not focal or unilateral, and they usually hurt at night but don't interfere with daytime activities."
An orthopedic disorder should be suspected if the patient has a positive joint exam but a normal temperature and a normal erythrocyte sedimentation rate, Achar said.
In his presentation, Taylor said physicians should think about physeal injuries before ligament injuries in the older child playing sports. Ligaments are tough by that age, while growth plates are still weak, he said.
Some conditions such as slipped capital femoral epiphysis will require surgery, but Seaver's disease, Little League Elbow, and Salter-Harris type-I and typeII fractures could heal with just a few weeks' rest, Taylor said. "If you catch these early, the kids can get back to sports very quickly."
 Philip Howard, J.D., urges family physicians to get involved in changing America's "lawsuit culture." |
It's a topic that strikes a chord with FPs and patients alike: America's "lawsuit culture." Patients are the biggest losers in this climate of justice run amok, said keynote speaker and attorney Philip Howard, J.D., during the AAFP Scientific Assembly Oct. 16 20 in San Diego. However, those who deliver health care are harmed as well.
Fear of the legal system has physicians hamstrung, Howard said.
"Because they distrust justice, physicians no longer feel free to act out their
best
judgment."
It's time to question long-held assumptions about the legal system and our rights as citizens, said Howard. The perceived "right" to sue, in particular, Howard finds troubling.
Howard is author of The Death of Common Sense and The Collapse of the Common Good and is chair of Common Good, a new bipartisan coalition dedicated to overhauling America's lawsuit culture.
Common Good is proposing a radical departure from the status quo, he said. "The only way to restore health to health care, we believe, is to establish an entirely new system of medical justice that affirmatively protects reasonable judgment as well as provides a mechanism for accountability for errors."
What the coalition has found has been startling: Most physicians distrust the justice system.
Thus, instead of practicing good medicine, physicians practice defensive medicine, said Howard. In a nationwide survey of medical professionals, many physicians admitted to ordering unnecessary tests, making unnecessary referrals and prescribing unnecessary drugs, all citing legal fear, said Howard.
Courts have proved unpredictable. The practice of medicine in the 21st century is complicated, but judgments are decided by lay judges and lay courts. "No one has any idea what a court will do," said Howard. "We've lost the protection of law."
Enter into the fray the public's naivete. People often do not understand that the cost of large jury awards is passed on to the population at large through increased insurance premiums.
During a question-and-answer session, an attendee asked how to neutralize the influence of wealthy trial lawyers. "Trial lawyers have made millions of dollars but have done nothing to add to the growth of America. They're robbers," Howard said simply. He told FPs that they should not underestimate their own credibility. "The power of ideas is much stronger than the power of money," he said.
Another asked his views on tort reform. Tort reformers focus on setting caps on jury awards, missing the point that the problem originates with the right to sue, Howard said.
Howard urged attendees to get their patients involved and to write down their own personal accounts of how their lives have changed as a result of the legal system. Common Good has a Web site -- http://ourcommongood.com -- set up for people to give feedback.
And in a gesture of reciprocity, AAFP President James Martin, M.D., of San Antonio addressed a special conference held by Common Good, the organization chaired by Howard. Martin spoke to that group Oct. 29 to describe how the medical liability crisis has touched him.
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HIPAA is analogous to eating spinach -- it's not something you get excited about," said David C. Kibbe, M.D., in his Oct. 16 Scientific Assembly presentation, "Pathways to HIPAA for Medical Practices: What You Need to Know."
Kibbe, director of health information technology at the AAFP, is a HIPAA expert -- and he knows that the Health Insurance Portability and Accountability Act is serious business to doctors. "After Oct. 16, 2003, Medicare won't accept paper claims, and so if you want to get paid, you need to know a little about this," Kibbe told a packed house.
The first few minutes of the presentation were devoted to HIPAA's history, as Kibbe defined terms and cleared up misconceptions. Avoiding HIPAA by forgoing technology in your practice is one commonly misunderstood area. "Going strictly paper won't help if you have any outside agents that transmit any of your data electronically," said Kibbe.
Kibbe was eager to pump physicians up about the plus side of the HIPAA standards. "The Transactions and Code Sets Standards are the largest computer conversion exercise in the history of the world," said Kibbe. "It's in the best interest of everyone to go 100 percent electronic."
Then he explained why.
Implementing the standards could save you money, said Kibbe, explaining that it currently costs the health care industry 300 to 500 times more than the banking industry to electronically transact a file. "Physicians pay for that because the insurance companies pick up the high transaction costs -- and then turn around and pay you less," he said.
The uniform standards that HIPAA will bring mean physicians will be able to transmit information more efficiently and less expensively, Kibbe added.
Kibbe said HIPAA has the potential to give providers a tremendous amount of power. "You'll be able to send tomorrow's patients' eligibility requirements to the payer today," said Kibbe. "So when the patient comes into your office tomorrow, you'll already know what the payer will cover and you'll already know the co-pay."
Just imagine this, continued Kibbe. When the standards are fully implemented, health plans must respond to physicians' requests for information in real time -- 60 seconds or less.
A murmur passed through the audience.
There's more good news, insisted Kibbe. Electronic transactions will ensure cleaner claims and fewer rejections. Currently, Kibbe said, 5 percent to 10 percent of claims are rejected by the payer because of data entry errors. Electronic transactions should cut that number considerably.
Kibbe covered the HIPAA privacy rule last, and he answered question after question with calm reassurance. He eased physicians' fears about "HIPAA police," presumably out searching for doctors not in compliance.
He closed by describing a new health care world, "where patients are going to understand their rights."
The media will play this issue up big, predicted Kibbe. "I think patients will be coming in and asking, 'Where is your privacy form?' -- because Connie Chung will be talking about this, and Oprah will be talking about this," he said.
Michael Fleming, M.D., of Shreveport, La., was chosen as AAFP president-elect by the Congress of Delegates during its meeting Oct. 14 -- 16 in San Diego. Others elected or chosen by acclamation for the following positions are:
Speaker -- Carolyn Lopez, M.D., of Chicago, first woman speaker of the Congress of Delegates;
Vice speaker -- Thomas Weida, M.D., of Hershey, Pa.;
Directors -- Rick Kellerman, M.D., of Wichita, Kan.; John Sattenspiel, M.D., of Salem, Ore.; and Mary Jo Welker, M.D., of Columbus, Ohio;
New physician Board member -- Cynthia Romero, M.D., of Virginia Beach, Va., first to hold this new seat on the Board;
Resident Board member -- Michael Coffey, M.D., of Somerville, Mass.;
Student Board member -- Marc Carey, Ph.D., of Portland, Ore.;
Finalists for AAFP position on the board of directors of the American Board of Family Practice -- Douglas Campos-Outcalt, M.D., of Phoenix; Alain Montegut, M.D., of Brunswick, Maine; and David Price, M.D., of Broomfield, Colo. (the ABFP board will choose one finalist next spring to serve on the board for five years); and
AAFP delegates to the AMA -- Patrick Harr, M.D., of Maryville, Mo.; Edward Langston, M.D., of Lafayette, Ind.; Jerry Martin, M.D., of Bowling Green, Ky.; Mary Elizabeth Roth, M.D., of Allentown, Pa.; Colette Willins, M.D., of Westlake, Ohio; and Joseph Zebley, M.D., of Baltimore.
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President
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President-elect
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Board chair
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Speaker
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Vice speaker
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Executive vice president
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 James Martin, M.D. San Antonio |
 Michael Fleming, M.D. Shreveport, La. |
 Warren Jones, M.D. Ridgeland, Miss. |
 Carolyn Lopez, M.D. Chicago |
 Thomas Weida, M.D. Hershey, Pa. |
 Douglas Henley, M.D. Leawood, Kan. |
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Directors
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 Nancy Wilson Ashbach, M.D. Loveland, Colo. |
 Mary Frank, M.D. Mill Valley, Calif. |
 Richard Wherry, M.D. Dahlonega, Ga. |
 Arlene Brown, M.D. Ruidoso, N.M. |
 Larry Fields, M.D. Ashland, Ky. |
 Daniel Heinemann, M.D. Canton, S.D. |
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Directors
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New physician director
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Resident director
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Student director
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 Rick Kellerman, M.D. Wichita, Kan. |
 John Sattenspiel, M.D. Salem, Ore. |
 Mary Jo Welker, M.D. Columbus, Ohio |
 Cynthia Romero, M.D. Virginia Beach, Va. |
 Michael Coffey, M.D. Somerville, Mass. |
 Mark Carey, Ph.D. Portland, Ore. |
Every year, the Academy bestows honors and awards on its members and others during the Annual Assembly. This year, the following awards were presented:
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Many family physicians attending the Scientific Assembly lecture "The Reality of Bioterrorism" Oct. 18 were there to learn how to better answer the questions they have been inundated with since last year's anthrax attacks.
"All we can do is educate those around us," said Raymond Weinstein, M.D., of Dale City, Va., the bioterrorism expert who delivered the course.
But one attendee, Lee Carter, M.D., of Scottsville, Ky., was taking the three-hour course because he has suddenly found himself on the front lines of the war on bioterrorism. Because of his certification in emergency medicine, Carter was selected by his county leadership to receive and select other medical personnel to receive vaccinia -- the vaccine used to protect against smallpox.
Such a task is not to be taken lightly. According to Weinstein, vaccinia is the most dangerous vaccine there is. There is danger not only to the person inoculated, but also to all others coming in contact with that person. Any patient who's immunocompromised or has eczema is at risk of harm from vaccinia, said Weinstein. Those inoculated must be confined for three weeks.
"My personal feeling is, if there are no cases of smallpox reported, my family is not getting the vaccine," said Weinstein.
But smallpox is just one of many agents that can be used in an attack, said Weinstein, chair of the Greater Prince William Chem-Bio Counterterrorism Committee and consultant to the Department of Defense and the Army Medical Command.
Biological weapons can be an efficient way to wreak havoc on society, said Weinstein. Terrorists look for agents that are cheap to produce, easy to weaponize and highly contagious and that have a short incubation period. It's also advantageous for an agent to have "brand-name" recognition, that is, diseases with names that strike fear -- smallpox, anthrax, botulinum, plague and Hantavirus, to name a few.
The use of biological weapons can be traced back as far as the sixth century B.C., said Weinstein, when Assyrians poisoned enemy wells with fungus. Fast forward a couple millennia, when smallpox was spread to Native Americans via infected blankets bestowed by the English in the 1760s.
More recently, a bioterrorist attack was carried out in 1984 in Oregon by commune members who poisoned area salad bars with salmonella, hoping to subvert local elections. Over 750 cases of severe enteritis developed, marking a terrible failure of the public health system to the community, said Weinstein. The cause was found out a year later.
But "everyone wants to know about anthrax," said Weinstein. As an agent of destruction, anthrax is not the best choice, he said, noting that for all the efforts of last year's mailer, "only" 11 people died. Person-to-person transmission of anthrax is rare, and the disease is treatable when diagnosed early. But anthrax has fear factor in its favor, he said. "You say anthrax and it's like shouting fire in a movie theater."
This is why knowledge is important, said Weinstein. Media reports can be inflammatory and suggest treatments that are inappropriate, he added. But the reality of bioterrorism is, "it's inevitable," he said.
Primary care physicians should conduct epidemiological surveillance of their patient populations, Weinstein advised. "If you start seeing large numbers of patients with the same symptoms, ask, 'Is this unusual?'"
Unfortunately, most biological agents initially cause flulike symptoms, so it's important to be able to differentiate. Look for an increase in cases of flulike illnesses or of flulike illnesses lasting longer than normal or causing unusual complications, Weinstein said.
You may want to apply for the following awards or grants or encourage others to do so. The Joint AAFP Foundation-AAFP Grant Awards Program is accepting requests for support of research in family practice/family medicine. Applications for the first review cycle of 2003 must be postmarked by Dec. 1. Go to http://www.aafpfoundation.org/jgap/jgapfact.html for more information.
Applications are due by Jan. 15 for the 2003 Pfizer Teacher Development Awards, which recognize excellence in part-time teaching. See http://www.aafpfoundation.org/pfizer.html for more information.
The Practice-Based Research Network Stimulation Grants support the initiation of research projects. Submit your proposal by Feb. 21. See http://www.aafpfoundation.org/jgap/pbrn_info.html if you would like more information.
Got questions? Contact Susie Morantz at smorantz@aafp.org or call (800) 274-2237, Ext. 4470.
 "Much of the important stuff that goes on to eliminate disparity is what goes on between doctor and patient," says Denise Rodgers, M.D. |
If providing preventive services for minority patients is a significant part of your practice, chances are you already know overcoming health disparities is the name of the game. That observation came courtesy of Denise Rodgers, M.D., during her Oct. 17 lecture, "Primary and Secondary Prevention in Minority Populations."
Rodgers is associate dean for community health at the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick. The session was offered as part of the 2003 Annual Clinical Focus on prevention, which kicked off at the Assembly.
Reports of health disparities based on gender, race, ethnicity and other factors are abundant in the medical literature, Rodgers noted. For example, in 1999, the most recent year for which data were available:
The numbers clearly show the problem. What they don't show is the solution. "Much of the important stuff that goes on to eliminate disparity is what goes on between doctor and patient," Rodgers said.
"As family physicians, we are extremely aware of the importance of effective communication in doing our jobs," she said. Poor communication leads to poor quality of care and, ultimately, poor outcomes.
Respect -- both for your patients and for their health beliefs -- is key in getting those patients to communicate with you, Rodgers added. Surveys have shown that a sizeable proportion of patients feel they are disrespected within the health care system. That percentage is greatest among minority populations, she said.
Pose the following question to yourself, Rodgers suggested: "'How do I begin as a physician to understand the health beliefs that you as a patient bring to the office?' Until we break down some of these health belief barriers and begin to learn from our patients, we're going to continue to see these disparities."
Putting that insight to practical use is the next step, according to Rodgers. "If we do not figure out how to streamline our practices so that we can once again develop meaningful, longitudinal relationships with our patients -- so that we can understand their health beliefs and their health practices -- we will not be able to educate patients in ways that will make a difference in the elimination of disparity," she said.
Patients are trying to find you. The AAFP wants to put them in touch with you. That's why the Academy in October launched an online resource for patients seeking family doctors. The AAFP's patient-oriented Web site, http://www.familydoctor.org, now offers a directory of AAFP active members (except international members and those in the uniformed services).
"The directory is a way for us to respond to patients and their
families who want online help in locating physicians," Michael Springer, vice
president for publishing and communications, said during the Assembly. "When
patients think 'family physician,' we want them to think of
familydoctor.org."
The directory, searchable by city, gives the name of each active member in that city and includes a link to an office Web site if the member's AAFP record includes a Web site.
Members who want to provide more information may create an information page, which allows them to give hours and directions, or a Web site, which allows them to describe their practice philosophy and educational background and even post pictures.
How can you create an information page or Web site? Have your AAFP ID number handy and go to http://www.aafp.org/myacademy, then choose "My Web Site." You can also opt out of the directory by choosing "My Contact Info" and marking the box that says "Do Not Include Me in the Directory."
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There is "fair evidence" that osteoporosis screening for women over age 65 years, or 60 to 65 and at high risk, provides a "moderate to substantial benefit," according to the U.S. Preventive Services Task Force. That is a "B" code recommendation based on the latest scientific data, recently upgraded from the previous "I" for insufficient evidence.
But the task force is not currently recommending osteoporosis screening for women under age 60 because evidence of benefit and harm is too closely balanced -- a "C" under the task force's new recommendation codes.
Rating preventive-intervention data as good, fair, bad or insufficient is not simply a matter of evaluating the science, says task force chair Alfred Berg, M.D.
"Science is the easy part," said Berg, professor and chair of the department of family medicine, University of Washington, Seattle. "The challenge is putting science into practice that benefits patients."
The task force evaluates evidence to determine whether an intervention is effective, whether it can work in practice and whether it can be cost-effective, he said in his Scientific Assembly lecture Oct. 17 titled "What's New From the U.S. Preventive Services Task Force." The session was offered as part of the 2003 Annual Clinical Focus on prevention.
Berg described some of the latest task force recommendations and also explained what the task force is not intended to do.
"It does not advocate for prevention, set clinical standards or make public policy," he said.
But it does tackle difficult topics.
The task force recently recommended against routine use of combination hormone replacement therapy, a "D" code, after it determined that evidence from the Women's Health Initiative study showed that potential harm from the therapy outweighed benefits.
"Hormone replacement is complicated -- it's the Rubik's Cube of prevention," Berg said. "We did find benefits to the combined therapy, but there were also significant harms. So our recommendation was that routine use to prevent chronic conditions is not a good deal for most women."
That leaves open the question of whether a woman who derives great benefit from HRT for perimenopausal symptoms might still want to stay on medication. The task force recognizes the importance of personal preference, Berg said, and in general advises physicians to discuss these questions as much as time permits with patients.
For example, the task force recognized that there is good evidence for a substantial benefit to aspirin in primary prevention of heart disease -- an "A" code. But it actually only recommends discussing aspirin therapy with the patient, not necessarily prescribing it. The recommendations are not the final answer for each individual patient, but they can be the stepping-off point to more patient and public education.
The task force publishes
recommendations in journals and news
releases, and it will issue loose-leaf binders later this year. It is also
using the Web for immediate release of recommendations.
The most important thing family physicians needed to know from his session was http://www.preventiveservices.ahrq.gov, Berg said.
This summer, when the Women's Health Initiative study comparing estrogen/progestin with placebo was halted early, the report raised more questions about hormone replacement therapy than it answered -- questions that women are now asking their family physicians.
The principal investigator for the San Diego portion of the Women's Health Initiative said that while he ponders these same questions himself, he asks physicians not to overgeneralize the study's results, and also to remember that the negative effects seen in the study were not very large.
"The Women's Health Initiative results are meaningful and probably accurate for the treatment that we stopped, the combination of conjugated equine estrogen and medroxyprogesterone acetate," said Robert Langer, M.D., professor of family and preventive medicine at the University of California, San Diego. "There are good reasons to believe that other combinations would not necessarily bring the same results."
In his Assembly presentation, "Hormone Replacement Therapy: The State-of-the-Art, 2002," Langer said prescribing for women in his own practice has not changed much, although he is switching many away from medroxyprogesterone acetate-containing regimens because it may be the reason for the adverse effects observed in the WHI and other studies.
"In contrast, there are alternative compounds of that same class shown not to have that adverse effect," Langer said.
He pointed out that there is a likelihood, as with any treatment, that any hormone replacement regimen will have risks and benefits.
"There is no free lunch, and we need to very carefully balance the risks and benefits and have a frank discussion with each patient on at least an annual basis," Langer said. "Then decide if for her, given what we are using and what we know about it, the benefits outweigh the risks."
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Robert Langer, M.D. "They are jumping |
Langer pointed out that all the questions posed in the Women's Health Initiative were not answered, and that the study was stopped under protocol rules and not because of the answers. He said he believed the study outcomes would have been different depending on the potency of the progesterone formula used. He said he would expect better outcomes with micronized progesterone because it seems to preserve more of the estrogen benefit.
He also stressed that few women need to be taken off HRT following the study's findings, but he advocated that all women be reassessed for which combination they should be taking.
Langer was asked about the recently released U.S. Preventive Services Task Force recommendation against using combined estrogen and progestin therapy for preventing cardiovascular disease and other chronic conditions in postmenopausal women.
"I think they are jumping the gun there, to say the Women's Health Initiative results apply to all forms of combined therapy," Langer said. "We don't have evidence for that. We only have evidence for the treatment that was tested in the Women's Health Initiative."
The issues raised by the Women's Health Initiative study of estrogen/progestin therapy in menopausal women have prompted such concerns that the NIH held a two-day meeting to summarize the findings. Barbara Yawn, M.D., M.Sc., of Rochester, Minn., represented the AAFP at the meeting Oct. 23 24 in Bethesda, Md.
In view of the WHI study results and the evidence report from the U.S. Preventive Services Task Force on hormone replacement therapy, the AAFP has updated its Summary of Policy Recommendations for Periodic Health Examinations, Yawn told the NIH panel.
The AAFP has moved from recommendations to counsel women on the
benefits of menopausal hormone therapy to counseling on the risks and benefits
of menopausal hormone therapy considering
short- and long-term use
separately, she said.
"There is no single recommendation that can be made for all women or for any single woman throughout her mid- and later life," said Yawn. "This complex issue requires joint decision-making between a woman and her family physician in light of individual risks and needs."
Weighing the risks and benefits for each woman is not easy, said Yawn, who recommends the NIH Web site -- http://www.nhlbi.nih.gov/health/women/pht_facts.htm -- for more information. The AAFP's counseling recommendations can be found at http://www.aafp.org/x10600.xml.
 "Family physicians can be so much a part of people, their lives, their families. And practicing in a rural community probably cements that in spades," says Darrell Carter, M.D. |
Many rural physicians burn out and leave their rural communities. Darrell Carter, M.D., of Granite Falls, Minn., honored at the Assembly as the 2003 AAFP Family Physician of the Year, knows it happens. But Carter found a way to avoid burnout -- he made learning to handle medical emergencies his mission.
He also helped develop a system for teaching other rural health care professionals to care for critically ill and critically injured patients.
"On a given day, I'm probably going to have to take care of very sick patients who are having heart attacks, maybe a kid who has fallen and has a head injury," Carter says. Sometimes he'll deliver a baby who's in distress.
Carter, a physician with the Affiliated Community Medical Centers P.A. in Granite Falls, has practiced medicine in the town for 30 years. Many times during his first 20 years in practice, Carter says, he felt inadequate to perform emergency procedures.
On one occasion, for example, a newborn went into cardiac arrest shortly after the delivery. Carter performed prolonged resuscitation to get the baby's heart started again. But the newborn started seizing, and Carter thought the baby would die. The baby survived, as Carter puts it, "by a gift of God." The following Christmas, the baby's family gave Carter a plaque reading, "Thanks for giving God a hand."
Carter says a series of similar "uncomfortable situations, where I felt inadequate," inspired him to learn more about emergency care. "One of the big driving forces was the feeling that I needed to do better," Carter says. "That's where the Comprehensive Advanced Life Support (program) was born." In 1993, Carter and a team of medical professionals started developing this emergency care training course for rural health care professionals. The team included family physicians, emergency physicians, nurses, physician assistants and paramedics.
In 1996, the course -- which includes home study, a two-day class and a one-day lab on procedural skills -- debuted. Since then, almost 1,000 Minnesota medical professionals have received the training.
Carter chaired a physician advisory committee that has set up pre-hospital care standards for ambulances in the region. "These are not paramedic ambulances," Carter says. "These are volunteer ambulance squads, staffed by people who work at the hardware store and the gas station who've taken some basic EMT training."
Carter says part of what he offers patients is the empathy that comes from knowing what it's like to be seriously ill.
Family Physician of the Year Runners-up
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About five years ago, Carter was diagnosed with kidney cancer and ultimately had to have one of his kidneys, a ureter and part of his bladder removed. He's disease-free now but changed, he says.
"There's no question that as I talk with patients and have to discuss some end-of-life or life-threatening issues, things are different. They (the patients) seem to know that I understand, and more than ever before, they really seek my input into what makes sense for them in terms of those life-and-death decisions."
As a small-town physician, however, Carter had a special bond with his patients even before his illness.
"Because I've been in the same place forever, these patients are friends. They're people I go to church with. They're people I see on the street," Carter says. "It's really rewarding to be able to help people through some of their life crises. Family physicians, in general, have that as a luxury that many other physicians don't. Family physicians can be so much a part of people, their lives, their families. And practicing in a rural community probably cements that in spades. People grow to depend on you and look to you for all kinds of help and all kinds of guidance. That's a very rewarding life."
The Congress of Delegates pulled out all the stops this year in acting on issues such as prior hospitalization for nursing home placement. The delegates unanimously voted for the Academy to tell the Centers for Medicare & Medicaid Services, "The regulation concerning mandatory hospitalization prior to Medicare-qualified skilled nursing placement is obsolete, wasteful of valuable resources and should be abolished."
No restraint in that statement.
"If my patients are not sick enough to be hospitalized but need placement in the nursing home next door to my practice, I don't know why they need to go to a hospital 50 miles away (for three days) to be eligible for Medicare coverage in the nursing home," Beulette Hooks, M.D., of Midland, Ga., chair of the Committee on Resident and Student Issues, told a reference committee Oct. 14.
Here's how another AAFP member described the hospitalization requirement: "This represents a 'stupid factor.'"
A range of other issues, including those noted below, prompted action from the delegates.
Tobacco settlement funds. Several years ago, states received funds for settling a lawsuit with tobacco companies. The funds, meant for projects preventing tobacco use and helping people stop using tobacco, are being withdrawn. "I sit on the tobacco council for Iowa, and we had been given $9 million, we just lost $4 million, and we'll probably lose more," Iowa delegate David Carlyle, M.D., of Ames told a reference committee. "The tobacco companies were behind the loss."
The delegates voted to have the Academy compile a "national scorecard" showing how states have allocated their tobacco settlement funds. The delegates also decided the Academy would serve as an information resource for states using their funds for tobacco-use prevention and cessation efforts.
Prohibitions on prescribing. Family physicians' prescribing privileges are being curtailed, the delegates said, by the CMS and the Department of Defense -- in rules against the prescription of certain drugs by certain groups of physicians. "There is a persistent effort to wean away the privileges family physicians have," Georgia delegate Tanya Jones, M.D., of Atlanta told a reference committee. "The Academy has to be proactive about this."
The delegates said the AAFP should ask the CMS and the Department of Defense to eliminate the prescription prohibitions if there is no evidence-based research justifying the prohibitions.
Gender equity in health plan benefits. Whatever terms and conditions an employer or health plan applies to prescription drugs, devices and elective surgeries, those same provisions should apply to prescription contraceptive drugs and devices and to elective sterilization procedures, according to a new policy the delegates adopted.
Benefits for family members. The Congress took several actions related to the AAFP definition of family, which reads in part, "The family is a group of individuals with a continuing legal, genetic and/or emotional relationship." Employees' medical benefits should extend to those within the employee's family for whom the employee has assumed responsibility, the delegates decided unanimously. They also voted unanimously for AAFP to support domestic partner benefits for same-gender couples.
Adoption. Several resolutions on adoption also pertained to AAFP's definition of family. After hearing lengthy debate, a reference committee developed a substitute resolution, asking the AAFP to "establish policy and be supportive of legislation which promotes a safe and nurturing environment, including psychological and legal security, for all children, including those of adoptive parents, regardless of the parents' sexual orientation."
The delegates passed the substitute resolution but the next day discussed whether to reconsider it. Florida delegate Thomas Hicks, M.D., of Tallahassee said he believed the reference committee had created a balanced compromise, one representing a variety of viewpoints. Standing by their first vote, the delegates decided against reconsideration.
Mental health care reimbursement. Family physicians should be reimbursed for mental health counseling and treatment, said the delegates. They asked the Academy to inform the American Association of Health Plans about FPs' critical role in identifying and treating mental illness. The Academy should also meet with officials of public and private third-party payers to advocate family physicians' reimbursement for mental health diagnosis and treatment, said the delegates.
Medicare reform. The delegates issued a clarion call to revamp Medicare: "The AAFP is gravely concerned about the viability, fairness and workability of the current Medicare program. Improvement is needed to keep pace with advances in the practice of medicine, changes in the demographics of the Medicare population and other developments in the health care system."
 The Tar Wars race truck, on display in the exposition hall, proves irresistible to Chris Doehring, age 3, of Augusta, Ga. |
BY CINDY McCANSE
July 31, 2003. That was the date originally set by the AAFP Board of Directors for the Academy's Tar Wars® tobacco-free education initiative to secure full external funding for its activities. After that time, said Board members, AAFP would no longer provide total program funding. The Board's action resulted from the Academy's recently completed budget prioritization process.
Then, on Oct. 15, the Congress of Delegates voted to have the Academy continue its support until external funding could be secured. It also directed the AAFP to "commit to seeking funding partners to continue the growth of the Tar Wars program on a national level" and to "retain overall ownership of Tar Wars with or without such sponsorship now and in the future."
"What the Congress did was direct the Board to make Tar Wars part of our major emphasis," said (then) AAFP President Warren Jones, M.D., of Ridgeland, Miss. "This is a program in which one out of six of our members participates and that reaches 450,000 children each year."
The discussion began at an Oct. 13 town hall meeting about the budget priority exercise. (Then) Board Chair Richard Roberts, M.D., J.D., of Madison, Wis., laid out the particulars of the budget process.
For a look at the budget exercise, which led to numerous cost cuts and proposed revenue enhancements, go to http://www.aafp.org/fpr/20021000/11.html.
Ben Oteyza, M.D., of Bel Air, Md., president of the Maryland AFP, was one of many who spoke in favor of continued AAFP support of Tar Wars, urging stakeholders to look closely at the program and the strong anti-smoking message it sends.
Jeffrey Cain, M.D., of Denver, who co-founded the program in 1988, also advocated continuing Academy support of the program. "Two years ago we sold Tar Wars to the American Academy of Family Physicians for a dollar because we thought this was the right home for it," said Cain.
The Board, said Roberts, agrees. "There's not a Board member who doesn't appreciate the tremendous value that Tar Wars has represented for individual members, for our state chapters and for the national Academy," he said. "That's not the issue. The issue is: Do you want a dues-paying organization sustaining that kind of a program, which has the potential to get even bigger and more expensive? Or are there other structures that would better and more securely fund this in the future?"
Academy EVP Douglas Henley, M.D., broke down the numbers during the town hall event, reporting that the AAFP's share of the program's annual operating costs run between $250,000 and $300,000. He anticipates that amount will be reduced through internal program cuts but still expects a shortfall of from $125,000 to $150,000 a year, he said.
The word has already gone out, Henley added, and the response has been heartening. Schering announced at the AAFP Foundation dinner Oct. 15 its pledge of $75,000 to the program and challenged other foundation supporters to follow suit.
Continuing to deliver the anti-tobacco message is critical, Jones asserted. "We have to do this to protect the future health of our youth," he said. "This is to stop teens from walking around with that tobacco tin mark on their back pockets, to stop them from chewing gum to hide the smell of tobacco on their breath."
The Academy has sealed a deal with leading medical publisher Elsevier Science to offer PDxMD to AAFP members at a special rate. This new, evidence-based, electronic clinical information system is specifically designed for use in primary care. PDxMD has full desktop features and handheld downloadable components. It offers continually updated files on more than 450 medical conditions with information on more than 750 medications and other therapies.
FPs also can access a database containing more than 1,400 potential diagnoses that are organized by chief complaint and categorized by age, relative prevalence and clinical findings. Patient information sheets on more than 300 diseases can be customized by the physician and tailored to the patient's specific care plan.
The affiliation with Elsevier Science, announced during the Assembly, was borne from the AAFP's desire to keep members on technology's cutting edge.
"The AAFP is committed to providing its members with tools that improve efficiency and accuracy," said Joetta Melton, director of AAFP's Publications Division and publisher of American Family Physician and Family Practice Management. "PDxMD's easy-to-use, intuitive design makes it an ideal electronic point-of-care clinical decision support tool for our members."
FPs can access PDxMD through the Academy's Web site, http://www.aafp.org, or by going to Elsevier Science's site, http://www.pdxmd.com.
A practice redesign course at the Assembly focused on ways family physicians can see how their practices measure up in terms of patient satisfaction, clinical outcomes, clinical and business efficiency, and financial health.
"These measures represent vital signs for your practice," said course leader Charles Kilo, M.D., M.P.H., an internist with GreenField Health System in Portland, Ore. "Think about your practice as a system, a microsystem. Do you know your patient population? Do you know your clinical and business processes? Do you know your outcomes?"
Kilo provided attendees with control charts and other measurement techniques. "You can't improve your practice without measuring it," he said.
He described ideal practices' key components, as defined by the Institute for Healthcare Improvement. They include easy access to care, excellent interaction with patient, reliability of care and financial vitality.
Ease of access
To help FPs measure the ease of patients' access to care, Kilo described a technique of measuring the third next available appointment, defined as the number of days it takes a new patient to get the third next available appointment time for a physical exam. Under this technique, the receptionist makes note, at the same time every day, of when the third next appointment time is available.
"Measuring the third next available appointment time provides a snapshot of patients' access to urgent and routine visits," he said. "Once you have measured access with this technique, you can work to shorten the time it takes a patient to make an appointment."
Interaction with patients
To chart patient satisfaction and the quality of the patient-physician relationship, Kilo recommended using a visit survey card. Patients can rate from excellent to poor such factors as their physician's sensitivity to their special needs or concerns, whether they got the help they needed, the amount of time they waited to get an appointment, and their recent experience in getting through to the office by phone.
The efficiency of the practice can be determined by measuring the patient visit cycle time -- the average time in minutes patients spend at an office visit. Practice staff can ask 15 patients per month to fill out a survey specifying the amount of time they sat in the waiting room, waited for their physician in a patient room and spent with their physician.
Reliability of care
Measuring the reliability of care in terms of patient outcomes involves determining the number of patients who are admitted to an emergency room or hospital for at least one overnight stay. Kilo gave the example of a patient with hypertension who is rushed to a hospital after a heart attack. Should the physician have provided this patient with better preventive care? "Collect data to guide your actions," he said.
Financial viability
Finally, the financial viability of the practice can be measured using accounting methods to determine the profit margin of the practice, defined as total medical revenues minus total operating expenses.
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"I love dizzy people," said lecturer Martin Samuels, M.D., in opening his humorous and insightful Assembly lecture, "Differential Diagnosis of the Dizzy Patient." Samuels closed by saying, "Dizziness is a wonderful thing, isn't it? It's common. It spans all medicine -- psychiatry, neurology and otolaryngology. It does not yield to technology. It is comprehensible. It is treatable. And I'll bet you can't wait to get back to your offices to see your next dizzy patient."
In between those comments, Samuels, who is neurologist-in-chief at Brigham and Women's Hospital in Boston and professor of neurology at Harvard Medical School, Boston, told his audience how best to diagnose and manage dizzy patients.
History is key
Dizziness is one of the five most common complaints patients have when they see a doctor. But to the layperson, the term can mean a variety of things, such as feeling woozy, light-headed or on the verge of fainting. The very fuzziness of the terminology presents a major diagnostic challenge to family physicians, said Samuels.
Taking a thorough history is key to the proper diagnosis of dizziness. "If you do not know the diagnosis at the end of the history, you will probably never know the diagnosis," Samuels said. He gave tips for taking a dizzy history:
Types of dizziness
Samuels defined four types of dizziness and suggested treatments:
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Total registration for the 2002 Scientific Assembly reached 16,300. This figure included 5,248 physicians.
Mark your calendar now for the 2003 Scientific Assembly Oct. 1 5 in New Orleans. See you there for exceptional CME opportunities and a chance to enjoy one of the South's favorite cities. For more information, visit http://www.aafp.org/assembly.xml.
The first-place award of $1,000 for a family practice research presentation went to Douglas Woolley, M.D., M.P.H., of Wichita, Kan., for "Mistreatment of Medical Students Based on Their Stated Career Interests."
The second-place award of $250 for a family practice research presentation went to Nicole Powell-Dunford, M.D., a family practice resident at Tripler Army Medical Center in Honolulu for "Electively Induced Amenorrhea Through Oral Contraceptive Pills (OCPs)."
The first-place award of $700 for a resident poster went to Angela Droz, M.D., of the Puget Sound Family Medicine Residency in Bremerton, Wash., for "Patient Notification of Normal Lab Results."
The second-place award of $300 for a resident poster went to David Wallis, M.D., of the University of California-Los Angeles Family Practice Residency Program in Santa Monica, Calif., for "Influenza Vaccine in Pregnancy."
The first-place award of $700 for a medical student poster went to Corey Martin, M.D., of Yale University School of Medicine, New Haven, Conn., for "Back-up Antibiotic Prescriptions."
The second-place award of $300 for a medical student poster went to Wayne Tsuange, B.A., of the University of Cincinnati College of Medicine for "Influenza Transmission in College Dorms."
American Board of Family Practice
AstraZeneca
Aventis Pharmaceuticals
Bristol-Myers Squibb
Gerber Products Co.
Highlights for Children
GlaxoSmithKline
Milex Products Inc.
The National Procedures Institute
Novartis Pharmaceuticals Corp.
Ortho-McNeil Pharmaceutical
R oss Products Division, Abbott Laboratories
Spacelabs Medical
TAP Pharmaceuticals
Thomson — PDR
UCB Pharma
Welch Allyn Inc.
Abbott Laboratories
Aircast, Inc.
Allegiance Healthcare
AstraZeneca
Aventis Pharmaceuticals
Basic Medical Industries
BD
Body Wise International
Bristol-Myers Squibb
Chlorine Chemistry Council
Daiichi Pharmaceutical Corporation
Forest Pharmaceuticals
GlaxoSmithKline
Janssen Pharmaceutica
Johnson & Johnson
Eli Lilly and Company
McNeil Consumer & Specialty Pharmaceuticals
Mead Johnson Nutritionals
Mylan Pharmaceuticals
Ortho-McNeil Pharmaceutical
Pharmacia Corp.
Procter & Gamble
Purdue Frederick
Ross Products, a division of Abbott Laboratories
Schering
Simulaids, Inc.
Spacelabs Medical
TEVA Pharmaceuticals
Unilever
Welch Allyn, Inc.
Wyeth Pharmaceuticals
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Copyright © 2002 by
American Academy of Family Physicians.