BY TONI LAPP
 In a paperless office, patients such as Frances Lowery enter their own (or their children's) medical history with a click of a mouse. |
It's almost ironic: The computer, tool of professional productivity, is enabling doctors to focus more on personal touch in their practices. Take, for instance, Karen Smith, M.D., who started her Raeford, N.C., family practice in April after years of being part of a hospital-owned practice.
"It was an amazing difference; the lifestyle change was dramatic," she said. "It's more than just monetary."
Having an electronic medical record system has enabled her not only to spend more time with patients, but also to have more of a life outside her practice, she said.
"What about the files?"
When Smith made the decision to hang out her shingle in a solo practice, she already knew many of the benefits of having an EMR system, having done her research. She was determined to go paperless.
"When I left the hospital practice, the senior vice president (of the system) asked, 'What about the files?' He wanted to know if I needed to have full access to paper charts, and out of my mouth came the words, 'No, my records are going to be at my fingertips,'" said Smith. "Then my search began."
She went with A4 Healthmatics®, which she described as "a typical EMR system." It offers an on-site EMR server that interfaces with a Web-based billing program and with the lab, as well as with an instant medical history program that allows patients to enter their own histories on the computer.
Smith's decision to go paperless was helped by a dictation bill of $5,000 one month -- about twice the normal fee. "I basically had to take part of my salary and give it to the transcriptionist," she said.
Enter another benefit of having an EMR system: no transcribing.
Instant documentation
When patients arrive at Smith's office, they check in with a receptionist, the same as they would in any traditional practice. Most similarities end there.
While patients wait to be seen, their insurance information is verified by computer with the insurance provider. Gone are the days when 60-day-old claims that have been denied have to be investigated and resubmitted by office staff, resulting in a loss for her practice, Smith said triumphantly.
Once this information has been verified (or updated, if necessary), the receptionist sends an instant message noting that the patient has arrived. The message appears on a computer at the nurse's station and on Smith's computer in the hallway. "I feel like an air traffic controller sometimes," Smith said recently as she checked the status of her patients in various stages of their visits.
Smith has a computer in each of her seven examination rooms, and patients enter their own histories, using the IMH program. The computer "interviews" the patient about symptoms through an interactive Q and A. It can take anywhere from five minutes to 30 minutes, depending on the types of answers the patient gives, said Smith. The IMH might make "suggestions" for treatment based on the answers.
The end result is that the documentation is done at the moment of the visit.
"Before going electronic, I would get home on Mondays at 11:30 at night," said Smith. "I worked through lunch, reviewing labs, doing dictation, completing home health paperwork, etc. There were times I'd have to go in on Sunday after church to do more documentation, do more reviews. The rest of the week, I was lucky to get home by 8:30 at night." Now she works a much saner schedule -- usually 8 a.m. to 6:30 p.m. -- and is able to spend more time with her husband and four children.
Chart reviews
Karen Smith, M.D., says her EMR system has made a "dramatic" difference in her practice. Her system has interfaces among billing, medical records, lab reports and instant medical history. The latter leads patients through an online interview to document symptoms (see photos at left). |
Just weeks after she reopened the office as a private practice, Smith was the subject of an audit by a private insurer. The company wanted clinical data for its insured patients, a task that would have required many charts to be manually pulled -- had Smith been using a paper system. "It was amazing," she said. "With the push of a few buttons, I was able to have that information in a neat fashion in a few minutes."
Patients' views
Smith's fears that patients might be reluctant to enter their own symptoms into their IMH were laid to rest early on. Even elderly patients who have little technical prowess have a curiosity about the computer and are eager to learn, she found. If patients are unwilling or unable to enter their symptoms into the IMH, a third party can still enter the information. And patients who are hard of hearing no longer have to strain to hear the nurse during history-taking.
"I like it," said Frances Lowery, who recently brought her children in for their appointments with Smith. "I want my kids to be familiar with computers, plus it gives you something to do while waiting for the doctor."
With the information literally at her fingertips, Smith was able to pull up growth charts for Lowery's children and show her where they were on the growth curve.
Smith noted that some things are still foreign to patients. "We've had people waiting patiently in the lobby for their prescriptions," she said. "Then we've had to tell them, 'that was faxed directly.'"
But some things haven't changed, she said. "Patients still want that interaction, like 'how have you been,' or 'I saw you at the store.'
"That will never go away."
To reach writer Toni Lapp, e-mail tlapp@aafp.org.
BY J. MICHAEL BRODIE
Bush administration officials have proposed cutting Medicare payments to doctors by 4.2 percent at the beginning of 2004 unless Congress passes legislation to reduce or eliminate the cut.
The proposal, published in the Federal Register Aug. 15, is open for public comment until Oct. 7.
The U.S. Senate and House of Representatives have passed different Medicare reform and prescription drug benefit bills. A conference committee is attempting to work out the differences between the bills and reach a compromise that can pass both houses and be sent to President Bush.
In 2002, Medicare reimbursement was reduced by 5.4 percent. In February of 2003, Congress prevented another cut and allowed a modest 1.6 percent increase.
The AAFP encourages you to contact your lawmakers and explain the impact Medicare cuts have had or may have on your patients. To send your lawmakers an e-mail, go to http://capitol.aafp.org/, click on "Tell Congress to Fix the Flawed Formula," and follow the prompts.
On Aug. 11, administration officials said the Medicare rule would give doctors a "slightly higher" allowance for malpractice insurance costs in 2004 because of "sharp increases" in providers' medical malpractice premiums. But this slight rise would be offset by decreases in the work and practice expense components of the fee schedule. The looming 4.2 percent cut is related to "slow growth in the economy and to a significant growth in physician outlays," said officials.
"This proposed cut demonstrates some of the current flaws in the system," said AAFP President James Martin, M.D., of San Antonio. "Health care costs and practice overhead are not tied to the economy, liability premiums are rising far out of proportion to the current 'adjustments,' and the productivity adjustments are inappropriate for primary care. Patients' medical needs are also not tied to the economy. A number of studies suggest that patients' medical needs increase during economic downturns."
The administration said that the 2004 payment reduction would not adversely affect Medicare beneficiaries or their access to care and that Congress could prevent the payment reduction. However, AAFP data showed a 28 percent increase in members not accepting new Medicare patients after the 5.4 percent cut in 2002.
Under the House bill, Medicare payments to doctors would increase at least 1.5 percent per year in 2004 and 2005. The Senate bill says the Medicare payment formula is "fundamentally flawed" and beneficiaries' access to care "may be compromised" if Congress does nothing.
"The administration may not be in touch with reality," Martin said. "The Academy's own surveys show that more than one in five of our doctors are not even taking new Medicare patients now. Lower reimbursement rates will only add to that problem. There will be an access problem."
To reach writer J. Michael Brodie, e-mail mbrodie@aafp.org.
 "Issues in Health Care" fliers fit in the pocket of this colorful easel, being sent by the AAFP to many active members. The fliers ask patients to contact Congress about health care legislation. |
BY J. MICHAEL BRODIE
Patients are gaining a strong voice in the U.S. Capitol, and the Academy is helping to make that happen.
When critical legislative debate occurs, family physicians will receive e-mails asking them to go to an Academy Web page (http://www.aafp.org/ptvoices.xml) to download helpful information relating to matters before Congress.
The Web site will contain a "Dear Doctor" letter that explains legislative topics and talking points to use in conversations with patients if they bring up the issues during visits with their family physicians.
For the patients, the Web site will have a flier titled "Issues in Health Care." The flier, revised two or three times a year to address new topics, will explain issues in plain English (or in Spanish upon request). Family physicians can download the flier from the Web site and copy it for patients to read in office reception rooms.
The initiative will help patients promote better health care and family medicine by giving them the tools to contact their congressional representatives on issues that affect them.
"Our patients want a voice in their health care," said AAFP President James Martin, M.D., of San Antonio. "Our patients want to speak up for better health care, and we have an opportunity to help them."
The AAFP is sending an easel to AAFP active members in solo, joint and multispecialty practices. The easels will hold the "Issues in Health Care" fliers that aim to get patients' attention and action.
If you do not soon receive an easel and would like to be part of the advocacy initiative, or if you would like additional easels for your office, call (800) 944-0000 and request item #305. The first 500 callers will receive the colorful 11" x 15" cardboard easels for free. Subsequent callers will be charged $10. A family physician can just print off the flier from the Internet, place the copies in the easel pocket, and set or hang the easel in the waiting room.
Patients will be asked to contact their members of Congress via e-mail, using the "Patients Speak Out" page on the AAFP Web site. While e-mails are the quickest way to reach Congress, the site also will have a third piece to assist FPs and patients -- a sample letter for patients who prefer to send faxes to their elected officials. The Academy does not recommend using regular mail because security procedures have slowed down the mail in Washington.
The current issue addressed on the Web site is the Medicare physician fee schedule. Eventually, other legislative materials will be available.
Martin said the Academy is providing a focus on how federal health issues impact both patients and family physicians. The new AAFP materials will give FPs what they need to discuss the issues with their patients so the patients can make their voices heard.
"As family physicians, we know that family medicine is the key to better health care in the United States," he said. "We also know that the issues we support bear a direct link to improved care for our patients, but our patients can also understand our frustration with governmental policies that propose unnecessary or inappropriate red tape and how that interferes with their care."
Martin said the initiative will help patients amplify the voice of family medicine before Congress.
"We can influence legislators to make health care laws and rules that will lead to better health care for our patients and will allow us to focus not so much on paperwork but, refreshingly, on providing better care to our patients," he said. "We want our patients' message to be effective and relevant."
To reach writer J. Michael Brodie, e-mail mbrodie@aafp.org.
 Cynthia Romero, M.D. |
BY SHERI PORTER
"They truly welcomed me with open arms," said Cynthia Romero, M.D., of Virginia Beach, Va., reflecting on her one-year term representing new physicians -- those in practice seven or fewer years -- on the AAFP Board of Directors. Because Romero was the first to hold this new seat on the Board (she was installed at the October 2002 Scientific Assembly in San Diego), FP Report asked Romero to share some thoughts about the past 11 months of her tenure.
Q: What have you enjoyed most about your position on the Board?
A: It's been an extremely productive year. What an enlightening experience to sit at the table with such dedicated, committed and passionate family physicians. It was an opportunity for me to work with individuals who keep their eyes on the bigger cause -- finding the best way to serve our colleagues across the country -- as we provide quality care to our patients.
Q: Do you feel you were able to influence Board decisions?
A: Yes. The Board has given me great respect and the freedom to express my opinions. In fact, in the beginning, Board members specifically asked me if I had anything to share. I've never felt intimidated, just humbled. The extent to which Board members take the time to listen to my perspective on issues goes far beyond what I had imagined.
Q: What specific issues has the Board tackled during your term?
A: The biggest issue has been the electronic health records project -- it was on the agenda at my first Board meeting. This project has brought the AAFP national attention and respect. Widespread implementation of an EHR system will help family physicians improve patient safety, promote quality of patient care and bring increased efficiency to our practices.
I've made it a point to share my views on topics that address specific needs of new physicians. I am sensitive to the needs of those members since I'm living through the same issues. Specific topics included providing discounts for CME programs and how to disseminate to new physicians practical "how-to" practice information on topics such as hiring and firing staff, managing supplies, and improving record keeping.
Q: How has this experience changed you?
A: Because of what I've seen at the Board level, I'm looking forward to a long, promising career in family practice. I'm more aware of the need to reach out to young minds -- students in medical school, college or even elementary school -- to show young people the quality of life we have as family physicians. I've seen the benefits of good organizational leadership, and that has convinced me to continue to seek leadership roles.
Q: Do you have any regrets?
A: My only regret is that this experience is coming to an end. My time on the Board has been limited, but I know that I have opened the door for physicians coming in behind me. It's time for someone else to enjoy this experience.
Q: Should the new physician Board seat be continued?
A: Yes, absolutely. Clearly, a physician who has been in practice fewer than seven years has a unique perspective on the issues that all family physicians face. In fact, I wish it were possible for all members to take Academy leadership roles at some point in time so they could see the good work that goes on at the Board level.
Editor's note: If approved by AAFP's Congress of Delegates in early October in New Orleans, Lisa Corum, M.D., of Fort Mill, S.C., will take over Romero's duties as new physician representative on the Board of Directors.
To reach writer Sheri Porter, e-mail sporter@aafp.org.
 |
A record 56 percent of respondents to the 2003 AAFP Member Attitude Survey said they were "very satisfied" with the Academy when comparing it with other medical associations. Overall, 85 percent viewed AAFP favorably (see the chart).
Moreover, 74 percent -- including 27 percent who "strongly agreed" -- said AAFP did a good job representing family physicians to the rest of organized medicine. An almost identical 73 percent agreed that the Academy was doing a good job representing family medicine to the public. Sixty-five percent said the Academy was doing a good job representing the specialty to the government.
In addition, 92 percent of survey respondents said they were well-informed about major actions and programs of the AAFP. Those who "strongly agreed" rose from 36 percent last year to 47 percent in 2003. The majority of members said they received that information through American Family Physician (81 percent) and Academy mailings (59 percent). Many members also said they obtained the information from the Web site (http://www.aafp.org), Family Practice Management and FP Report.
The respondents gave the highest rankings to these AAFP products and services: computerized CME record keeping, American Family Physician, the Academy Web site, patient education materials, toll-free phone number, Family Practice Management, regional CME, Annual Scientific Assembly and the AAFP Web site for patients (http://familydoctor.org).
Seventy-two percent of respondents said family physicians provide higher-quality health care now than 10 years ago. Ninety-three percent said outside regulations were making it more and more difficult to practice medicine.
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Ready for a health education publication with style and substance that you could set out with pride in your waiting room? Want extra copies that you could give to patients on request -- free?
Good news: Your wait will be over in the first quarter of 2004. That's when Family Doctor: Your Essential Guide to Health and Wellbeing is scheduled to start shipping.
It's a consumer health publication produced and distributed by the AAFP in partnership with custom publisher Boston Hannah. The publication, to be provided free to AAFP members' practices, will:
More than 500,000 copies will be available for use as permanent display copies in AAFP members' waiting rooms; for handing out to patients on request; and for purchase on http://familydoctor.org, AAFP's health education Web site. Supported by advertising, the publication will be updated annually.
As the Oct. 16 compliance date for the Health Insurance Portability and Accountability Act's transactions and code sets standards draws near, the Academy continues to provide resources to members via the AAFP Web site.
Go to http://www.aafp.org/hipaa.xml -- the AAFP's HIPAA resource Web page -- to check out the latest additions. To access new items, click on "Ready to Go" and then on "Transactions and Code Sets Standards."
Scroll down the list of selections. The items listed below are new:
Recently the Academy surveyed all active members available by e-mail to ascertain their level of knowledge about and readiness to implement the filing of electronic claims compliant with the Health Insurance Portability and Accountability Act.
Responses were received from 1,200 members. Highlights of the survey questions and answers are:
The survey's last question was perhaps the most telling. When asked, "Has your practice started testing the required X12837 billing form with payers?" 23.8 percent of respondents said yes, 27.9 percent said no, and 46.8 percent said they didn't know. Some 1.5 percent didn't respond.
"The survey numbers indicate that FPs rely heavily on electronic claims submission and they are aware of the necessary changes to maintain cash flow following Oct. 16," said John Swanson, director of the AAFP Division of Socioeconomics. However, it is a bit discouraging to see that just roughly a quarter of AAFP members have begun testing their insurance claims, said Swanson. "Without testing now, there's no way for a practice to know what kinks in the system might kick their claims out come October."
Go to http://www.aafp.org/fpr/20030800/1.html to read a story from the August FP Report on the upcoming TCS standards deadline and how to prepare for it.
Ensuring that low-income patients get the prescription drugs they need is a concern for many family physicians.
Now,
a collaboration with Volunteers in Health Care -- a resource center funded
by the Robert Wood Johnson Foundation -- will allow AAFP members to tap into
VIH's extensive resources on pharmaceutical assistance programs. PAPs generally
provide medications at no cost to patients with low incomes and no prescription
coverage.
A pilot program at three family practices -- in New Mexico, Texas and Maine -- is now under way. VIH is visiting the practices to help staff members develop and improve systems to access medications through the myriad PAPs offered by pharmaceutical companies. The three practices were selected from those of members of the AAFP Committee on Special Constituencies.
The results of the program will be released at the January meeting of the AAFP committee, when committee members will discuss how to best disperse the findings from the practice visits to all AAFP members.
Of course, members already have access to tools to tackle medication access problems. These tools include:
The Congress of Delegates will consider three amendments to the AAFP Bylaws during its meeting Sept. 30 Oct. 2 in New Orleans. The proposed amendments call for these changes:
You can review the proposed amendments at http://aafp.org/congress.xml or can request a copy of them by calling (800) 274-2237, Ext. 6602.
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Despite a Medicare reimbursement cut in 2002, family physicians reported a jump in income for that year in a recent AAFP survey. The Academy asked, "What was your 2002 net individual income (after expenses) from medical practice before taxes?"
The 1,541 respondents to this section of the two-part survey had an average income of $142,400 for 2002. A snapshot of FPs' mean income since 1992, not adjusted for inflation:
| 2002....... | $142,400 |
| 2001....... | $134,000 |
| 2000....... | $137,000 |
| 1999....... | $133,900 |
| 1998....... | $133,900 |
| 1997....... | $134,100 |
| 1996....... | $136,100 |
| 1995....... | $133,900 |
| 1994....... | $120,900 |
| 1993....... | $114,700 |
| 1992....... | $109,900 |
"Income leveled off near $134,000 in 1995 and stayed close to that until 2002," says Greg Tolleson, manager of data analysis and collection in the AAFP Research and Informa-tion Services Division. "This is the first clear raise for family physicians in seven years."
A sampling of other survey results, most of them similar to last year’s results:
One survey result that gained media attention last year dealt with whether respondents' practices were accepting new Medicare or Medicaid fee-for-service patients. (The results were adjusted for nonresponse, a statistical application that was not applied to figures in the rest of this story.) In 2001, 17 percent of respondents were not accepting such new patients; in 2002, 21.7 percent were not; and in 2003, 23.9 percent were not. "The 23.9 percent is not a statistically significant increase from last year, because of a plus-or-minus 2.5 percent margin of error," says Tolleson. "But the difference between this year’s 23.9 percent and the 2001 figure of 17 percent is statistically significant."
 Kondracke |
What's around the corner in health care? The Academy's 2003 and 2004 Scientific Assembly keynote speakers promise to provide insights into that question.
Morton Kondracke, a Washington-based journalist and long-time political commentator, will address Medicare, Social Security and other policy issues Oct. 2 during this year's Assembly in New Orleans.
Francis Collins, M.D., Ph.D., director of NIH's National Human Genome Research Institute, will be the keynoter for the Assembly Oct. 13 - 17, 2004, in Orlando, Fla. The meeting, to be held in conjunction with the world conference of Wonca (the World Organization of Family Doctors), will mark the launch of AAFP's 2005 Annual Clinical Focus on genomics.
WEB
EXTRA!
 Darrell Carter, M.D., talks with students and residents about managing trauma patients with hard-to-secure airways in a rural practice. |
About 3,000 people live in the tiny town of Granite Falls, Minn. Just about all of them have visited the office of Darrell Carter, M.D., at one time or another. And in the surrounding area, another 18,000 patients call Carter's practice "home."
"I set out to help one patient at a time, to use my God-given talent to make lives a little longer and a little happier," said Carter, a family physician at the Affiliated Community Medical Centers P.A. in Granite Falls and the AAFP 2003 Family Physician of the Year. Carter spoke Aug. 7 to students and residents attending the National Conference of Family Practice Residents and Medical Students in Kansas City, Mo.
Long gone is the signature beard "Dr. Darrell" -- as he is known in the community -- sported in the early days of his practice more than 30 years ago. He spoke almost matter-of-factly as he showed conference attendees slides of his interactions with patients and shared stories of his career.
Earlier that day, Carter talked about his experiences working with critically ill or injured patients in remote settings. His free-ranging chat covered critical care algorithms, managing patients with hard-to-secure airways and rapid sequence intubation.
Carter is known throughout Minnesota as the founder of the Comprehensive Advanced Life Support program, or CALS. It trains rural providers to manage crisis health situations with limited resources. Since its inception in 1996, more than 1,000 medical professionals have been trained in CALS.
Carter also serves as volunteer medical director for Project Turnabout, a nonprofit chemical dependency-compulsive gambling program, and for the Granite Falls ambulance service. In 2001, Carter was named the Minnesota Rural Partners' Rural Health Hero for his innovative work, leadership skills and efforts to establish CALS programs throughout the state. He was also chosen Family Physician of the Year by the Minnesota AFP that year.
Carter said he has enjoyed the time he has spent serving patients in the Minnesota hinterlands. The opportunity to know them as friends and neighbors and to share in their life journeys is part of what makes rural family practice special, he said.
"Where else but in family medicine could we have so many opportunities
to stretch the limits of our talents in service to others?" asked Carter.
He said he's turned down larger teaching opportunities to remain in rural
practice but has no regrets: "It's made it possible for me to grow."
• Resident and Student News •
Past,
present, future converge at 30th National Conference Attendees at this year's National Conference of Family Practice Residents and Medical Students Aug. 6 - 9 in Kansas City, Mo., had a chance to rub elbows with past resident and student leaders -- many of them now Academy leaders. The students and residents were also able to voice their opinions on issues confronting family medicine and to choose representatives who will help lead the specialty into the future. Out of 2,591 total registrants, 529 residents and 628 students attended the conference.
by J. Michael Brodie
 Lori Alvord, M.D. |
A young Navajo woman comes to the Gallup Indian Medical Center in Gallup, N.M., looking for Lori Alvord, M.D., the surgeon.
"My sisters won't eat my fry bread," the woman tells the surgeon. The woman has breast cancer, which in her community is something to be feared. She is shunned by the members of her tribe, by her own family.
But soon after her visit to the surgeon's office, the woman will take part in a night chant in which the tribal yei'ii, or dancers, don traditional garb -- that of the talking god, the clown and the hunchback. Through their surefooted steps and rhythmic chants, the dancers celebrate the beauty of earth and sky and call for the gifts of good health and nature's bounty.
The ceremony is important to the young woman. It clears her mind of all thoughts. It readies her for cancer surgery. It also readies Alvord for her role in that procedure.
"It matters that your environment is pure," said Alvord, who delivered the Stephen J. Jackson, M.D., Memorial Lecture at the AAFP National Conference of Family Practice Residents and Medical Students Aug. 8 in Kansas City, Mo. "The ceremony is a way to heal the healer as well. Words have an extraordinary power.
"One thing was certain after the surgery: No one would be afraid to eat Carolyn Yazi's fry bread anymore."
Alvord is the first Navajo woman to become a surgeon. She grew up on a Navajo reservation in New Mexico where she attended public schools that were 95 percent Navajo. One of the few students in her graduating class to attend college, she enrolled at Dartmouth College in Hanover, N.H., later earning her medical degree from Stanford University in Stanford, Calif.
"I was raised with tribal people, and I didn't know what to expect from college," Alvord said. "I had to try to reconcile two cultures."
Her book, The Scalpel and the Silver Bear, describes the healing practices of the Navajo people and the challenges Alvord faced on entering the realm of Western medicine. Her book comes at a time when alternative medicine is garnering attention, and many patients are turning from Western medicine -- with its pills, costly equipment and modern procedures -- to other forms of healing.
"It is ironic that the so-called primitive cultures are the ones making medical breakthroughs," said Alvord, now a practicing surgeon at Dartmouth-Hitchcock Medical Center and associate dean of minority and student affairs at Dartmouth Medical School. She referred to a long-held Navajo belief in the power of words and the thoughts that propel them -- that both good and bad can be "spoken" into existence -- calling to mind biofeedback techniques that have been shown to boost immune system function.
Thought and spirit are integral parts of the Navajo healing process, as is an appreciation of the beauty inherent in all things. Illness, Alvord explained, results from being out of balance or harmony in any area of life. It is the healer's task to restore that harmony.
"I became a surgeon because I love the beauty of the human body," she said, "and I wanted to restore the beauty of that body."
To reach writer J. Michael Brodie, e-mail mbrodie@aafp.org.
Some things really are just skin deep. Take the skin characteristics of blacks, for example. Researchers are finding that the same skin disorders can take on different appearances in blacks than in whites, on whom most skin research is done.
"There have been (black) families charged with child abuse because of marks on the skin," said Richard Usatine, M.D., who presented "Dermatology in African Americans" Aug. 8 at the National Conference. Usatine, assistant dean of student affairs and associate clinical professor of family medicine at the University of California, Los Angeles, urged physicians who work with black populations to learn the differences in skin characteristics of divergent racial groups.
Skin diseases occur in all types of skin, regardless of the pigment of the skin, said Usatine. But there are skin problems that are more common among blacks than among whites. And there are skin characteristics that are quite natural and harmless in blacks but that would be seen as problems if they occurred in whites.
Usatine said certain types of hyperpigmentation, for example, are quite common in blacks after even minor trauma. An area of the skin may darken after an injury such as a cut or a scrape or after certain skin disorders. Other conditions, such as some forms of dermatosis, are part of the aging process in blacks.
"The dermatosis papulosa nigra disorder seems to have a genetic predisposition," he said, adding that simple excision of the papules with sharp iris scissors may be all the treatment needed.
Vitiligo, which came to the public's attention when entertainer Michael Jackson was diagnosed with it, is a condition in which pigment cells are destroyed and irregular white patches appear on the skin. It has been estimated to affect 1 percent to 2 percent of the total U.S. population and can cause extreme distress to sufferers because of its unusual appearance.
"If you were to touch the skin, it would feel the same as normal skin," Usatine said. "No one knows what causes this condition, but they do make special makeups that can help."
To reach writer J. Michael Brodie, e-mail mbrodie@aafp.org.
BY LESLIE CHAMPLIN
Mother Nature designed humans to breastfeed, but for 50 years, many patients and physicians have ignored that fact. Now, however, medicine and the public have begun to revisit the health benefits of mother's milk for newborns.
Family physicians should be at the forefront of that trend, say David Meyers, M.D., assistant professor and director of the CAPRICORN Research Network in the Department of Family Medicine at Georgetown University in Washington, and Julie Wood, M.D., faculty member at the Baptist-Lutheran Family Practice Residency in Kansas City, Mo. Meyers and Wood spoke Aug. 7 to packed sessions of "Breastfeeding 101" and "Breastfeeding 201" during the National Conference.
The rate of breastfeeding began to slide in the 1950s and has never fully recovered, said Meyers. The environmental and women's movements in the 1970s prompted a small revival of breastfeeding, but interest dipped again in the 1980s.
New breastfeeding guidelines issuedThe U.S. Preventive Services Task force recently released its first-ever set of breastfeeding guidelines. Those recommendations, along with a research article on the effectiveness of primary care-based interventions to promote breastfeeding, were published in the July/August Annals of Family Medicine. To view the guidelines, go to http://www.annfammed.org/content/ vol1/issue2/index.shtml and scroll down to the link to the USPSTF item. |
Over the past decade, breastfeeding has regained some acceptance as research has consistently demonstrated health benefits to mothers and their children, said Meyers. Studies have shown dramatic reductions in incidences of common infantile illnesses -- diarrhea, lower respiratory infections, otitis media and urinary tract infections -- among breastfed infants. These babies also experience far fewer serious illnesses, including bacteremia and sepsis, bacterial meningitis, sudden infant death syndrome and necrotizing enterocolitis.
Equally important, breastfed babies develop fewer chronic conditions such as asthma or allergies, show better cognitive progress, and exhibit more stable psychological development, Meyers said. And their mothers are at lower risk for postmenopausal hip fractures and ovarian and breast cancers.
The data have prompted national medical organizations to adopt policies supporting goals set in the U.S. Public Health Service's "Healthy People 2010" initiative. Those goals -- that 75 percent of newborns, 50 percent of 6-month-olds and 25 percent of 1-year-olds be breastfed -- have not yet been met. Several obstacles stand in the way. Society discourages breastfeeding, and the medical community has little knowledge and less interest in promoting the practice, said Meyers.
Active support from family physicians can wear down those barriers, said Meyers and Wood. The first and most important step is eliminating physician ignorance and apathy.
"We don't really care, and we have misinformation and myths that we learned from the culture and that we pass on," said Meyers.
By educating expectant parents about the birthing process, health benefits of breastfeeding and techniques for successful nursing, family physicians can influence the short- and long-term health of their patients. The AAFP's position paper on breastfeeding, available at http://www.aafp.org/x6633.xml, calls on family physicians to become breastfeeding advocates by working through health care settings such as community clinics, supporting changes in public health policy, and implementing breastfeeding-friendly procedures in their offices and hospitals.
According to the World Health Organization, baby-friendly hospitals have:
To reach writer Leslie Champlin, e-mail lchampli@aafp.org.
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 Carter |
 Turner |
 Brown |
 Laming |
Delegates to the National Congress of Family Practice Residents and National Congress of Student Members on Aug. 9 elected the following officers to represent them in the coming year:
Students and residents attending the conference testified on multiple issues facing the Academy, the specialty and the nation. Here's a sampling of resolutions considered by the two congresses, along with the source of each resolution.
 "It is the responsibility of this Academy to provide information that we can use in good decision making," says Angel Foster of Harvard University, Cambridge, Mass., of a student resolution concerning reproductive health education for physicians. |
The congresses asked AAFP to:
More information on resolutions considered by the congresses is scheduled to be published on the National Conference Web site at http://www.aafp.org/conference.xml. Check there later this fall for updates.
The two congresses tackled other tricky topics -- including additional reproductive
health issues and the definition of
marriage -- occasionally splitting on how they voted to handle those measures.
 Officially recognizing domestic partnerships between same-gender couples seems a logical extension of AAFP's positions supporting diversity and family health advocacy, says Abbas Hyderi, M.D., of the Oregon Health & Science University Family Practice Residency in Portland. |
 Amy Miglani, M.D., of the family practice residency at Montefiore Medical Center, Bronx, N.Y., says she's cared for many young women who could benefit from a resolution she helped write that's meant to safeguard FPs' ability to care for their reproductive health patients. |
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The National Congress of Family Practice Residents and National Congress of Student Members tackled some tricky issues Aug. 9, sometimes splitting on how they voted to handle those measures. For example, residents voted to refer to the AAFP Board of Directors a resolution calling for the Academy to recognize marriage as a "partnership between two individuals regardless of gender or sexual orientation." Students took a more definitive stance, narrowly adopting a resolution asking the AAFP to advocate extending the "civil rights, privileges and responsibilities of marriage to couples regardless of gender or sexual orientation."
Patrick Conner, a student at East Tennessee State University, Johnson City, was among those opposing the measure. "We don't need this resolution," he said. "We don't have to isolate ourselves or do something that may make our patients angry."
Compared with their action on the marriage resolution, the students seemed more hesitant on other reproductive rights resolutions. Whereas each resolution received a thumbs-up in the resident congress, students voted both of them down.
The first resolution asked the Academy to oppose infringement on a physician's ability to "treat, counsel or refer patients for reproductive health care that is within the physician's scope of practice." In the second, residents called for AAFP to support a proposal to the FDA making progesterone-only emergency contraception available over the counter. They further asked the Academy to recommend to the FDA labeling that would encourage patients to contact a primary care physician, clinic or the product distributor for counseling about use of such products.
Resolutions regarding the length of family practice residency training also drew mixed reactions from students and residents. A measure introduced in the student congress that called for the AAFP to "declare an official position in favor of a four-year family medicine residency" was not adopted. Rather, students took the position that the Future of Family Medicine project would address this issue in due time.
Residents considered a resolution calling for the Academy to "explore the creation of four-year residency programs for rural track family practice residents." After vigorous debate -- including rejection of a proposed amendment to omit the words "rural track" -- the congress adopted the measure. Much of the debate centered on concerns about funding an additional year of training and whether extending rural residency programs to four years would result in discontinuation of existing rural fellowships, eliminating the option of training for rural practice after completion of a three-year residency.
Craig Denham, M.D., of the University of Louisville (Glasgow, Ky.) Family Medicine Residency shot straight from the hip with his concerns about the prospect of extending family practice residency training. "We've got to cut the cord sometime and get people out of residency training," he told his colleagues in the congress. "Longer training isn't necessarily better training, and we're going to drive people into peds or general medicine."
To reach writer Cindy Borgmeyer, e-mail cborgmey@aafp.org.
WEB
EXTRA!
BY CINDY BORGMEYER
Like most practicing family physicians, Katherine Miller, M.D., sees a lot of patients with a lot of different health problems. And, like other FPs, she's devoted to solving those problems. For Miller, that's become quite a sticking point.
 Jana Nussen, M.D., of the Bryn Mawr Family Practice residency, examines a model displaying acupuncture meridians and pressure points. |
Miller, assistant clinical professor of family medicine and community health at Tufts University in Boston, is one of some 20,000 certified acupuncturists in the United States. About one-third of them are medical doctors, she told students and residents during her Aug. 8 workshop at the National Conference of Family Practice Residents and Medical Students in Kansas City, Mo.
Acupuncture certification requirements vary from state to state, Miller explained, with four states providing no regulation of the practice. In most states, MDs and DOs can legally practice acupuncture with no formal training. "Only 12 different states -- although this may have changed recently -- require physicians to get specialized training," she said. In contrast, most states require other health professionals to be certified by the National Certification Commission for Acupuncture and Oriental Medicine.
A look at the numbers may help explain why.
Americans make more than 12 million visits to acupuncturists each year, said Miller, seeking treatment for a wide range of conditions. Many of those patients apparently find the relief they seek, a result borne out by a growing number of well-designed clinical trials.
Take postoperative pain and nausea, for example. A 2001 study in the journal Anesthesiology found that patients treated with acupuncture used half as much intravenous morphine for pain after surgery as the control group used. Patients in the treatment group also experienced less postoperative nausea compared with those in the control group. The study further demonstrated 30 percent to 50 percent reductions in levels of plasma cortisol -- a known indicator of stress -- in patients treated with acupuncture.
Those results reaffirm a 1997 NIH consensus statement that found acupuncture effective as a primary treatment for adult postoperative pain, nausea and vomiting caused by chemotherapy, and postoperative dental pain. The NIH statement also upheld the usefulness of acupuncture as an adjunctive treatment for several other conditions, including headache and fibromyalgia, and for rehabilitation after stroke.
 Course leader Katherine Miller, M.D., uses a pen and a volunteer to show the proper placement of a commonly used acupuncture point. |
Miller is the first to admit that it's difficult to ascertain exactly how acupuncture works, although some studies have suggested that the placement of the needles used in acupuncture causes endorphin release.
As for the why, she told participants at the session: "You have to take your brain out of your allopathic training. This has nothing to do with your allopathic training; there's no match-up with it. So forget about it for a minute."
She gave a brief overview of the philosophy behind traditional Chinese medicine, beginning with an explanation of Qi, pronounced "chee." "Qi is sort of a life force, a life energy. It's what lets you think, it's what makes you move," Miller said. When Qi is out of balance, when it fails to flow smoothly along the body's 12 main meridians, or pathways, that's when problems develop. Acupuncturists use needles to redirect the flow of Qi.
Go online to read upMiller recommends visiting these Web sites for reliable acupuncture information:
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In this context, treatment -- that is, proper needle placement -- varies
according to the nature of the problem. "For example, when you break
a bone, or you get a sprain, the thought is that all of the energy goes to
that place and gets stuck there, and that's why you have so much pain. So
the goal in that case is to pull the energy away from there," she said.
In other instances, such as with chronic low back pain, Qi may be depleted,
said Miller. In that case, the needles are placed to increase the flow of
Qi through the affected area.
Diagnosis is based largely on the symptom complex described by the patient, although some acupuncturists also use the traditional tongue exam and pulse diagnosis techniques. More advanced practitioners may even integrate patients' food, temperature and color preferences into the diagnostic process.
Reimbursement can be an issue, Miller admitted: "Sometimes you need to get a little creative." Once you've agreed on specific treatment goals with a patient, she recommends setting up an initial timeline for treatments -- once a week for one month, for example -- to gauge whether treatment is likely to succeed. Then treat until therapeutic goals have been met.
To reach writer Cindy Borgmeyer, e-mail cborgmey@aafp.org.
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To the editor:
I read the article in the July FP Report on maintenance of certification. The new rules look more and more like the Joint Commission on Accreditation of Healthcare Organizations "rules." Most if not all physicians believe JCAHO is a hindrance to patient care. Now our own Academy is about to go down the wrong road with the best of intentions. I predict the same results that JCAHO has achieved. Lots of additional paperwork. Lots of changes. Patient care loses. The paperwork involved will grow exponentially, as with the Health Insurance Portability and Accountability Act. Patient care will suffer because of the increased effort to keep up with the added paperwork. Doctors' income will suffer. There is no foreseeable benefit, only harm. Although I believe change is needed to assure quality care, I doubt this approach will benefit anyone other than the new group of "consultants" that will come out of the woodwork to offer their help to meet recertification requirements. The idea is good. This approach is wrong.
Scott Johnston, M.D.
Wright, Wyo.
To the editor:
| 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. |
This letter responds to Dr. Johnston's letter expressing concerns about the American Board of Family Practice's new Maintenance of Certification Program for Family Physicians, or MC-FP. The ABFP is very sensitive to the issues he has raised and has attempted to address them in planning for the introduction of MC-FP in January.
First, let me clarify that the maintenance of certification process is a mandatory initiative of the American Board of Medical Specialties, an organization of 24 medical specialty boards, including the ABFP. This new process responds to national concerns about the quality of the American health care system.
Each board was required to submit its plans for a specialty-specific maintenance of certification process to the ABMS by July 1, 2003, with implementation to follow shortly thereafter. The ABFP has designed MC-FP so that it will take no more time than the current recertification process. The only difference is that Diplomates will be asked to participate in selected components on a regular basis (namely, the Self-Assessment Modules in Part II). It is important to note that the actual amount of time spent completing these modules, as well as the Performance in Practice Modules in Part IV, will be credited toward the 300-hour CME requirement. Diplomates will be able to complete these modules from their home or office computer, thus offsetting some of the cost and time they would have incurred obtaining CME.
The ABFP believes that the cost of participating in MC-FP will be less than that associated with the current recertification process. The cost of accessing MC-FP via the Web should be offset by the savings realized by CME offsets for completing parts II and IV, and by avoiding travel, hotel costs and lost income from practice now associated with taking the recertification exam at a limited number of written test centers on a single day (by 2005, the exam will be offered by computer at more than 200 sites and on multiple dates).
MC-FP is designed to be a value-added activity for physicians. In the future, reimbursement will be tied to quality. The ABFP expects participation in MC-FP to satisfy these requirements, as well as those being discussed by several state licensure boards.
MC-FP will help board-certified family physicians provide even better care to their patients by continuously measuring their ongoing competencies in medical knowledge, patient care, interpersonal and communication skills, professionalism, practice-based learning and improvement, and systems-based practice. As a result, the process will help assure the American public that every ABFP Diplomate has met the highest standards of accountability.
James Puffer, M.D.
Executive Director
American Board of Family Practice
To the editor:
I wish to add my support to the letter "Midlevel Providers Undermine Specialty of Family Practice" in the July FP Report.
Medicare's fees are a third of what my "fee-for-service" patients pay. Insurance companies have offered contracts at 80 percent of Medicare allowable rates. They can do this because there is an "oversupply" of primary care providers. Insurance companies do not care whether patients receive care from family physicians or by less-qualified nurse practitioners or physician assistants.
To borrow from Jonathan Swift, I wish to make a modest proposal. We should reduce the number of family medicine residency positions by up to 50 percent. This will eliminate our "fill rate" problems. Following supply-demand economics, our value will increase.
This strategy only works if we also address the midlevel provider problem. We should resist all attempts by them to practice independently. They are not qualified to see patients without supervision. We should also discontinue employing midlevel providers in our office.
Initially, practice income will decrease from the loss of "passive income" from midlevel providers. The loss of residency slots will further shift the percentage of primary care to specialist physicians. But there is a payoff: We will gain respect from our patients by becoming their "physician," as opposed to their "primary care provider." Having fewer providers of primary care services will increase our demand and our negotiating power, allowing us to receive fair compensation for our time.
Kenneth Woliner, M.D.
Boca Raton, Fla.
To the editor:
I read with great interest the August FP Report story "HIPAA Transactions Standards: Ready or Not, Here They Come."
Let me share my experience. According to my office manager, we've been through the first of three computer software upgrades to deal with changes to implement the Health Insurance Portability and Accountability Act.
During this first upgrade, changes were made from our end and from our clearinghouse (which then sends out claims to each individual insurance company). We had claims rejected because of problems on both ends and had to refile some of those rejected claims three times before the software problems were corrected.
Our cash flow during this time was down about 15 percent, and the lag time to get that money back in our system was three to six months.
I have taken out a $50,000 line of credit that I can tap into at any time. Fortunately, I haven't had to do that yet, but I have told my wife and family that I don't feel we should plan any big vacations or buy any big-ticket items until we are all the way through this transition.
Ed Bujold, M.D.
Granite Falls, N.C.
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An AAFP CME course, Case Studies in Family Medicine, will debut Feb. 26 - 28 in San Francisco. The course will feature case studies in two-hour segments on clinical topics. Tentative topics include asthma, diabetes mellitus, hypertension and stroke, menopause and hormone replacement therapy, headaches, and pediatric development. Some topics offered will be covered in the self-assessment modules that form part of the American Board of Family Practice Maintenance of Certification Program for Family Physicians, or MC-FP. The case studies course may assist physicians participating in MC-FP, to be introduced in January. For more course information, go to http://www.aafp.org/x23277.xml. The registration information will soon be posted. |
Proven value: AAFP Home Study is now in its 25th year of providing CME to members -- in fact, nearly 200 members have been subscribers since the first issue premiered in 1978. Home Study components include FP Audio (the monthly audio series that provides practical discussion on hot topics), FP Essentials (the monograph series with a six-year FP curriculum), and FP Comprehensive (a collection of the above programs on one CD-ROM). Check out online samples at http://www.aafp.org/homestudy.xml and then join the more than 6,500 members who currently subscribe. Questions? Call (800) 274-2237, Ext. 5298. |
| Proven value: It's back-to-school time, and that means lots of young patients showing up in your office for sports physicals. Stock up on a tool that will help -- AAFP's Preparticipation Physical Evaluation (second edition). This is the only publication on sports physicals endorsed by five major medical societies. It's comprehensive, easy to read, and contains charts and illustrations. The following items are available at special discount prices: PPE Monograph (#227), reduced to $14.50, and the PPE Exam Tear Pad (#228), reduced to $4.50. Order by phone or through the online catalog at http://www.aafp.org/shop/227. |
| A shipping fee may apply; Kansas residents pay an 8.05 percent tax. |
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