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BY J.M. BRODIE
Michael Lewis, M.D., of Hudson, N.C., is a small-town family physician who has run his solo practice in the same place since 1972. "I've been here forever," he said, though he's finding that staying in practice may ultimately mean jettisoning part of his patient base -- his Medicaid patients.
Lewis has about 60 Medicaid patients and has decided not to take new ones because of diminished Medicaid payments. The reimbursement keeps falling further behind rising practice costs. "The only Medicaid patients I'm taking are those who are already in the practice or their family members," he said.
Physicians fear that deep cuts in Medicaid could result in clinic doors shutting completely, patients having greater difficulty accessing physicians and eligibility standards rising. The result could be an increase in emergency room visits as Medicaid patients are priced out of primary care. Emergency room costs are much higher, and cities and counties would have to pick up the tab.
Patients lose coverage as their Medicaid eligibility -- up for review every few months -- comes and goes. "Just today, a fellow came in and said, 'I don't understand why they've taken me off,'" Lewis said. The patient was on Medicaid all of last year, and then suddenly Lewis got a letter saying the patient wasn't on Medicaid anymore.
"What will happen if you carry out all of the Medicare and Medicaid coverage (cuts), if you carry out all the managed care to its conclusion -- all of that trimming? There won't be any small-town doctors," predicted Lewis. "In a practice like mine, I can't spread my overhead among six people. It's just me. I'm only one person."
Yvette Rooks, M.D., assistant professor at the University of Maryland School of Medicine's family medicine department in Baltimore's inner city, agreed many physicians may stop seeing Medicaid patients. She noted physicians may get only minimal Medicaid payment for a full physical. "Doctors in private offices will stop accepting Medicaid patients -- especially those doctors who have been out there awhile and have tasted the fruits of the past," she said.
"The global picture is that there needs to be more money spent on health care," Rooks said. "There are so many things on the table, but the only way to fix this is if there is more money to fund services. There is not enough money for primary health care."
In Miami, Bernd Wollschlaeger, M.D., supports any attempts to overhaul an increasingly unwieldy system while expressing doubts that any relief would be in time to reverse his decision to stop taking Medicaid patients.
"I got a renewal letter in the mail wanting me to renew my Medicaid, and I just dropped it," said Wollschlaeger, a solo practitioner. "When you look at the efforts you put in and the reimbursement that you take out, you have a negative balance. I made the decision because it was just unbearable."
Wollschlaeger said his sentiment is shared by a number of FPs who entered the profession to treat patients in need, only to find themselves struggling to stay afloat in a sea of rising medical costs.
"I took (Medicaid patients) because I felt very strongly that physicians should provide Medicaid services to an indigent population," Wollschlaeger said. "Now I am making a very simple survival decision. I just cannot do indigent care anymore."
For now, many physicians are watching and waiting, hoping for relief.
"They (government officials) are coming very close to cutting small practices out of Medicaid," said Lewis. "A few years back, they said, 'We'll cut the rates and the doctors will just compensate by seeing more people.' I can't see more people. I'm full and over full every day."
To reach writer J.M. Brodie, e-mail mbrodie@aafp.org.
Burgeoning state budget deficits totaling $60 billion to $85 billion are projected for fiscal year 2004. Given that 49 states must show balanced budgets each year, many are taking the scissors to programs such as Medicaid. The cuts may have an adverse effect on many poor and near-poor working families insured through Medicaid and the State Children's Health Insurance Program, according to a study on Medicaid released in January by the Center on Budget and Policy Priorities.
California, Colorado, Connecticut, Kansas, Massachusetts, Missouri, Montana, Nebraska, Nevada, New Jersey, Oklahoma, Oregon, Tennessee, Texas and Washington have announced plans to trim Medicaid programs. Missouri and Texas have considered doing away with SCHIP programs.
In February, the Bush administration proposed fundamental changes in the Medicaid program. The Bush proposal would do away with federal rules that now apply to about one-third of all Medicaid recipients and two-thirds of all Medicaid spending. The proposal would give states power to reduce, eliminate or increase benefits for millions of low-income people, including many who are elderly or disabled. But some have argued that it will take more than this to address cuts in the state-run programs that could force many physicians to shut their doors to Medicaid patients.
More recently, the House, in its FY 2004 budget resolution, voted to cut some $93 billion in Medicaid spending over the next 10 years. In a letter to House/Senate budget committee conferees, AAFP Executive Vice President Douglas Henley, M.D., urged the legislators to uphold funding for the program. "In context of the current financial hardship many families are facing, now is particularly an inopportune time to scale back on our nation's health care safety net," he wrote. At press time, the conferees had avoided the $93 billion cut, heeding the requests of the AAFP and other organizations.
Family practice residents are watching the Medicaid drama unfold as they make their decisions on where to practice.
"It's very serious for docs who are going to be looking (for a practice), but it is also serious for patients in the inner cities, where Medicaid is their health insurance," said Yvette Rooks, M.D., assistant professor at the University of Maryland School of Medicine's family medicine department in Baltimore. "Our residents get some practice management (training) from our clinical director, and they say they are going to leave the state or go practice in the county, where the payer mix is different."
 FPs were completely engaged in learning medicine's business side. |
BY SHERI PORTER
It was time to get down to business -- literally -- at the AAFP's new Crash Course on Cash, Codes & Computers. You'd never have guessed the room was filled with physicians at the March 13 14 meeting. No, it looked like Finance 101. Images loomed large on the overhead screen -- balance sheets, income statements and financial reports -- and the docs-turned-students were completely engaged.
"I've always been more interested in practicing medicine than in finances," said FP Harry Brodie, M.D., of Littleton, Colo. "But I'm here to learn how to do the business end of medicine better."
Max Bayard, M.D., of Johnson City, Tenn., came to New Orleans to learn how to better teach practice management skills to his residents at the Johnson City Family Practice Residency Program. Bayard used to consider the practice management requirement (60 hours) "just teaching residents to survive." In recent years, though, his attitude has broadened. "I'm teaching them to thrive. I don't want to send residents out without this business foundation," said Bayard.
Course speaker George Xakellis Jr., M.D., M.B.A., from the University of California, Davis, did not disappoint his eager students. "Your practice needs to be both satisfying and financially viable," Xakellis said. "You can't afford to be the proud owner of a money-losing business."
A show of hands confirmed the audience was a mixed group. There were residents and residency program directors, as well as FPs in solo practices, small practices and practices owned by large hospitals.
Xakellis asked his audience to shout out the characteristics of a successful medical practice. "Good patient care!" "Financial viability!" "Cohesive staff!" "Job satisfaction!" "Low overhead!" "Good patient base!" his audience responded.
 When it came time for the physicians to put pen to paper and fill out a mock financial statement, Misuzu Yuasa, M.D., of Terre Haute, Ind., left, and Olasunkanmi Adeyinka, M.D., of Houston tackled the task with vigor. |
All good answers, said Xakellis, because "unless you know what you're aiming for, it's hard to know when you get there."
Xakellis moved from topic to topic, providing practical financial information and answering questions with the ease of a Wall Street financier.
•Balance sheets. He described the balance sheet as the value of the practice -- "a snapshot in time of what you own and where the money came from."
•Financial reports. He said simple managerial strategies distinguish "high-performing" family practices from the rest, and he called financial reports "the compass for a successful practice."
•Office overhead. He addressed the problem of crushing overhead. Too often, physicians try to solve the problem by seeing more patients, Xakellis said. "It seems like an easy fix, but it comes with a cost." Physicians should be able to make their practices work without seeing one more patient per hour, he said. But solutions vary depending on the practice, he added.
•Patient population. Part of the answer to achieving a profitable practice is to seek a balanced patient base. "No single physician can care for all the very sick patients from a larger, more heterogeneous group of patients," said Xakellis. It can be physically exhausting, wreak havoc with your patient flow and negatively affect your office's financial performance. On the other hand, cautioned Xakellis, a practice composed of only generally healthy patients can become monotonous over time. "A balanced practice can provide intellectual stimulation, increase access for all patients regardless of their severity of illness and contribute a valuable service to your community at large," he said.
The bottom line of practice management, said Xakellis, is that physicians must understand the numbers that drive their practices. "Then you can identify the right answers for your setting based on what the detailed information reveals about your individual practice," he said.
To reach writer Sheri Porter, e-mail sporter@aafp.org.
It's a rule: Coding is imperative to the business of medicine. So said coding instructors Thomas Felger, M.D., of South Bend, Ind., chair of the AAFP Commission on Health Care Services, and Marie Felger, a certified professional coder, during AAFP's Crash Course on Cash, Codes and Computers March 13 14 in New Orleans. Here's a sampling of quotable quips from instructors and participants, heard during the course:
When the New Orleans course quickly filled up, the Academy's Board of Directors approved two additional sessions in 2003: May 8 9 in Chicago and Sept. 11 12 in New York City. Go to http://www.aafp.org/crashcourse.xml to register.
BY SHERI PORTER
Family physicians are playing a critical role in the war in Iraq -- providing medical care to soldiers on the front lines -- as well as seeing more patients at home to cover for colleagues who have been deployed.
No statistics are available regarding the number of FPs serving in Iraq. But Cmdr. John Holman, M.D., M.P.H., director of primary care services at Naval Hospital Camp Pendleton in California, told FP Report how the war has affected his staff.
"I can't give you specific numbers" for security reasons, he said, "but what I can tell you is that half of the faculty from our residency program is now serving with the Marines in Iraq."
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Even though the departure of so many physicians has left the hospital short staffed, "we haven't changed what we do here," said Holman. "We're taking care of all the wives, the husbands, the children -- they're all still coming right here for their primary care.
"Of course, that means we've got a lot of folks working long hours. But we look at what our colleagues are doing in Iraq and we say, 'OK, we can work 60 or more hours this week -- not a problem.'"
Holman also praised the Naval Reserve FPs "who have come on board, filled in the gaps and been absolutely professional." The reservists, some of whom left behind busy practices, "come with such breadth and depth of experience," said Holman, that they can fill in anywhere, "from the primary care clinic to taking care of Marines who are out training."
Lt. Cmdr. Maureen O'Hara Padden, M.D., M.P.H., director of family practice residency training at Naval Hospital Camp Lejeune in North Carolina, expressed admiration for her colleagues on an Academy e-mail discussion list.
"There are many military docs deployed to the front lines and in harm's way," she wrote. "I had young doctors who were supposed to come back to start their second year of residency training in our program who, after having served the last several years with the Marines, turned down their training to stay with the Marines and support them during this difficult time. I am in awe of their honor, commitment and courage."
Lt. Mike Shusko, M.D., is one of those physicians postponing his family practice residency training at Camp Lejeune.
"It's truly a minimal sacrifice compared to what those 18-year-old lance corporals are doing in Iraq and Afghanistan," he said. "I was a Marine for 13 years ... I was a young infantryman like them. I just want to be over there to take care of them. It's the least I can do. Residency will always be there."
Shusko expects to be deployed to the Middle East in June.
John Kugler, M.D., family practice consultant to the U.S. surgeon general for the Army, estimated in mid-April that one-fourth to one-third of the Army's family practice staff physicians were deployed to the Middle East. "They are assigned to combat support hospitals and other medical units, and they work alongside other primary care and ER docs," Kugler said. "When the shooting part of the war is over, we'll have an idea of what kind of ongoing medical support will be needed and for how long."
To reach writer Sheri Porter, e-mail sporter@aafp.org.
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For FPs who have felt the absence of a family practice research journal acutely, this month will bring a sort of homecoming: Annals of Family Medicine will launch its first issue May 30. The issue will hit mailboxes in early June.
Annals, a collaborative effort of AAFP and five other sponsoring organizations, will publish peer-reviewed research to support the field of generalist health care. The only ads that will appear will be those of the six sponsoring organizations and classified advertisements. Joetta Melton, publisher of Academy journals American Family Physician and Family Practice Management, will serve as publisher of Annals.
The first issue of the bimonthly journal will be sent to AAFP active members, second- and third-year FP residents, and members of the other sponsoring organizations. Recipients can return a postcard from that issue to request a free one-year subscription.
The journal will help readers be effective physicians, says editor Kurt Stange, M.D., Ph.D. of Cleveland. An online discussion group for each published article will allow Academy members and others to discuss Annals articles and interact with their colleagues.
Living up to its purpose of covering topics of importance to primary care, Annals' first issue will include original research articles on the treatment of comorbidities, attention-deficit/hyperactivity disorder and prostate cancer screening.
The task of selecting articles has been aided by the many excellent papers submitted already, said Stange.
"I am personally very excited about the high quality of papers that we are receiving," he said. "Academy members and others are really coming through by sending us some of their best work, including original research from both practice and academic settings, as well as some pieces that advance knowledge of methods and theory."
In addition, Academy members and others have devoted much time and energy to the peer-review process, said Stange.
The articles also will appear on Annals' Web site, free of charge. To read more, go to http://www.annfammed.org.
BY TONI LAPP
It's a conundrum of modern medicine: Despite having more organ donors than ever before, there are still more patients than ever waiting for life-saving transplants.
According to the Organ Procurement and Transplantation Network, in 1998, 5,900 donors led to transplants in 12,600 individuals from a waiting list of 15,000. In 2001, 12,973 donors furnished transplants for 24,000 individuals. But the waiting list had grown to 80,000.
The best way to encourage patients to become organ donors is to talk about it -- and set an example, says Christine Petty, M.D., of Moline, Ill., vice president of medical management for John Deere Health Care. Petty is a member of the AAFP Commission on Health Care Services.
"Not only do we need to talk to patients about end-of-life issues, but we must communicate the need for organ donations," she says. "We as physicians can be an active piece of that puzzle."
Petty, a past president of the Illinois AFP, felt strongly enough to draft a resolution that the 2002 Congress of Delegates passed last October to encourage more education about the issue.
Says Petty: "I've had patients who've had unfortunate injuries, and I've discussed with those patients the possibility of being an organ donor -- and that's a difficult situation. But it's better to discuss prior to an unfortunate accident or illness."
"The more times people hear about it, the more inclined they'll be to become an organ donor," she says. "Especially when they hear about it from their doctor whom they respect -- and especially if their doctor can say, 'I plan to be an organ donor myself.'"
Perhaps most frustrating are the disparities among minorities. Transplant success rates increase when organs are matched between members of the same ethnic and racial group. Yet at present, for example, 12 percent of the U.S. population is African-American, but 35 percent of all patients waiting for a kidney transplant are African-American.
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For a downloadable organ donor card, go to
http://www.organdonor.gov/ |
Often cultural barriers and health illiteracy make it difficult to disseminate education, says one doctor.
"My patients have a hard enough time grasping the concepts of their current illnesses, let alone the possibility of giving the gift of life," says Edgar Figueroa, M.D., who sees a large Latino population as chief resident at the family practice residency program at New York-Presbyterian Hospital in New York City.
In New York, a 1998 law requires hospital staff to discuss each death with the state organ donor network. Patients are then screened, and if the expired patient could possibly be an organ donor, trained personnel come in and help approach the family about organ donation, Figueroa says.
He sometimes mentions the possibility of organ donation to patients, but the prime audience for this discussion -- younger and middle-age patients -- tend to be "too focused on the here and now," he says. But even elderly patients may be able to donate items such as skin for burn victims.
Kim Yu, M.D., of Novi, Mich., an FP in private practice, educates patients by telling about her own family's experience: "My mother received a kidney transplant that lasted 20 years. Even though she was Chinese, her kidney came from a Caucasian male -- and she would sometimes joke that when she started becoming a little hirsute, it was due to her 'male' kidney!"
Yu says that education should begin at the community level -- in churches, at malls, in the hair salon. "I truly believe it will take concerted community efforts to reach people and tell them about these issues in an informal, nonthreatening situation," she says.
Like in an FP's office.
To reach writer Toni Lapp, e-mail tlapp@aafp.org.
• Focus on prevention •
Why do I knowingly continue a habit that puts my health at risk? A national poll commissioned by the AAFP found that many Americans continue risky health behavior because of a lack of willpower and time, and the pressures of a stressful life. Source: American Academy of Family Physicians/2002 Wirthlin Worldwide poll. |
by Cindy McCanse Borgmeyer
Think about it: When's the last time you fell victim to the siren's song of that second (or third) slice of cheesecake? Or, forced to choose between hitting the walking trail after dinner or playing couch potato in front of the TV, opted for the latter? Well, your patients are no different.
This is not to say that a little self-indulgence every now and then doesn't have its place. But these examples illustrate the fact that people make choices affecting their health each and every day, often without considering the consequences.
"Our patients are constantly bombarded with health information," said AAFP President-elect Michael Fleming, M.D., of Shreveport, La. "Some of that information -- like what they hear from their family doctors -- is reliable. Some of it is not.
"To be able to work effectively with our patients to achieve their health goals, we need solid evidence showing us what they know about maintaining and improving their health and how that information translates into behavior."
A recent AAFP survey provides exactly that insight.
As part of last fall's kickoff of the 2003 Annual Clinical Focus on prevention, the AAFP commissioned a poll by Wirthlin Worldwide to determine what patients know about safeguarding their health and how they make use of that information. Survey results and related materials have been posted to the AAFP Web site at http://www.aafp.org/members/acfpresskit.xml.
Findings from the telephone survey, which included 1,000 adults living in the United States, showed a consistent -- if disappointing -- trend: Although most Americans have a strong grasp of the importance of healthy behaviors, a good many of them still don't do what they know they should be doing.
The survey shows that 98 percent of Americans admit that they have at least one of nine unhealthy habits such as tobacco use, sedentary lifestyle, poor stress management or inadequate sleep. The largest portion, 24 percent, say they lack the willpower or self-control to overcome their unhealthy habits.
By and large, demographically defined population groups tended to respond as one might suspect they would. For example, denial that one's health would be affected by negative consequences was most frequently seen in survey respondents under 35 years of age. Those most likely to blame unhealthy behaviors on a lack of self-discipline included people between ages 35 and 54 -- particularly women, college grads and those with the highest incomes. And a disproportionate number of men in the under-35 age group, along with those for whom high-school graduation was the highest educational level achieved, tended to say risky behaviors are enjoyable.
In many cases, the rationales for specific behaviors also followed expected patterns. Most smokers and people with poor nutritional habits, for example, attributed their continued unhealthy behavior to a lack of willpower.
Other cases were not so clear, however. Those who reported not getting enough sleep, for example, most often attributed that fact to lack of time rather than to excessive stress. And of those who said they failed to exercise as much as they knew they should, most blamed their actions on time constraints rather than on not having sufficient willpower.
So, those are some of the numbers -- now what to do with them? How can family physicians help their patients achieve better health -- especially when some patients seem intent on pursuing the opposite course?
"You have to reach for it whenever you can," said AAFP Past President Richard Roberts, M.D., J.D., of Madison, Wis., who has served as an AAFP spokesperson on motivating patient lifestyle improvements. "From working with these patients over time, you develop a sense of when it's reasonable to bring up certain topics.
"There are some things -- smoking, for example -- I continue to bang the drum about every time I see a patient."
Granted, "selling" prevention to patients can be a challenge.FPs may see some patients quite rarely and only when the patients are in dire health straits. Under those circumstances, "It's hard to get much traction on many prevention issues. I think we do this better than anybody else, but it still ain't great," Roberts quipped.
The key is to customize your approach.
Take exercise, for example. For a patient with a significant health problem, Roberts said, that may mean devising a unique physical activity plan.
Other times, it can mean recognizing an individual as part of a larger population and making best use of that identity. With women, for example, it's often helpful to suggest participation in an exercise group because then it becomes a social activity, he said. Women's sense of interdependence can lead them to engage and support one another in exercise, thus keeping the cycle going.
"Men, on the other hand, tend to prefer to exercise alone," Roberts said. "When men come together in exercise, it's typically for competitive reasons. So you need to keep that in mind."
And learn to see the big picture, Roberts advised. "If you're actually going to move the needle, you have to think beyond the individual. You have to think about the whole community and change the community's way of looking at things."
To reach writer Cindy McCanse Borgmeyer, e-mail cborgmey@aafp.org.
• Focus on prevention •
BY SHERI PORTER
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It's no secret that a fit body is much better equipped to ward off disease.
According to the American Heart Association, cardiovascular disease is the leading cause of death in the United States. Tell your couch potato patients that their lack of physical activity could set them up for heart disease and other health problems including obesity, diabetes and high blood pressure.
While you're at it, give them these AHA stats to chew on:
How many of your patients insist they would exercise if only they had time?
The "time crunch" is always an issue, says FP Derek Clevidence, M.D., of Cottage Grove, Wis. He asks patients to reserve 30 minutes a day, four days a week for exercise.
"That's just 1.2 percent of their entire week -- I tell them they owe it to themselves," Clevidence says. He encourages the use of a pedometer, a heart rate monitor or some other "feedback device." Sometimes he schedules patients for a treadmill test. "It's just to let them know how much work they need to do to achieve an adequate heart rate -- it gives them a frame of reference," he says.
The "I'm too busy" excuse never flies with Maj. Leslie Knight, M.D., of Lakenheath, England. She counters by pointing out her own hectic schedule. "I work 12 hours a day and manage to fit exercise in -- make it a priority and you'll have time," she tells patients.
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Knight encourages people to pick activities they like -- try cycling, walking, running, rowing, rollerblading or swimming -- and then vary the routine to fend off boredom. "The key to success is variety and persistence," she says.
But what about motivation? "My experience is that even though patients say it is a problem with time, it's really about willpower," says John Chomer, M.D., of Noblesville, Ind. "I tell patients to motivate themselves by wha tever mind games are necessary: Do five push-ups and sit-ups before their shower; take the stairs; fit in a quick walk while the dishes soak." Chomer says the hardest part is getting started and developing a lifestyle change.
Eugene Guazzo, M.D., tells his patients to run. The 74-year-old FP from Chaptico, Md., has been running since his teens and considers it the best overall exercise. "It's the most efficient use of time and money -- it's cheap, and you can do it anywhere," says Guazzo. He doesn't let his "frequent flyer" patients off the hook, either: "I tell them to pack their running shoes."
If a patient can't run, Guazzo suggests walking briskly -- aim for a 15-minute mile. "Get a little perspiration going and you'll know you've stressed your body enough," he says.
Here's the bottom line: Set a good example for your patients. Tell them exercise will help them feel and look better, increase their stamina, improve their circulation, tone their muscles and strengthen their bones. If they still resist, tell them this, says Guazzo: "It improves your sex life. It's true ... it's that cardiovascular business again."
To reach writer Sheri Porter, e-mail sporter@aafp.org.
• Focus on prevention •
Will you have trouble later this year convincing the last few holdouts in your practice that -- yes -- getting the flu shot really is a good idea? Maybe this'll help: A recent study suggests the same shot you give your older patients to ward off the flu bug may help safeguard them from other ills as well.
According to a large cohort study published in the April 3 New England Journal of Medicine, influenza vaccination of patients older than 65 was associated with reduced rates of hospitalization for cardiac and cerebrovascular disease.
The study, conducted by researchers at the University of Minnesota and the Veterans Affairs Medical Center, both in Minneapolis, tracked medical records for more than 286,000 seniors during the 1998 1999 and 1999 2000 flu seasons.
"In the elderly, vaccination against influenza is associated with reductions in the risk of hospitalization for heart disease, cerebrovascular disease, and pneumonia or influenza as well as the risk of death from all causes during influenza seasons," the study authors concluded. "These findings highlight the benefits of vaccination and support efforts to increase the rates of vaccination among the elderly."
Among immunized senior citizens, the study found, the risk of being hospitalized for heart disease was 19 percent lower than that for their nonimmunized counterparts, while the risk of being hospitalized for stroke was as much as 23 percent lower. Researchers also documented a reduction in hospital stays for flu or pneumonia of as much as 32 percent in those who had been vaccinated.
Some clinicians have hypothesized that the influenza virus may alter clotting proteins and impair blood vessel function, thus increasing the likelihood of cerebrovascular or cardiovascular events. Therefore, protecting patients against infection with the virus would be expected to negate these risks.
Go to http://content.nejm.org/cgi/content/full/348/14/1322 to read the study online.
• Focus on prevention •
What can primary care physicians do to help patients overcome their unhealthy behaviors? Practice-based research networks are finding answers to that question through a $5 million initiative.
The Robert Wood Johnson Foundation and the Agency for Healthcare Research and Quality have launched a five-year program, Prescription for Health, to identify primary care interventions for these risk factors: sedentary lifestyle, unhealthy diet, tobacco use and risky drinking.
"What makes this project different is that it is all being conducted in practice-based research," says Larry Green, M.D., director of the Robert Graham Center in Washington and director of Prescription for Health at the University of Colorado Health Sciences Center, Denver. "This represents an invitation to family doctors to innovate and develop tools, techniques, strategies and incentives to help patients deal with these four areas."
The first results from the studies may be released in about a year and a half. Prescription for Health will issue a second call for proposals in 2004. For more information, go to http://www.prescriptionforhealth.org/.
• Focus on prevention •
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For more information about the 2003 Annual Clinical Focus on prevention, go to http://www.aafp.org/x15013.xml.
For consumer-friendly information about fitness, prevention and other health topics, there's no better source than the Academy's award-winning patient education Web site, http://familydoctor.org. For materials in English or Spanish, it's the place to go.
In addition, more fitness information is available at the American Heart Association Web site at http://www.justmove.org/fitnessnews.
Promoting heart health in women isn't just the right thing to do -- it's now "haute couture."
The National Heart, Lung and Blood Institute took the unusual step earlier this year of teaming up with America's most prestigious fashion designers to create the Red Dress Project -- the centerpiece of NHLBI's "The Heart Truth" campaign. The Red Dress Pin symbolizes the ongoing campaign's simple message: "Heart disease doesn't care what you wear. It's the #1 killer of women."
The project represents a partnership of NHLBI; Mercedes-Benz USA; top fashion designers; and 7th on Sixth, the producers of Mercedes-Benz Fashion Week. Nineteen renowned couturiers displayed their Red Dress Project interpretations during the fashion week, held Feb. 7 14 in New York City.
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In addition to the Red Dress Project, "The Heart Truth" campaign includes no-nonsense television, radio and print public service advertisements designed to deliver a wake-up call and help women focus on both their "outer" and "inner" selves.
The PSAs are supplemented by various consumer materials, including:
A speaker's kit is also available to assist health professionals, community leaders and consumers in spreading the word about heart disease to women at the local level. Go to http://www.nhlbi.nih.gov/health/hearttruth/material/material.htm to find out how to order these materials.
And speaking of spreading the word, there's no better time than now to talk with women about all aspects of their health. During National Women's Health Week -- May 11 17 -- thousands of women throughout America will have a chance to focus on improving their health.
Sponsored by the National Women's Health Information Center, a service of HHS' Office on Women's Health, the goal of NWHW is to educate, screen and counsel women about risks to their health and how to avoid them. Partners in the endeavor include national women's groups, local and national health organizations, civic and social services agencies, businesses, and others.
The week kicks off on Mother's Day but really gears up with the first-ever National Women's Check-up Day May 12. On this day, community health centers, hospitals and individual health professionals across the country will encourage women, especially medically underserved women, to receive proper health screenings and other preventive services.
For more information about the week's events, including activities in your area, visit the health information center's Web site at http://www.4woman.gov/whw/ or call (800) 994-9662.
BY CINDY McCANSE BORGMEYER
Residents, July 1 is probably already marked on your calendar. But if it's not, you might want to consider noting it. That's the deadline to comply with resident work hours standards issued in February by the Accreditation Council for Graduate Medical Education.
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Understandably, the standards were one of the hot topics at this year's Residency Assistance Program Workshop for Faculty and Staff of Family Practice Residencies March 31 in Kansas City, Mo. A presentation by Richard Viken, M.D., professor and family medicine department chair at the University of Texas Health Center at Tyler, and Scott Lawrence, M.D., also on the health center faculty, focused on key elements of the standards.
The two presenters first laid out some of the basics of the ACGME guidance, and then followed up with questions for participants to weigh in on. Here's a rundown:
As for family practice programs vying for such an exception -- "Forget it," Viken flatly declared. "There's no way the RRC for Family Practice will honor any 10 percent increase."
"We, as program directors, have to avoid the trap of scheduling people for at-home call on a regular basis because of the possibility that they'll wind up coming in all the time," he said. Once that resident sets foot inside the facility, the 80-hour clock starts.
What's important to remember, said Lawrence, is keeping to the spirit, as well as the letter, of the standards. Ultimately, it's the residency's responsibility to assess each resident's fatigue level, with a goal of ensuring both the safety of the resident and that of the resident's patients.
The ACGME standards are quite similar to AAFP policy on resident work hours established by the Commission on Education and Commission on Resident and Student Issues more than a year ago.
To read the full text of the standards, go to http://www.acgme.org/dutyhours/dutyhourslang_final.asp. A news release about them is at http://www.acgme.org/media/dutyhoursrelease.pdf, and you can visit http://www.acgme.org/dutyhours/dhfaqs.pdf for answers to frequently asked questions about implementing them. Information about accessing and reading PDF files is at http://www.aafp.org/pdf.xml.
To reach writer Cindy McCanse Borgmeyer, e-mail cborgmey@aafp.org.
For more information on these programs, click on the links below.
Tar Wars. Winning posters in the state Tar Wars poster contests must be received at AAFP headquarters by May 16 to be considered for the national competition. For more information, visit http://www.tarwars.org/.
Research. If you'd like a research grant from the Joint AAFP Foundation-AAFP Grant Awards Program, apply by June 1. For an application and details, go to http://www.aafpfoundation.org/x270.xml.
You may have creative ideas for a research project in a practice-based research network. Submit your proposal by Aug. 29 for a PBRN Stimulation Grant. For information, go to http://www.aafpfoundation.org/x446.xml.
Patient education. Note the July 1 deadline for awards to be presented at the 25th Annual Conference on Patient Education Nov. 20 – 23 in San Antonio. The Patient Care Award for Excellence in Patient Education Innovation will be given to a health professional or nonprofit organization. The H. Winter Griffith Award for Excellence in Patient Education Materials will be presented to an individual, practice or organization. For information and applications, visit http://www.stfm.org/awards/awardhub.html.
Family practice residents are encouraged to apply for scholarships or grants to attend the patient education conference. Send AAFP the application with a letter of recommendation from your program director by Aug. 15. Applications are available through your residency and at http://www.aafp.org/pec.xml
BY JANE STOEVER
Input from patient safety stakeholders -- that's what the Academy wanted, and that's what it got at the Strategic Planning Meeting for Patient Safety in the Primary Care Ambulatory Setting here March 27 28.
Early on, FP Thomas Evans, M.D., of Des Moines, Iowa, representing the National Patient Safety Foundation, stressed the need for the meeting. He noted that, at a mid-March meeting on patient safety, someone asked Carolyn Clancy, M.D., director of the Agency for Healthcare Research and Quality, what was happening with patient safety in ambulatory care. Clancy paused, then said, "The ambulatory arena is in chaos."
Evans, a member of the AAFP Commission on Health Care Services, reported that NPSF's efforts have focused on building awareness about patient safety and providing education on communication between patients and health professionals. Most efforts in patient safety have addressed inpatient concerns, he said. "Specific emphasis on the ambulatory arena has been tough to focus." Evans summed up the patient safety climate in primary care: "True north hasn't been identified."
The group spent two days churning out suggestions for how the Academy could help find true north. The recommendations, after being fine-tuned by the Commission on Quality and Scope of Practice, will be forwarded to the Board of Directors.
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"The common response to managing error is swatting mosquitoes rather than draining the swamp." -- Kerm Henriksen, Ph.D. |
Kerm Henriksen, Ph.D., from AHRQ's Center for Quality Improvement and Patient Safety, issued a warning about patient safety efforts in general: "The common response to managing error is swatting mosquitoes rather than draining the swamp." Too often, frontline personnel are at the mercy of hidden problems, he said, such as poor workspace design, miscommunication, supervisory gaps, clumsy automation, inadequate training.
"We're standing at the front part of the patient safety bridge, getting ready to walk across. Studies are under way; results are starting to come in," said Henriksen. "The Academy should educate its members about latent conditions that lead to adverse events. Convert the rich experiences of the membership into common knowledge."
Internist William Golden, M.D., representing the National Quality Forum, said to expect such things as certification of the ambulatory setting, profiling of group practices, reduction of failure rates and public reporting of adverse events.
"Consumers and purchasers of health care are frustrated with the pace of change and don't understand why there is variation in medical practice," he said. "In the average primary care office, three partners will treat three patients differently."
But patients and their problems are not standardized, said George Shannon, M.D., of Columbus, Ga., a member of the Commission on Continuing Medical Education. "Recognizing errors is retrospective. Primary care doctors practice in a prospective fashion. Our environment is multifaceted, not oriented to a single disease state. The educational opportunities we develop have to be in the real world."
Internist Charles Kilo, M.D., representing the Institute for Healthcare Improvement, said, "Our aim is to improve the performance of practices overall," not just patient safety. "Language has a lot to do with the way people will respond," he said.
Safety is defined by what it's not -- error, said Kilo. "Talking about the absence of accidental injury or reducing the harm from hazards does not make me feel good." He compared the negative focus to betting on which baseball team will be the least worst this summer.
"I urge you to think about reliability," Kilo said, "the ability to provide the right care at the right time for each patient." He added that efforts toward reliability have made enormous progress in the last five years.
The group drafted directions the Academy should consider, including:
To reach writer Jane Stoever, e-mail jstoever@aafp.org.
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To the editor:
Why only in malpractice lawsuits does the prevailing party not always have its legal costs paid by the non-prevailing party? That is, if you fall on my property and sue me, the costs all fall on the non-prevailing party. If I prevail, you must pay your attorney, court costs and my attorney. If you prevail, I must pay all costs.
But in malpractice cases, this does not happen. The doctors always pay all of their legal costs even if they prevail.
Even the playing field -- let the plaintiff pay all costs if the plaintiff doesn't prevail! But detractors would say the little guys then cannot sue the big, rich doctors. But yes, they could. The plaintiffs could get bonding beforehand in case they should lose.
This would be one more way to prevent frivolous suits. Or the plaintiff's attorney could foot the costs.
Alan Gunsul, M.D.
Burien, Wash.
To the editor:
As an AAFP charter member, I'd like to express how I feel about universal health care (see "AAFP Chapters Join Grass-roots Effort to Cover the Nation's Uninsured" in the March FP Report).
Together with AMA Past President Edward Annis, M.D., I fought to keep government from intruding on the private practice of medicine.
Before Medicare and Medicaid, we had the most advanced system of care in the world, and no one was dying in the street. Those who could not afford care received it free, and the cost to those who could pay was nominal.
Enter government intrusion, and scores of nonmedical administrative personnel -- not to mention trial lawyers -- are placed between the doctor and the patient. The price of care skyrocketed to where it is today and is still going higher. Before government health care, you had a medical bill only if and when you became ill. If you stayed well, it cost you nothing. Now you must pay over $1,000 every month whether you are sick or not. And the quality of care is decreasing, while the cost increases.
No, we do not desire universal health care; we will do much better without it.
Are there other members who feel as I do? Speak up!
Bernard Vinoski Sr., M.D.
Beaufort, S.C.
To the editor:
I really like receiving the e-mailed FP Report table of contents with links to the online issue. It's like scanning a newspaper -- I can read the headlines and a brief abstract of all the articles in the issue, then delve into those stories that most interest me.
I hope you get lots of support to continue this format!
H.E. "Pat" Crow, M.D.
Sun City Center, Fla.
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To the reader Write us a letter of 200 words or fewer (subject to editing). FP Report, 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672; fax them to (913) 906-6089; call (800) 274-2237, Ext. 5230; or contact fpreport@aafp.org via e-mail. |
To the editor:
I'm a family practice resident, and I want to congratulate the AAFP for its continued pursuit of "health care coverage for all." I read the February FP Report story that described how AAFP spearheaded the effort to get the AMA to pledge to seek a U.S. Congress resolution endorsing coverage for all. However, the AMA resolution said that reform must be "consistent with AMA policy" -- e.g., tax credits and medical accounts that do little to help the increasing numbers of Americans with inadequate coverage. This reveals that the current medical establishment is not committed to reforms that will truly achieve universal coverage.
The AAFP must educate members about both the types of health policies that would expand coverage (including AAFP's own proposal) and methods of political activism. Meanwhile, we must continue working with other specialties that share our goals and collaborate with coalitions that represent our patients.
Physician walkouts for tort reform are not the answer. Let's raise our voices in support of reforms that will achieve universal coverage and transform both the patient-doctor relationship and our specialty. Only then will we capture credibility with local communities, the public and lawmakers as the "go-to" organization for the medical profession.
Jeff Huebner, M.D.
Seattle, Wash.
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Earn 3 hours of CME credit through a new online video CME program, "Diagnosis and Management of Childhood ADHD in the Family Practice Setting." To view the program, go to http://www.aafp.org/x19151.xml. |
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Proven value: Order an AAFP handbook developed for the office setting, "Patient Education in Your Practice" (#953, $34.95). Available online at http://www.aafp.org/pehandbook.xml or by phone. |
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Proven value: Schedule time now to attend the Academy's 2003 Scientific Assembly, Oct. 1 - 5 in New Orleans. Visit http://www.aafp.org/assembly.xml for the latest information. Online registration opens May 31. |
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A shipping fee may apply; Kansas residents pay a 7.525 percent tax. |
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FP Report is published by the
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Copyright © 2003 by
American Academy of Family Physicians.
