 Thrill of victory: Mary Frank, M.D., center, flanked by sisters Joanne, left, and Cathie, celebrates news of her election. |
Truly, women have "arrived" in the AAFP. Or, New Orleans-style: Les femmes sont arrivées! Delegates proved that during the AAFP Congress of Delegates Sept. 30 - Oct. 2 in New Orleans when they elected Mary Frank, M.D., of Mill Valley, Calif., the Academy's first woman president-elect. Go to "Academy delegates choose new leaders, ABFP finalists" to read about all of the officers and directors chosen for 2003 - 2004.
Yet in an interview after her election, Frank preferred to focus not so much on her gender as on how she views her role as an Academy leader.
"You could hear the glass ceiling tinkle" when the election result was announced, she said with a smile. However, for her, it's never been about being the "first woman to do this or that," she said. It's simply been about doing what she believed in and believing in herself.
"I've always lived my life as someone who never thought anything was impossible," said Frank. It's a message she'd like Academy members to hear -- and pass along.
She spoke during the candidates' forum before the election, urging the delegates and other members to counter negative images about family medicine by becoming advocates for the specialty. "When I invited members to talk to the students and the residents, it was a call to them (the members) to remember what we do, remember what we're about," she said later.
Her speech at the forum focused on three areas: reimbursement, quality and access. Those issues, she said, are key to moving the specialty forward and helping family physicians best serve their patients.
"Those are the three things that are most important to me and that I think are really important for our members," she said. "And you can't do any one of the three without addressing all of them."
All three issues are part and parcel of the Academy's overall strategic plan. Only by passing Medicare reform legislation that ensures adequate, sustainable physician reimbursement can patients be guaranteed unfettered access to the quality care family physicians provide, Frank said.
Patients can be the greatest resource in making that happen, she observed, pointing to the Academy's new Patient Voices in Washington initiative (http://www.aafp.org/ptvoices.xml) as a tool patients can use to lobby legislators to effect positive change.
And it's a two-way street: "Patients are going to be our most effective advocates -- and we for them," she said.
"We have an opportunity to become the public voice, the human face, of medicine to our patients," she told delegates. Quoting Margaret Mead, she added, "Never doubt that a small group of thoughtful, committed people can change the world. Indeed, it is the only thing that ever has."
BY CINDY BORGMEYER
One of the most contentious issues considered by this year's AAFP Congress of Delegates in New Orleans received neither a thumbs-up nor a thumbs-down from delegates. The issue: the American Board of Family Practice's new Maintenance of Certification for Family Physicians program, or MC-FP. The decision: Refer the whole matter to the AAFP Board of Directors, with a report back to the 2004 Congress.
For specifics on the new program, visit the ABFP Web site at http://www.abfp.org and click on "Maint of Cert for FPs" in the menu to the left.
 American Board of Family Practice Executive Director James Puffer, M.D., responds to AAFP members' concerns about the board's new maintenance of certification process. |
Academy members had plenty of opportunities to voice their concerns about the new process, starting with a jam-packed town hall meeting Sept. 29.
ABFP Executive Director James Puffer, M.D., and ABFP President Ronald Christensen, M.D., of Anchorage, Alaska, addressed the more than 300 people who showed up with questions about the new program.
During that meeting, some common themes emerged, among them the timetable for implementation.
Why now?
"One of the questions we've been asked is, 'Why are you doing this now? With all the other problems besieging family physicians in the trenches, this is the worst possible time you could do this,'" Puffer said.
Strictly speaking, Puffer said, the ABFP had little choice in the matter. The directive to develop and implement specialty-specific maintenance of certification processes came from the American Board of Medical Specialties, which oversees the ABFP and the other 23 medical specialty boards.
ABMS acted in response to increasing concerns about patient safety and physician accountability -- concerns first expressed in the landmark Institute of Medicine report, To Err Is Human: Building a Safer Health System.
As for the timing of implementation -- that, too, is according to the ABMS schedule, Puffer said. "The ABFP is probably on track with the other large specialty boards in rolling out this maintenance of certification process."
The prospects of added cost and added burden were also sticking points for members who attended the Sept. 29 meeting, as well as for those who testified about three resolutions on the topic in an Oct. 1 reference committee hearing.
Puffer sought to quell the financial concerns at the town hall meeting, saying the ABFP has estimated the cumulative cost of the complete MC-FP cycle -- that is, the cost in 2010 -- as roughly equivalent to that for recertification under the current system. Diplomates would have the option of either paying up front for the entire seven-year cycle or paying incrementally, he said.
As for the time needed to complete the program, Puffer said, "Let me reassure you: Mainte-nance of certification as currently envisioned will not take any more time than the current recertification process."
Communication breakdown
 Oregon alternate delegate John Saultz, M.D., of Portland testifies about the need to educate family physicians about the ABFP's role. |
Perhaps one of the most galling issues for some members grappling with MC-FP was the ABFP's failure to consult its Diplomates, who see themselves as major stakeholders in the venture, as it developed.
Puffer replied that the ABFP's role is to ensure the quality of the nation's family physicians. "Each of the 24 medical specialty boards has a sacred covenant with the American public," he stated. "The American Board of Family Practice does not serve you; it serves the American people."
Nevertheless, insisted Arkansas delegate Joseph Stallings Jr., M.D., of Jonesboro, "We are stakeholders. We represent the people who take care of the majority of people from New Mexico to New York."
South Carolina delegate Audrey Boyd, M.D., of Columbia said she would be among the first group to enter the new process. "I would have liked to have been given the opportunity to give input on why and how (this program) should be implemented," she said.
To be continued ...
The AAFP and ABFP executive committees have met twice since early summer, when the Academy first learned about MC-FP. (Then) AAFP President James Martin, M.D., of San Antonio told attendees at the town hall session those meetings had proven fruitful in helping define the Academy's participation in the new process. However, there clearly remains much yet to be accomplished by the two organizations, he said.
To reach writer Cindy Borgmeyer, e-mail
cborgmey@aafp.org.
American Academy
of Family Physicians
11400 Tomahawk Creek Parkway
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66211-2672
BY CINDY BORGMEYER
Right in step with today's evolving health care environment, the AAFP Congress of Delegates called Oct. 1 for a few changes of its own -- starting with the name of the specialty.
The delegates directed the Academy to replace the term family practice with family medicine when referring to the specialty. The substitute resolution effecting the change combined proposals introduced by the Joint Constituency of the National Conference of Special Constituencies and the Minnesota AFP.
In reference committee testimony Sept. 30, Minnesota alternate delegate Patricia Lindholm, M.D., of Fergus Falls embraced the proposed change, saying it would help family physicians be recognized as the specialists they are.
"While it may be semantics to some, perception is everything," Lindholm said. "I specialize in family medicine. If our own colleagues in medicine don't understand that we're specialists, I don't think our patients can (understand), either."
Also banished is the dreaded "P word": Those who specialize in family medicine are family physicians, not practitioners, delegates affirmed. It's a move New Physician Constituency alternate delegate Michael Sevilla, M.D., of Salem, Ohio, welcomed.
"How many times have we been asked, 'How is a family practitioner different from a nurse practitioner?'" he inquired during the reference committee hearing.
Finally, the resolution called for the AAFP to encourage the American Board of Family Practice to change its name to reflect the family medicine nomenclature.
The specialty's name is one of many issues being considered by the ongoing Future of Family Medicine project. That project includes input from all of the family medicine organizations.
BY TONI LAPP
Physicians need to galvanize their patients to action -- engage them in the lobbying effort to change the Medicare reimbursement landscape, said keynoter Morton Kondracke during the Scientific Assembly's opening ceremony, a highlight of the Oct. 1 - 5 meeting in New Orleans.
 "Why not enlist patients to do lobbying now (for changes in Medicare) rather than wait till they've been denied treatment?" keynote speaker Morton Kondracke asks attendees at the Assembly's opening ceremony. |
Kondracke, executive editor of the biweekly political newsletter Roll Call, brought this and other insights to his address, delivered in the casually droll manner seen in his appearances as a panelist on the TV discussion forum The McLaughlin Group.
Other topics up for discussion included the "perfect storm" that is brewing as more Americans lose insurance in a climate of rising health care costs, the role health care will play in presidential candidate platforms and the reimportation of drugs from Canada.
Medicare
Kondracke said it was unlikely that Congress would produce a Medicare prescription drug bill by Oct. 17. It's important politically and could be a campaign issue, he noted, but President Bush himself would have to roll up his sleeves and work on it because of the significant differences between the House and Senate on the issue. He added that it was likely a smaller measure would be passed offering a discount card for seniors.
Regarding declining reimbursements for physicians, the formula being worked on in Congress probably won't include a fee schedule fix for physicians, but it probably will include one for hospitals, Kondracke said. His advice to physicians was simple: "Lobby like crazy if you want to change this picture."
"If reimbursements keep going down, physicians won't take new Medicare patients," he said. "Why not enlist patients to do lobbying now rather than wait till they've been denied treatment?"
Reimportation of drugs
Governors see reimportation as a way to decrease Medicaid costs and ease their own budget crises. Although the Bush administration opposed the reimportation bill when it was going through Congress, Kondracke said, Bush "won't veto it if this is the only legislation he can hold a Rose Garden ceremony around."
Kondracke said his experience on behalf of his wife, a Parkinson's disease patient, made him sensitive to the issue, but he said Congress' attempts to legislate a remedy were "odious." Such legislation would discourage research for new drugs, he said, noting that it was difficult to name the last drug to be developed in Canada.
"The next 'John Q. Public' (movie) will be about drug companies," he said.
When it comes down to it, however, he sees little for lawmakers to do to alleviate the situation. Look for pharmaceutical companies to develop public image problems like those that HMOs had in the 1990s, he said.
Election 2004
It's going to be a close election, Kondracke predicted, offering candid comments about the presidential candidates -- and Bush:
Kondracke recommended that physicians visit the Web site of the Commonwealth Fund (http://www.cmwf.org/) to see the various candidates' health care proposals.
"Unfortunately, there are so many candidates, and health care is so complicated, that it rarely gets debated, so the public can't get educated about medical economics," he said. "The details are lost to the average voter."
 Delegates applaud (then) President- elect Michael Fleming, M.D., when Fleming announces his personal commitment to modeling healthy behaviors as part of the Academy's new Americans in Motion initiative. |
BY TONI LAPP
It's going to take a new AAFP -- an AAFP with an attitude -- to meet the challenges of modern health care, (then) AAFP President-elect Michael Fleming, M.D., of Shreveport, La., told the Congress of Delegates Sept. 30.
The Academy has many items on its agenda as it moves forward, he said, ticking off such issues as the Medicare fee update, the Future of Family Medicine project and the health of state chapters.
Add to this list the Academy's interest in improving public health.
Fleming told the Congress about a fledgling program -- a program with an attitude -- that AAFP hopes will address a major public health issue: the epidemic of obesity.
That program is Americans in Motion, a new 10-year initiative of the AAFP Commission on Public Health.
"AIM will give family physicians tools to help their patients, their families and their communities fight obesity," he said.
Join fight against obesity
A unique component of AIM is that it will first challenge family physicians themselves to lead healthier lives. Fleming announced his own goal to "walk the talk" when it comes to health and fitness.
 |
"I am making a personal commitment to accept that (AIM) challenge," he said. "I have committed our Academy to act -- to join in the fight against the epidemic of obesity. I urge each of you to join me. Be a role model for your patients, your family and your community by living a healthier life."
With Fleming's acceptance of the challenge, the first phase of the program was set into action: that FPs themselves will model healthy behaviors.
Fleming said he wasn't taking the challenge lightly: "Because of my commitment to AIM, there will be less of me to speak to you" at the 2004 Assembly.
Get involved now
Want to take the AIM challenge yourself? Go to http://www.aafp.org/flemingchallenge.xml. Once there, you can enroll in the Active Lifestyle Program, part of the U.S. President's Council on Physical Fitness and Sports, and take the President's Council challenge as Fleming has. You can also read or download AAFP's obesity monograph (see story, "New monograph helps you help overweight patients"), tell about your own efforts to stay healthy and take the "Fleming Challenge."
In a move that shows AAFP's dedication to improving Americans' health, the Academy has published a physician's guide to helping overweight patients. Practical Advice for Family Physicians to Help Overweight Patients calls for adding two key obesity measures -- body mass index and waist circumference -- to vital signs that are recorded at each office visit.
"We've become an 'oversized' nation due to decades of overeating and underexercising," said (then) President-elect Michael Fleming, M.D., of Shreveport, La., during a speech to the Congress of Delegates Sept. 30. "America's family physicians are committed to doing whatever we can to help our patients avoid the unhealthy consequences of being overweight."
The monograph, which was distributed to members who attended the Scientific Assembly Oct. 1 - 5, is available online at http://www.aafp.org/obesitymonograph.xml. It is scheduled to be mailed to all members later this fall. The monograph is supported in part by an educational grant from McNeil Nutritionals.
WEB EXTRA!
BY J. MICHAEL BRODIE
Michael Fleming, M.D., of Shreveport, La., takes the reins of the AAFP at a critical time in medicine.
Many family physicians are faced with privileging battles, rising insurance rates, reduced fees and challenges that go to the heart of how family physicians view the profession. This is a time, for example, when physicians ponder whether to continue taking new Medicare patients.
During his first official address as AAFP president Oct. 3, Fleming recalled an interview he did on a local TV station about the potential impact of reduced Medicare payments.
"Later, Maggie, one of my wonderful little ladies from a local assisted-living facility, tearfully asked me, 'Dr. Fleming, will you still take care of me?'" Fleming said. "I gave her a hug and a reassuring promise: 'Not only will I take care of you, but I will care about you!'"
Fleming explained to her how Medicare cuts threaten access to care, and he advised writing Congress about the cuts. Several weeks later, he heard from his lawmakers that a whopping 386 letters from the assisted-living facility had deluged their offices.
"Did it make a difference?" Fleming asked. "You bet it did!"
He called the specialty the heart, the mind and the soul of medicine. Accenting the mind, he said, "About two years ago, this specialty decided that we needed to take a look at ourselves to see what we had accomplished. We started the Future of Family Medicine project." In the coming months, the Academy will release a set of recommendations for the profession based on FFM research, Fleming explained. "The challenge is -- what will we do with those recommendations?"
Fleming reflected, "For a long time, we were the heart, the mind and the soul of medicine who sometimes stood aside while others made decisions that affected us. We stood by while others decided our destiny."
"No more," he said.
Fleming urged members to use tools such as "Speak Out" (at http://capitol.aafp.org) to express their views to lawmakers. He lauded the AAFP's Patient Voices in Washington program (http://www.aafp.org/x21354.xml), which includes information on legislative topics and talking points physicians can use in conversations with patients and lawmakers.
Fleming said he welcomed the chance to represent the Academy in Washington, where Congress has been embroiled in addressing issues vital to family practice.
"I expect a great deal from me, I expect a great deal from this Academy and I expect a great deal from you," he concluded.
The AAFP Congress of Delegates elected Mary Frank, M.D., of Mill Valley, Calif., to the post of president-elect. The delegates' action Oct. 2 marks the first time a woman has been chosen to lead the Academy (see story, "New president-elect is -- first and foremost -- a family physician" ).
Others elected or chosen by acclamation for the following positions are:
| President |
President-elect |
Board
chair |
Speaker |
Vice
speaker |
Executive vice
president |
 Michael Fleming, M.D. Shreveport, La. |
 Mary Frank, M.D. Mill Valley, Calif. |
 James Martin, M.D. San Antonio |
 Carolyn Lopez, M.D. Chicago |
 Thomas Weida, M.D. Hershey, Pa. |
 Douglas Henley, M.D. Leawood, Kan. |
| Directors |
|||||
 Arlene Brown, M.D. Ruidoso N.M. |
 Larry Fields, M.D. Ashland, Ky. |
 Daniel Heinemann, M.D. Canton, S.D. |
 Rick Kellerman, M.D. Wichita, Kan. |
 John Sattenspiel, M.D. Salem, Ore. |
 Mary Jo Welker, M.D. Columbus, Ohio |
| Directors |
New physician
director |
Resident
director |
Student
director |
||
 Jim King, M.D. Selmer, Tenn. |
 Thomas Kintanar, M.D. Fort Wayne, Ind. |
 Timothy Komoto, M.D. Mendota Heights, Minn. |
 Lisa Corum, M.D. Fort Mill, S.C. |
 Saria Carter, M.D. Davie, Fla. |
 Eddie Turner Memphis, Tenn. |
BY J. MICHAEL BRODIE
 Hugh Taylor, M.D., defends the safety record of progesterone-only contraceptives. |
The AAFP Congress of Delegates on Oct. 2 called for the Academy to support a proposal under consideration by the FDA to make progesterone-only emergency contraception available over the counter.
The measure, a substitute resolution, also urged the FDA to approve "appropriate labeling of progesterone-only emergency contraception" packages that would encourage patients to seek guidance from their primary care physicians on proper use of all over-the-counter contraceptives and would include safe sexual practice information.
The substitute resolution passed in the Congress without debate, in stark contrast to the considerable testimony presented on the issue during an Oct. 1 reference committee hearing. The committee had decided, after long deliberation, to support the measure.
Those in favor of an OTC progesterone-only contraceptive told the reference committee about the long-term safety record of the drug and how easy it has been for patients to use. "We do see a need to improve access to the progesterone-only contraceptive pill," said alternate delegate Hugh Taylor, M.D., of South Hamilton, Mass. Making it available on an OTC basis would be a logical way to do that, he added.
Other supporters told the reference committee they wanted to see the drug made more available to the uninsured. "Young people are disproportionately represented among the uninsured, and not many entry-level jobs come with health insurance," said delegate Rachel Wheeler, M.D., of Concord, Mass.
Pennsylvania AFP President Ronda Filer, M.D., of York pointed to a poll in her state that showed 23 percent of sexual assault victims weren't offered any emergency contraception in the state's emergency rooms. All the more reason to support an OTC progesterone-only contraceptive, she suggested.
| Rachel Wheeler, M.D.
"Young people are disproportionately represented among the uninsured, and not many entry-level jobs come with health insurance." |
Opponents of an OTC emergency contraceptive expressed concern to the reference committee that making the drug more available could damage doctor-patient relationships. They argued that there was a danger that some patients would misuse the drug. This could particularly be a problem among teenage girls, who often are not likely to see a physician on a regular basis, they said.
Witnesses also disagreed on the mechanism of action of the drug, such as whether it was a form of contraception or an abortion drug.
Some even questioned the wisdom of having the Academy take a stance on the issue. "The Academy has a policy of staying neutral on contraception," said FP Dave Schneider, M.D., of San Antonio. "This could be the beginning of a slippery slope. This could be a divisive issue."
BY CINDY BORGMEYER
Click on this icon to go directly to online-only
content.
 Special constituency representatives add value and leadership to the Academy, says Telita Crosland, M.D. |
Responding to impassioned pleas to maintain a strong leadership pathway for underrepresented constituency groups in the AAFP Congress of Delegates, delegates voted Oct. 1 to adopt a new policy concerning special constituency seats in the Congress.
The policy establishes six special constituency delegate seats and six alternate seats for groups other than new physicians (those with up to seven years in practice). The New Physician Constituency will continue to hold its two delegate and two alternate seats separate from the new "combined" seats.
No more than two representatives from any one of the other special constituencies attending the annual National Conference of Special Constituencies can be selected to fill the new combined delegate and alternate seats. The newly adopted seats will sunset in 2010. The new physician slotted seats will not sunset.
The special constituency groups currently approved by the AAFP Board of Directors are gay, lesbian, bisexual and transgender physicians; international medical graduates; minority physicians; new physicians; and women physicians.
"Think of this as an investment -- an investment in future leaders," Robert Garcia, M.D., of Phoenix told a reference committee Sept. 30 concerning constituency representation. Garcia is an alternate delegate from the Minority Physician Constituency.
With the sunsetting of the Women Physician Constituency slotted seats after the 2002 Congress, the number of special constituency seats dropped from six delegates and six alternates to four of each. In the 2003 Congress, those seats were evenly split between the Minority Physician and International Medical Graduate constituencies. Supporters of the move to expand the number of slotted delegate seats back to six testified that the current ration of seats doesn't allow adequate representation of the special constituencies.
"The value added to the Academy is obvious by the number of excellent leaders who have risen through these constituencies," Minority Physician Constituency delegate Telita Crosland, M.D., of Dupont, Wash., testified in the reference committee hearing. She singled out (then) AAFP Board Chair Warren Jones, M.D., of Ridgeland, Miss., and Speaker Carolyn Lopez, M.D., of Chicago as examples.
True, the Academy stands to incur some additional expense, because the AAFP covers the cost of bringing all special constituency representatives to the Congress. But, as Minority Physician Constituency alternate delegate Kim Yu, M.D., of Novi, Mich., asked, "Can you put a price on Warren Jones? Can you put a price on participation?"
Delegates also considered how to best select the Academy's delegation to the AMA House of Delegates, voting to initiate a system whereby AAFP delegates and alternate delegates to the AMA are appointed through the Board of Directors screening committee process rather than elected by the Congress of Delegates.
This process, which occurs in November, would allow more accurate estimation of the size of the AAFP's AMA delegation. Also, the Board's Executive Committee, which attends AMA meetings, could provide input on qualifications needed on the delegation at any one time.
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online-only content.
Delegates and others attending the Congress of Delegates voiced their opinions on several resolutions dealing with patient care this year, but few measures drew as much attention as a series of eight resolutions that were not approved.
Those resolutions revisited the 2002 Congress of Delegates' action on children's access to health care, a measure that supported "legislation that promotes a safe and nurturing environment for all children ... including those of adoptive parents, regardless of the parents' sexual orientation." All eight resolutions were subject to spirited testimony.
The resolutions were introduced by the Arizona, Kansas, Nebraska, Ohio, Texas, Utah and Mississippi chapters and by the Joint Constituency of the National Conference of Special Constituencies. Each proposal sought to rescind last year's position by replacing it with neutral language that proponents argued would be less divisive.
Opponents of the eight resolutions argued that it was not appropriate for the Academy to take a neutral stance on a significant issue protecting children. One resolution, defeated Oct. 1 along with the others, was revisited the following day but was ultimately defeated in a 61-56 vote. The 2003 Congress, in effect, reaffirmed the statement adopted in 2002.
Here's a sampling of other Congress actions.
Privileging battles
|
George Shannon, M.D. "We need to show these hospitals that there is a 10,000-pound gorilla in this fight." |
In a reference committee hearing, FP Jason Cox, M.D., of Valdosta, Ga., discussed his battle to have his epidural, surgical and obstetrical privileges restored, a struggle that has cost him tens of thousands of dollars.
Responding to Cox's plight, the Georgia chapter introduced a resolution asking the AAFP to come to the aid of FPs faced with privileging challenges. "This is an issue of keeping our promise (to new physicians)," Georgia delegate George Shannon, M.D., of Columbus said on the Congress floor. "We need to show these hospitals that there is a 10,000-pound gorilla in this fight."
The original resolution called on the Academy to fund what some had termed a "SWAT team" to fight privileging battles. However, concerns were raised over the cost of such action, resulting in the removal of the cost provision from the final version. The amended resolution was overwhelmingly approved; the Academy is to develop a list of family physicians willing to travel and testify on behalf of FPs fighting for privileges.
The Academy will also work with FPs early in the privileging process to help prevent battles from erupting in the first place.
Preventive care reimbursement
Reimbursement issues -- not surprisingly -- resounded with the Congress, with delegates on Oct. 1 adopting an amended resolution directing the Academy to "work with the U.S. Congress, payers, other medical associations and other appropriate organizations to promote reimbursement for evidence-based preventive interventions for all patients."
The original resolution asked AAFP to work with HHS and the other groups. However, in a Sept. 30 reference committee hearing, a representative from the Centers for Medicare & Medicaid Services testified that the U.S. Congress (not HHS) would have to create a new benefit category to enable CMS to pay for preventive services.
The amendment rescuing the resolution came from the floor of the Congress, when Arizona delegate Carlos Gonzales, M.D., of Patagonia proposed replacing "HHS" with "U.S. Congress." Gonzales proposed the change to "rise to the challenge CMS has issued," he said.
Credit for CME activities
Anticipating a need for more flexibility in acknowledging physician participation in new learning modalities, the AAFP Commission on Continuing Medical Education this summer recommended, and the Board approved, a change to the terminology used to refer to AAFP CME. That change -- in the form of a Bylaws amendment -- has now received the Congress of Delegates' stamp of approval.
The change from "CME credit hours" to "CME credits" allows AAFP to recognize those educational activities -- such as quality improvement, performance measurement and point-of-care activities -- for which a simple accounting of "time spent" may not reflect the true value of the learning experience.
Dental access and fluoride varnish treatment
The Congress approved a measure supporting the concept of having family physicians provide prophylactic dental fluoride varnish treatments to children. Concerns about how the resolution would be seen by dentists were countered by testimony that dentists, who usually do not treat children younger than 3, would deem the treatments appropriate. The resolution also asked the Academy to "work with the American Dental Association to encourage dentists to partner in the responsibility" to provide treatments to all children.
Hate crimes
The Congress adopted a policy statement identifying "hate crimes as a specific and distinct health risk" for some people. "We have patients who live every day with the fear of being injured," Maine delegate Judith Chamberlain, M.D., of Brunswick told a reference committee.
Gun control
Gunshot wounds are among the leading causes of death for young American men, said members testifying at a Sept. 30 reference committee hearing. The committee said gun violence is "an important public health issue." The delegates voted to have the Academy support legislation that requires criminal background checks for all gun sales at gun shows and public events -- to close a loophole in the federal gun law known as the Brady bill.
Meningococcal vaccination
The Congress approved a substitute resolution to "produce or support a position statement, with other interested health organizations, on the use of meningococcal vaccine in matriculating residential college students."
A reference committee heard mixed testimony on the measure, which targets meningococcal illness and promotes the vaccine as a preventive treatment.
WEB EXTRA!
 The discussion about the future of the specialty just kept on rolling after the town hall meeting. Steven Bruner, M.D., of Lawrence, Kan., left, drove home a point to AAFP Director Rick Kellerman, M.D., of Wichita, Kan. |
BY SHERI PORTER
The most striking moment of the Oct. 2 Future of Family Medicine town hall meeting came at the close of the one-hour session. The room didn't empty.
Dozens of physicians -- passionate about the future of their specialty -- gathered in groups of two, three or more to continue the discussion with AAFP leaders and physician colleagues.
Here's how the meeting began: (then) President James Martin, M.D., of San Antonio; (then) Board Chair Warren Jones, M.D., of Ridgeland, Miss.; (then) President-elect Michael Fleming, M.D., of Shreveport, La.; and EVP Douglas Henley, M.D., took to the stage to relay results of two years' worth of research on the future of the specialty.
According to the research presented by the four AAFP leaders, five challenges that need to be met are:
Martin pointed out that FPs interact at all levels. "Who else touches every aspect of the health care system but us?" he said. "We're known as the 'warm fuzzy' physicians."
But, Martin continued, while that is a positive image, it needs to be broader. "We also have to have a research agenda," said Martin, and "we're going to show the world we're advocates of quality and safety."
Reimbursement issues loom large as well. "If we can't change the way family docs are paid, this (project) is not going to work," he said.
To take the FFM project from the think tank to an action plan "is going to take energy and leadership from about 94,500 people," said Martin.
When it was time for audience feedback, members -- from Montana to Colorado to South Carolina -- rose to offer views including these:
An hour after the "official" town hall meeting concluded, physicians finally filtered into the hallway, still engrossed in conversation.
 Eric Ossowski, M.D., dispenses equal parts compassionate care, community involvement and administrative leadership in his practice. |
BY J. MICHAEL BRODIE
Eric Ossowski, M.D., of Scottsdale, Ariz., was acclaimed AAFP's 2004 Family Physician of the Year during the Scientific Assembly opening ceremony Oct. 2 in New Orleans.
As chief of family and primary care medicine and acting chief of internal medicine for the Phoenix Indian Medical Center, Ossowski has garnered a reputation for dispensing equal parts compassionate care, community involvement and administrative leadership.
Ossowski says his patients face health challenges such as diabetes; obesity; hypertension; and heart, liver and kidney disorders. "There are a lot of serious health problems here," he says. "Some tribes here have as much as 50 percent of the adults diagnosed with diabetes."
Ossowski helped develop the ger iatrics program and smoking cessation program at the medical center, which serves more than 39 tribes in the Southwest. He has participated in Tar Wars® programs organized by the Arizona AFP in public and parochial schools and belongs to Arizonans Concerned About Smoking & Chewing Inc. Tar Wars is the AAFP's tobacco-free education program for youth.
Over the past 23 years, Ossowski's patients have taught him some valuable lessons. "I learned to listen closely to my patients," he says. "They know what's wrong, and if you ask them, they will tell you."
Ossowski discovered the role culture and perception play in patient care when the first few young children were brought into his office at an Indian Health Service reservation clinic in 1980. "These infants would come to the well-child clinic with hair that was sticky and matted," he recalls. "I thought, 'Well, this isn't clean,' blaming poor hygiene. But that was not the case."
The parents had applied mesquite sap to the soft spot on each child's head, Ossowski soon learned. The elders believed it would protect an infant's health until the soft spot closed.
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Finalists for 2004
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"The mother followed her culture but also came to me for Western medicine," he says. "She was trying to do what was right by both cultures."
Ossowski went to medical school at the University of Minnesota, Duluth, and the University of Minnesota, Minneapolis. He attended the Duluth Family Practice Residency. During residency, part of his training occurred in Alaska north of the Arctic Circle. "It was the experience of a lifetime," he says of his six-week rotation with the Indian Health Service in Kotzebue. "I was looking for a different cultural and medical experience. I thought, well, I've never been there before, so why not?"
Ossowski later was offered jobs with the IHS in Alaska and Arizona. He reflects, "I went from the freezer to the fryer!"
Ossowski began his IHS career in 1980 at the Phoenix Indian Medical Center, where he served as deputy chief of family and primary care medicine until 1988. He has worked at four IHS clinics in the Phoenix area and two rural South Dakota IHS sites. A captain with the U.S. Public Health Service Commissioned Corps, he has chaired the medical executive committee of the Phoenix center, one of the largest IHS facilities in the Public Health Service.
Ossowski says he will end his career in Arizona, where he met his wife and where they are raising their two children.
"I signed a contract for two years and thought I'd go back to Minnesota," he says. "I never did."
WEB EXTRA!
Each year, the Academy bestows honors and awards on its members and others during the Annual Assembly. The Family Physician of the Year award was presented to Eric Ossowski, M.D., of Scottsdale, Ariz., during the Oct. 1 opening ceremony (see article at http://www.aafp.org/fpr/20031100/12.html). In addition, the following awards were presented during this Assembly. Click on the Web address shown after most listings for a news release on the award and its recipient:
WEB EXTRA!
Members of the AAFP Committee on Scientific Program bestowed awards during the Scientific Assembly for family practice research presentations and for poster presentations by medical students and family practice residents.
Awards of $1,000 apiece went to the following researchers for their family practice research presentations:
Awards of $250 apiece went to these researchers for their presentations:
The first-place award of $700 for a resident poster went to Jonathan Shraga, D.O., of the Cabarrus Family Medicine Residency Program in Charlotte, N.C., for "Bladder Scanning in Family Medicine."
The second-place award of $300 for a resident poster went to Jun Mao, M.D., of the Somerset Family Practice Residency Program in Piscataway, N.J., for "Adolescent Male Testicular Health Study."
The first-place award of $700 for a medical student poster went to Matthew Thompson of the University of Minnesota -- Duluth School of Medicine for "Ranking Applicants to FP Residencies."
The second-place award of $300 for a medical student poster went to Patricia Myung, B.A., of Brown Medical School, Providence, R.I., for "Sexual Transmission of Hepatitis C."
BY PEGGY PECK
Obesity is a chronic, relapsing disease that requires chronic treatment -- that's a long-haul message that family physicians need to deliver to their patients, said Raul Zimmerman, M.D., co-director of the Halifax Medical Center Weight Management Program, Daytona Beach, Fla.
Moreover, obesity is fast becoming a major health problem for Americans of all ages and incomes, he explained during his Oct. 1 Assembly lecture, "Obesity: Battling an Epidemic." FPs, said Zimmerman, "don't need a national nutrition summit or a call to action or a special issue of JAMA to tell us obesity is a problem -- because as family physicians, we see it daily in our offices and sometimes in our homes. Obesity is not an occult problem."
But many FPs don't even try to treat obesity, Zimmerman said. For example, he said few physicians "tell the patient that he or she needs to lose weight," even though that is an effective first step in behavioral modification. This reluctance is understandable, Zimmerman said, because treatment is "expensive, time consuming and often frustrating."
Best treatment approach
What, then, is the best approach to treatment? Zimmerman said a simple, consistent approach works best for office-based management of obesity.
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First, identify and risk-stratify patients. "Remember that the problem is not just weight, but also fat and the location of the fat," he said. A muscle-bound body builder who weighs 260 pounds is not in the same risk category as an office worker who weighs 260 pounds. So a simple tool for stratifying fat risk is a measuring tape: Waist measurements of 35 inches in women and 40 inches in men are risk factors for cardiovascular disease and diabetes. "Each of us should go into the examining room with a tape measure," he said.
Risk also increases as body mass index increases -- 18.5 to 24.9 is a "normal" BMI, 25 to 29.9 is overweight, 30.0 to 39.9 is considered obese and more than 40 is considered extremely obese, Zimmerman explained.
When treating children, "use the CDC BMI for age tables and remember that among children, both age and gender are factors in determining BMI," he said.
Start small
In terms of weight loss, Zimmerman said he prefers to start small because small weight loss can yield big health benefits.
Given that one pound equals about 3,500 calories, cutting back by 500 calories a day should translate into a weight loss of a pound a week. But rather than starting out by counting calories, he recommended:
He also urged behavioral changes such as "getting up from the table immediately" to avoid seconds. If these changes don't achieve the desired goal, "it's time to count calories" and weigh food, he said.
And while these approaches address "energy in," Zimmerman said a daily exercise program can balance the "energy out" side of the equation.
If more is needed
Diet and exercise will not, however, be sufficient for all patients. A logical next step is pharmacologic therapy in selected patients. Two drugs -- sibutramine and orlistat -- are currently available. Although there have been no head-to-head studies of these drugs, Zimmerman said, "my observation is that they are about equally effective; both are associated with about a 10-pound weight loss at six months."
Finally, some patients should be considered for surgical treatment, Zimmerman said. For patients who don't succeed with lifestyle modification and pharmacologic therapy, surgery may be a good option and can even reduce the likelihood of comorbidities such as type 2 diabetes and hypertension.
BY PEGGY PECK
A year after implementing a chronic care model designed by the AAFP Asthma Collaborative, staff at La Familia Medical Center in Santa Fe, N. M., noticed an impressive result: The proportion of all children at the center who regularly took peak flow measurements as part of their asthma management plan increased from 36 percent to 76 percent, said nurse-educator Paula Devitt, R.N.
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Even more impressive: Peak flow measurements increased to 100 percent among patients referred to the chronic care education program, she said.
Devitt and representatives from two other family practices discussed implementation of the quality improvement initiative during an Oct. 3 Scientific Assembly session, "Improving Chronic Illness Care in Family Practice: Lessons from the AAFP Asthma Collaborative." Jonathan Sugarman, M.D., professor of family medicine at the University of Washington, Seattle, said the program was designed to improve management of childhood asthma, but "this chronic care model can be used for other chronic illnesses such as diabetes."
Other outcomes at the La Familia Medical Center included substantial increases in use of both as-needed and maintenance medications among all patients and patients in the education program. Use of NIH severity classification increased from 10 percent to 52 percent for all patients and increased to 93 percent among patients in the education program. "Moreover, 64 percent of all asthma patients are now receiving flu shots, and this rate is even higher -- 96 percent -- among patients in the education program," Devitt said.
Thirteen practice teams participated in the yearlong Asthma Collaborative, a program facilitated by the National Initiative for Children's Healthcare Quality. The panel at the Assembly session featured three practice models: public health clinic, residency practice clinic and private practice.
Devitt said her public health clinic concentrated on self-management "because we think this is the area that can make the biggest difference in practice." One feature of the La Familia program was the decision to use asthma patients as the "promotoras," or promoters of health, she said.
Gregory Lyon-Loftus, Ph.D., M.D., who practices in Mont Alto, Pa., represented private practice. He said one of the take-home messages from his participation in the collaborative is that "the best asthma care is delivered when the patient is well," which underscores the need for regular follow-up. "The other major message is that it is important to measure disease, not symptoms," which is why his practice is concentrating on the use of peak flow and spirometry, he said.
William Price, M.D., director of the Enid Family Medicine Clinic of the University of Oklahoma Department of Family Medicine, said he and his residents have worked to involve the community -- schools, coaches and the local health department -- in asthma care. After a year, he said, this effort has been so successful that "we are now getting calls from the schools asking, 'How bad should the peak flow be before we send the child home?'"
BY TONI LAPP
When it comes to treating children with attention-deficit/hyperactivity disorder, Penny Tenzer, M.D., is uniquely qualified to understand the challenges. That's because she's the mother of a son with the disorder.
Tenzer, associate professor of clinical family medicine at the University of Miami School of Medicine, made a presentation on the topic Oct. 2 at the Assembly. ADHD can be confused with many other diagnoses, and comorbidity is the rule, Tenzer said. Although rating scales should be employed, these don't make the diagnosis -- the doctor does, she said.
Children with ADHD have a distinct advantage when the disorder is recognized early, said Tenzer. These children need classroom interventions, and they may need advocacy on their behalf in dealing with schools. Once the diagnosis is made, the physician should request psycho-educational testing for learning disabilities because of the frequency of comorbidities.
Tenzer advocates a multimodal treatment plan. "Educate everywhere you can -- at home, school or work," she said. Sometimes educators need to be educated about the condition.
A diagnosis of ADHD qualifies a student for the Individuals With Disabilities Education Act, which can ensure accommodations for a child needing preferential seating, smaller class sizes and shorter work periods. Behavioral counseling should also be considered, said Tenzer. These children may not understand nonverbal cues. This deficit becomes more of an issue in adolescent years, when peer acceptance is so important, she said.
In addition, medications can and often should play a role in treatment. "We're treating to function," she said, not to sedate. The physician's armamentarium includes stimulants, atomoxitene, alpha agonists and antidepressants. Fear of abuse is not an issue, she said, quipping that drugs such as Adderall® have low street value.
Finally, "parents have to be willing to be educated about this," she said. "Grandparents may be telling them that they're not correctly disciplining the child, but time-outs don't work."
Tenzer was quick to point out that some patients do not outgrow their ADHD. Adults with ADHD often experience career difficulties, so job choice is important. But those who pick the right career can be hardworking and loyal, Tenzer said.
"With more education, we can take that instability and turn it into ambition," she said. "These are people that are driven."
BY TONI LAPP
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content.
Are most family physicians just not system-oriented? Are they laboring in faulty structures but blind to the fact? This was one theme echoed at the first National Ambulatory Primary Care Research and Education Conference on Patient Safety Sept. 18 - 19 in Chicago.
The AAFP was a sponsor of the conference. While many meetings have focused on patient safety, this was the first national gathering devoted solely to safety in ambulatory primary care settings.
Tools are there
When the Institute of Medicine concluded in its groundbreaking 1999 report, To Err Is Human: Building a Safer Health System, that the know-how already existed to prevent many medical errors, it struck a chord among health care professionals in all settings. Indeed, conference participants frequently cited the report at the patient safety conference.
| Ben-Tzion Karsh, Ph.D. "Maybe it's time to bring people in from an outside perspective and look at the situation from a design point of view." |
Granted, the IOM report looked mainly at hospital-based errors. But some family physicians have come to the same conclusion -- that office-based practices have flaws in their systems of care that work to the detriment of patients.
Perhaps physicians could learn from engineers, said one attendee. "Maybe it's time to bring people in from an outside perspective and look at the situation from a design point of view," said Ben-Tzion Karsh, Ph.D., an industrial engineer from the University of Wisconsin, Madison, who specializes in health care settings.
"We talk too much about errors, not about hazards in design," he said.
When Karsh first visits a site, he takes it all in, he said. What he sees is an information-rich field in which doctors must weigh data coming from many sources: written history, test results, patients and family members.
Models of safety
The concept that existing ideas could be culled from other industries proved to be a frequently voiced refrain at the meeting. What enterprise could health care professionals learn safe practices from?
"UPS," Karsh said. The shipping company has engineered a business design in which packages at various stages in the shipping process can be tracked with pinpoint accuracy throughout the world. And although no one is arguing that patients are like packages, the concept presents an example of using tried-and-true technology.
In her keynote address, Helen Burstin, M.D., M.P.H., director of the Agency for Healthcare Research and Quality's Center for Primary Care Research, spoke of the importance of information technology for patient safety.
"The IOM noted in its report that grocery stores have better technology than doctors," she said, expressing the hope that physicians will soon make use of such technology as bar codes and computerized records.
The patient safety conference arose from discussions among members of the Primary Care Organizations Consortium and staff of the AAFP Developmental Center for Research and Evaluation in Patient Safety in Primary Care, or DCERPS-PC.
Learning from lawsuits
Plenary speaker Gerald Hickson, M.D., associate dean for clinical affairs at Vanderbilt University, Nashville, Tenn., predicted that his role as a malpractice researcher would do little to win him friends in medical practice. But lawsuits offer clues on how to improve the medical system, he said. His research has shown that regardless of specialty, relatively few physicians -- 9 percent -- account for roughly half of complaints.
"We need patients to be our partners," he said. "Our colleagues who are disruptive don't promote that."
And even when a lawsuit is dismissed, it offers a lesson for others, Hickson said. "Poor communicators are sued more often."
He added, "There's been much said about the 'tip of the iceberg.' The unsolicited patient complaint is the iceberg. For every one who complains, 30 will not."
His point? Physicians should not stand by silently while a colleague provides bad care. And this idea needs to be implanted early on, Hickson said. Medical students and residents should be trained to provide feedback to their colleagues.
Plan for the future
Although it was apparent that health professionals need to evaluate and understand primary health care systems better and plan new system designs for the future, it is not yet known whether this conference will be followed by a second conference in 2004.
"We hope that the content and format of this unique meeting will lead to stimulating discussions, new alliances, collaborations and program developments lasting long after we're adjourned," said John Hickner, M.D., M.S., conference chair and director of the AAFP National Network for Family Practice and Primary Care Research.
With sufficient interest among participants, the event could become an annual meeting for those seeking to improve primary medical care delivery through research and education, said Hickner.
Want to learn more?
The proceedings of the National Ambulatory Primary Care Research and Education Conference on Patient Safety will be published online this winter at the AAFP DCERPS-PC Web site. Go to http://www.aafp.org/ptsafety.xml.
To reach writer Toni Lapp, e-mail tlapp@aafp.org.
Photos: Sheri Porter and Jane Stoever/AAFP
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BY DENNIS CONNAUGHTON
 Jane Murray, M.D., center, of Mission, Kan., practices "Western family medicine with an open mind" alongside clinical hypnotherapist Valorie Wells, Ph.D., left; naturopathic physician Mehdi Khosh, N.D.; and others. "I was losing the joy of being a physician," Murray said of her previous academic position. |
Have you ever thought about changing your practice, striking out in a new direction? Three family physicians who not only thought about it but actually did it took part in the Oct. 3 panel discussion "New and Innovative Practice Models for Family Physicians" at the Assembly.
Hospitalist model
Michael McMillan, M.D., a physician at Porter Adventist Hospital in Littleton, Colo., is a hospitalist -- exclusively. McMillan is board-certified in family medicine and was in a traditional office practice for about 12 years before making the switch to hospital-based care. "I decided I'd better find something that met my need to do more inpatient care," he said.
Hospitalists provide continuity of care in partnership with family physicians and other health professionals who are not able to provide inpatient care for their patients. In addition, they often care for unassigned patients admitted to the hospital. They regularly consult with attending physicians, office-based family physicians and other specialists, and social workers. They also deal with representatives of insurance companies.
Managed care was the impetus that drove creation of the hospitalist practice model, McMillan said, in an effort to reduce hospital stays and health care costs. He cited statistics that hospitalist practice has reduced the cost of inpatient care and lengths of stay by 15 percent to 20 percent.
The major benefit of hospitalist practice over office-based practice? Fewer time constraints, McMillan said. "What makes it wonderful is the flexibility of hours. I can't overestimate that part of it, after being in the office for 12 years and constantly behind in appointments. Now I can give patients the time they need."
Cash for care
Jane Murray, M.D., is medical director of an integrative health care center that bills patients directly and does not deal with managed care organizations, Medicare or other insurers.
"I was chair of a family medicine department in a medical school for many years, and I was getting tired of the way medicine is typically practiced -- trying to see more and more patients; having fewer and fewer resources; and following other people's rules, such as those from managed care companies," Murray said. "I was losing the joy of being a physician."
So she decided to start a practice with providers who offer complementary and integrative medical care, such as Chinese or Oriental medicine, massage therapy, hypnotherapy, craniosacral therapy and naturopathic medicine. Murray now practices what she calls "Western family medicine with an open mind" at the Sastun Center of Integrative Health Care in Mission, Kan.
Although the center accepts no health insurance plans, it provides patients with forms they can fill out and submit to their own insurance companies for reimbursement for the care they receive.
Murray said she thinks physicians should be open-minded about alternative forms of health care. "I get patients who are fleeing the same system I fled," she said. "I have learned that patients really want their doctor to be open-minded. Patients want to be heard and taken seriously, and they want us to offer hope. They want us to take enough time to consider what options might be open to them."
'Residentialist' practice
Norman Vinn, D.O., M.B.A., is part of a growing trend toward physicians in "residentialist" practice -- that is, physicians who provide care for homebound patients, including the frail elderly, disabled patients and terminally ill patients. Vinn is chief medical officer for Housecall Doctors Medical Group Inc. in San Clemente, Calif.
In light of the aging U.S. population and the availability of new technology, house calls have become a booming industry, he said. "Half of my practice consists of end-of-life, hospice-eligible patients. The fact is we give these people huge amounts of hope with palliative care through emotional and physical pain relief. As residentialists, we specialize in providing comprehensive primary care services in the home."
In 1998, Medicare established nine new CPT codes designed to reimburse physicians who provide home care to certified homebound patients. Thanks to technological advances, residentialists can provide routine lab testing and X-ray services in people's homes. Vinn said he spends 30 minutes or more with each patient.
Vinn appreciates the flexible hours, being out of an office, the potential for growth in the market, the relatively low overhead and his own personal satisfaction in doing this work.
"People are unbelievably grateful that somebody cares about them and somebody showed up," he said. "The average survival time in our practice is 10 months, so these people don't have a big window to their life. You can make pretty good money doing this if you work hard, but money isn't everything. There's a lot of career satisfaction."
BY DENNIS CONNAUGHTON
It's becoming painfully clear: The old practice model just doesn't work anymore. Family physicians are under increasing pressure to improve the quality and efficiency of care by adopting such new practice models as open-access scheduling, group visits and care teams. Still, nobody said it would be easy.
Make the task a little less daunting by realizing that a key element is your ability to change the culture of your practice, said Charles Kilo, M.D., M.P.H., president of GreenField Health in Portland, Ore.; an internist; and a fellow at the Institute for Healthcare Improvement in Boston. Kilo led the Oct. 1 Assembly practice redesign course "System Wide Improvement: Where to Aim."
Defining the culture
When Kilo talks about culture, he doesn't mean spending a night at the opera. The culture of an organization or practice is "the way we think and believe about our behavior," he said.
Most physician practices were created to maintain the individual rights of the physician, such as autonomy in making decisions. But new practice models require teamwork to improve quality and service and to reduce costs, Kilo said. And therein lies the rub. Any physician in a group practice who wants to make his or her own decisions about the design of the practice and ignore the majority opinion needs a cultural turnabout.
"Understand your practice as a whole system, not as individual parts," Kilo said. "The quality of the care you deliver depends on the interaction among the parts of the system."
An ideal clinical office practice design requires some key changes to improve performance, including care teams, open-access scheduling, electronic medical records, patient self-management and performance measures, he said. All the parts of that design need to function as an effective whole system -- and that requires altering the culture of the organization to support the changes.
Altering the culture
Changing the culture involves leadership and thinking in terms of the macro health system -- that is, the health care environment in which you practice, Kilo said.
"There are only two problems in health care -- the way it is delivered and the way it is financed," he quipped. "The failure we are experiencing in health care is largely a failure of primary care and a failure to organize health care resources around primary care."
Because primary care physicians develop long-term relationships with their patients, they are in a prime position to improve health care. "Primary care is the only natural locus for the overall control of cost and quality in health care," Kilo said.
Hospitals and other specialists need to be reorganized around the needs of primary care physicians, Kilo stated. "The financing of primary care, in particular, must change. Primary care physicians need twice as much money or half as many patients" to reduce health care costs and improve the quality of care.
There was definitely an electronic health record "buzz" at the Assembly in New Orleans with the recent announcement of the establishment of AAFP's Center for Health Information Technology. The mission of the center -- based in the AAFP's Leawood, Kan., headquarters -- is to promote and facilitate the adoption and optimal use of health information technology. David C. Kibbe, M.D., has been named director of the center.
In his role as center director, Kibbe will represent the Academy in forging agreements with technology companies. All agreements are to be based on four guiding principles: affordability, compatibility, interoperability and data stewardship.
Hang on for an exciting ride during the next few weeks, as the Academy announces alliances with EHR hardware and software businesses.
BY TONI LAPP
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Once when his elderly parents were visiting him, the mother of Richard Sadovsky, M.D., pointedly asked about a book he was reading, Sex After 60, and what he had learned from it.
"I said I learned that it takes longer for older women to become ready for sex," said Sadovsky, who delivered a session on sex after 60 Oct. 3 at the Scientific Assembly. "And she replied, 'Will you tell that to your father?'" said Sadovsky, drawing laughs from the crowd that had gathered to learn more about a topic that can be disconcerting for family physicians to discuss with their patients.
Dispelling myths
In fact, perhaps one of the more common female sexual problems is hypoactive sexual disorder, said Sadovsky. This label is not without controversy, he said, noting the work of a researcher who instead describes elderly women who are "neutral, but willing to be motivated," with the appropriate partner and appropriate stimulation.
Unfortunately, most people get much of their information about sex from TV, books and friends, rather than from health care professionals, said Sadovsky. Having pop culture as a source of information leads to misinformation, he said.
One myth: Seniors aren't interested in sex.
More than half of seniors between 60 and 70 continue to have sex regularly, said Sadovsky, an associate professor of family medicine at State University of New York, Brooklyn, and an associate editor of American Family Physician. Furthermore, of those who are active, 61 percent report that they are as satisfied or more satisfied with sex than they were in their 40s, he said.
Let's talk
You don't have to be an expert to talk to seniors about sexual health, and FPs should because it relates to patients' overall health, said Sadovsky. A vast array of medical conditions are associated with sexual dysfunction, so sexual problems can be a tip-off to an underlying comorbidity.
"Develop a dialogue you're comfortable using," he suggested, "such as, 'In order to safeguard your health, I need to ask about your sexual activity.'"
He advised, "They may smile or blush, but usually they won't hesitate to talk about it."
Inevitably, physical changes occur in the elderly, often having a negative effect on their sex lives. Men may have decreased libido or erectile dysfunction. Women may be dealing with estrogen deficiency, the after-effects of breast cancer or vaginal dryness. Both genders grapple with lifestyle changes such as retirement, loss of a partner, depression and illness.
Sometimes a doctor is to blame. Some antidepressants, for example, have significant adverse effects on sexual performance. "We cause 20 percent of sexual dysfunction by pulling out our prescription pads," said Sadovsky. Because patients often won't self-report sexual side effects, it's important to ask patients about such effects so the offending medication's dosage can be titrated before a patient discontinues use, he said.
On the flip side, medications can enhance sex -- for both men and women, said Sadovsky.
Yet despite the physician's best efforts, there may come a time when outside help is needed. A patient's problems may be too challenging or may require more time than a busy FP has in an office visit.
For that reason, Sadovsky urged, become familiar with sex therapists in your area -- don't wait until you have a patient who needs referral.
BY TONI LAPP
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Face it: When the stakes are life or death, the differential diagnosis of chest pain can be an awesome challenge for the family physician. Since a missed diagnosis of acute myocardial infarction is the most commonly lodged malpractice claim against FPs, "no one wants to take a risk," said Clare Hawkins, M.D., associate professor of family medicine at Baylor College of Medicine, Houston.
Hawkins, who also is family medicine residency director at San Jacinto Methodist Hospital in Baytown, Texas, discussed four coronary syndromes -- stable angina, unstable angina, non-ST elevation myocardial infarction and acute myocardial infarction -- in his Oct. 1 Scientific Assembly presentation, "Acute Coronary Syndromes."
Differential diagnosis
Many's the physician who was about to diagnose what seemed to be a straightforward case of gastroesophageal reflux disease but -- in the interest of being thorough -- did a complete work-up, fearing hidden heart problems, said Hawkins.
In addition to GERD, the differential diagnosis includes pericarditis, myocarditis, aortic dissection, pneumonia, pleural effusion and dyspepsia. Patients' jaw, arm or back pain could be caused by heart problems; it's important to keep an open mind, Hawkins said.
Array of tests
The meticulous physician has an array of tests to choose from, said Hawkins, but FPs will want to be familiar with the pitfalls of those tests. For instance, 15 percent of electrocardiograms are normal at initial presentation, and only 50 percent are sensitive for detecting an MI, Hawkins said. Echocardiograms offer subjective results. Some "flashy tests" such as C-reactive protein and interleukin-6 assays may be tempting, but when it comes to predictive value, "biochemistry's not there yet," said Hawkins.
Physicians need to view the issue with the knowledge that, put simply, a coronary problem points to an area of the heart that's not getting oxygen when it needs it, Hawkins said. Stress tests are quite effective in this regard.
Posthospitalization
"Most patients want to be cured, not just managed," said Hawkins, and that's where FPs come in.
The fact is, where cardiologists leave off, FPs often must pick up the ball. And acute phase risk -- when the danger is highest -- is two months after discharge following a cardiac event, said Hawkins.
He encouraged FPs to take advantage of the "teachable moment" presented by a heart attack. This is the time to talk with patients about lifestyle choices, be it smoking cessation, diet or exercise.
It's also time to talk to the patient (and family) about the patient's goals -- reducing anxiety, returning to driving, returning to work, returning to sex. And just as hospice care is advisable for certain cancer patients, it is sometimes advisable for certain heart patients and should be discussed, Hawkins said.
BY JANE STOEVER & CINDY BORGMEYER
Not long ago, most of us considered mosquitoes little more than a minor annoyance. Unfortunately, that's no longer the case.
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Mosquitoes infected with the West Nile virus usually get their "blood meals" by biting birds, and the birds are carrying the virus relentlessly toward the West Coast, Ted Epperly, M.D., told Assembly-goers Oct. 5.
That is spelling big trouble for the folks living out West.
Last year, the five top states with the virus were Illinois, Michigan, Ohio, Louisiana and Indiana. This year, by early October, the top five were Colorado, Nebraska, South Dakota, Texas and Wyoming.
Unlike 2003's other headline-grabbing infections -- severe acute respiratory syndrome, or SARS, and monkeypox -- West Nile is here to stay. "Monkeypox was one and done," Epperly stated flatly. "It's a 50-50 bet on whether SARS will re-emerge this year, and the World Health Organization has already been invited to help monitor and suppress SARS if it resurfaces in China. But West Nile is permanent."
Epperly is director of the Family Practice Residency of Idaho, Boise, and immediate past chair of the AAFP Commission on Education. Most of his lecture and the audience's questions zeroed in on West Nile.
Culex and other types of carrying mosquitoes fly only half a mile in their lifetime; they don't migrate. Birds do migrate, however, and "the disease is following bird migratory patterns," Epperly said. "Birds and mosquitoes continue to bite and infect each other. They spin it up among each other. These vector mosquitoes are looking for birds and searching for birds. But once the burden of the virus is high enough, bridge-vector mosquitoes spread the virus to other things -- humans, horses and other animals."
This year, the virus has gone gangbusters, he noted. "We could easily hit 8,000 to 9,000 cases this year, compared with 4,156 total cases last year." By early October, 133 people had died of West Nile; last year's total number of deaths was 284. Epperly advised checking http://www.cdc.gov/ncidod/dvbid/westnile/surv&control.htm for updated information.
Given the generally lower incidence of West Nile this year in states where it was strongest last year, Epperly suggested birds may become immune to it and stop transmitting it. "It may become a low-level disease," he said, noting that immunity to West Nile in humans looks to be lifelong.
Four out of five persons infected with West Nile show no symptoms, he said, and the vast majority of those who become symptomatic suffer only a mild flu-like illness known as West Nile fever.
Only 0.6 percent of those infected with the virus develop West Nile disease, characterized by severe and progressive neurologic signs and symptoms, said Epperly. Treatment for these patients is supportive, and the mortality rate ranges from 5 percent to 14 percent.
Three patient groups are at particular risk: people older than 70, people with diabetes and people who are immunosuppressed.
Diagnosis starts with an exposure history in patients with suspicious symptoms. "The hallmark for us as family physicians is this: a fever at the wrong time of year, one that lasts three to six days," he said. State health departments provide free enzyme-linked immuno-sorbent assay, or ELISA, testing for West Nile. It takes about 24-48 hours to get the IgM antibody test results back. The FDA has recently approved a new IgM ELISA test that will detect antibodies in about two hours.
Encourage patients to adopt a three-pronged prevention strategy, Epperly said. Wear long sleeves and pants at dusk and dawn. Use DEET, or diethyltoluamide, to fend off the mosquitoes. Third, drain off any freestanding water.
Regarding SARS and monkeypox, Epperly said, "Here were two relatively rare outbreaks that gained notoriety because of widespread publicity. It's a two-edged sword: The publicity may have helped shut down a worldwide epidemic, but along with that came a lot of anxiety."
What's become clear is the importance of FPs having a good working knowledge of the public health system -- knowing what number to call to get questions answered or tests performed, Epperly said. "If there's been a positive side to all this, it's been the re-emergence of the importance of public health departments and the CDC working together to educate people -- the CDC to educate the nation, public health departments to educate doctors and the community, and doctors to educate patients."
If you weren't able to join your colleagues in New Orleans this year, take heart. Several high-demand 2003 Assembly lectures are being offered online for CME credit.
The online CME presentations are taped versions of the live Assembly courses -- so you won't miss out on any of the information presented. In addition to the taped lectures, you'll be able to read speakers' biographies and download presentation slides and handouts.
Sound like a great deal? Then take advantage of this hassle-free CME opportunity by visiting http://www.aafp.org/assembly.xml. Click on "2003 Lectures" and then choose from these lecture titles:
An additional lecture, "Sepsis of the Newborn," was scheduled to be posted by the end of October.
This CME activity has been reviewed and is acceptable for up to 10.5 Prescribed credits -- that's 1.5 credits per lecture. Better yet, it's free to AAFP members. Your CME credit will be processed quickly and easily online. The term of approval for this CME credit is one year.
One word of caution -- no double-dipping allowed. If you attended the CME presentation at the Assembly and obtained credit, you cannot apply for additional credit for the same coursework online.
BY DENNIS CONNAUGHTON
Managing patients with hepatitis C infection is a tedious business, no doubt about it. Pinning the infection down in the first place is perhaps even more difficult. But hepatitis C may be more common among patients in your practice than you think.
In his Oct. 1 seminar, "Hepatitis C in Primary Care," William Cassidy, M.D., associate professor of medicine at Louisiana State University Health Science Center in Baton Rouge, gave Assembly attendees insights into how to diagnose, treat and counsel patients infected with hepatitis C virus, or HCV.
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The leading cause of cirrhosis in the United States -- responsible for 10,000 to 20,000 deaths per year -- HCV infection represents the most common reason for liver transplantation. About 4 percent of Americans have chronic hepatitis, and, among 20- to 45-year-olds, its incidence is as high as 15 percent. But only about 20 percent of those infected with the virus develop symptoms, said Cassidy. All of which makes this infection extremely challenging for family physicians to diagnose and manage.
Mercurial virus
HCV is an RNA flavivirus that mutates every time the immune system attacks it and, as a result, tends to cause chronic, resistant infection. "Because of its hypervariability, vaccines so far have been impossible to develop, and immunoglobulin is ineffective," Cassidy said.
Transmission is bloodborne, and fully 60 percent of individuals who contract hepatitis C infection in the United States are injection drug users. It is rarely transmitted sexually, Cassidy said, but having a large number of sexual partners is associated with a higher risk of infection.
HCV infection causes a fibrotic liver disease that progresses linearly at a slow, intermediate or rapid pace, Cassidy said. Alcohol use and certain comorbidities, such as hepatitis B virus or HIV infection, increase the rate of progression, as do continued intravenous drug use and hepatic steatosis.
Clinical presentation
Patients typically present with subclinical disease. "Symptoms develop in only 20 percent of patients, and 10 to 20 percent of those have nonspecific symptoms," Cassidy noted.
Certain lab results give clues to a diagnosis of HCV infection. HCV RNA can be detected in blood within one to three weeks after exposure to the virus, and alanine transaminase becomes elevated within four to 12 weeks. The average time from exposure to seroconversion is eight to nine weeks; the average time from exposure to the development of symptoms is six to seven weeks, he said.
The infection is most prevalent among 30- to 39-year-olds, Cassidy said, so be vigilant for it in these patients. Prevalence is higher among men than women, especially among African-American men. An astounding 95 percent of HCV-infected African-American men become carriers of the virus, he said.
Treatment options
Current treatment options are either twice-weekly interferon with ribavirin or pegylated alpha interferon given once weekly with ribavirin. Patients should begin to respond to drug therapy within 12 weeks. If there is no response within that time, stop giving the drugs, Cassidy said. The goal of treatment is to prevent the infected patient from progressing to cirrhosis.
In addition to interferon and ribavirin therapy, all patients should be vaccinated against hepatitis A, and those who are not in monogamous relationships should be vaccinated against hepatitis B, Cassidy said. Patients should also be counseled to avoid alcohol, maintain a healthy weight, and avoid using nonsteroidal anti-inflammatory drugs and aspirin. People with cirrhosis should also receive annual flu shots and they should be appropriately immunized against pneumococcal infection. They should also avoid areas with poor sanitation, which can expose them to hepatitis A.
In an effort to ensure widespread awareness and knowledge about hepatitis C, AAFP has mailed a packet of information to all Academy members.
The packet, "Hepatitis C: Treatment and Monitoring," is an additional element of the 2003 Annual Clinical Focus on prevention. It includes a summary of the most recent NIH consensus statement on management of hepatitis C infection, a fact sheet to be used when talking with patients about preventing transmission, patient education materials and a "personal treatment contract" that engages patients to participate in their care plan.
The NIH update reviews treatment recommendations and goals, how to manage the side effects of treatment, and special treatment considerations for patients who are also HIV-positive or who have liver disease.
The easy-to-understand patient handout describes the illness, treatments and how to cope with the infection.
The hepatitis C packet was supported by an educational grant from Schering Corporation.
BY PEGGY PECK
 "When you ask about exercise or diet, ask yourself: 'Did I exercise today? What am I eating?'" America Bracho, M.D., tells family physicians during her Assembly lecture on helping people with diabetes. |
For family physicians who claim they can successfully manage people with diabetes, America Bracho, M.D., executive director of Latino Health Access, Santa Ana, Calif., has this message: "Control is in the hands of the person affected by diabetes, not the health care provider."
Bracho, who lectured Oct. 2 at the Assembly on the topic "Helping People with Diabetes Help Themselves," said physicians and other health care professionals need to rethink the way they address diabetes, beginning with the terminology used. "We need to separate the person from the disease," she said, noting that rather than using terms like "diabetics" or "patients with diabetes," health care professionals should say "people with diabetes" or "people affected by diabetes."
What's your lifestyle?
The next step for physicians is to take a hard look at their own lifestyles. Bracho noted that this message was driven home when she worked with an HIV education program. "We had a great educator who would lecture about safe sex and the use of condoms -- and then he would take a break to smoke," she said. "So what did that behavior say about his own commitment to a healthy life?" In the end, she said, the HIV educator's actions undermined his message in the community.
"So when you ask about exercise or diet," she said, "ask yourself: 'Did I exercise today? What am I eating?'"
Simplify nutritional info
Even physicians who are good examples of healthy living are likely to have difficulty delivering the healthy eating message to people with diabetes because "nutrition information is complex," Bracho said. To illustrate the point, she noted how Latino Health Access explains carbohydrates during its 12-week course for people with diabetes.
"We tell our patients that carbs break down into sugars. Four grams of carbohydrates equal one sugar cube," she said. With that knowledge, she attacks nutritional information from labels: a package of tortillas has 25 grams of carbohydrates, which equals six sugar cubes, while three Oreos have 24 grams of carbohydrates, again six sugar cubes. Even SnackWells, which are labeled as diet snacks, have "23 grams of carbs -- six sugar cubes -- so you can see how frustrating it can be for the person with diabetes," she said. But as difficult as the process can be, "learning how to eat is the key to freedom for people with diabetes," she said.
Put patient fears foremost
Although physicians tend to be concerned about comorbidities such as heart disease, people with diabetes are more likely to worry about "blindness, amputations and kidney disease," said Bracho. Education programs need to address these fears.
The Latino Health Access course focuses on the need for people with diabetes to take charge of their eye and foot health. "We tell them that the body has little pipes and big pipes. Diabetes clogs up these pipes, but just like in a home, the little pipes get clogged before the big pipes," she said. They are told that "little pipes" are found in the eyes and in the toes, so regular eye exams are necessary to protect their eyes. And they are told to take off their shoes and ask their doctors to check their feet, she said.
WEB EXTRA!
BY PEGGY PECK
Like many other musculoskeletal problems, most hand and wrist problems can be diagnosed by carefully considering three factors: anatomy, mechanism of injury and epidemiology, according to Edward Shahady, M.D., professor of family medicine and rural health, Florida State University College of Medicine, Tallahassee.
For example, when a 20-year-old patient presents with a "knee injury caused by a lateral blow, the diagnosis is usually medial collateral ligament damage. But when the patient is 11 or 12 years old, the most likely diagnosis is Salter-Harris fracture," Shahady said. He discussed this and other "practice pearls" Oct. 2 in an Assembly seminar, "Common Musculoskeletal Problems."
In his first case study, Shahady discussed injuries caused by a common mechanism known as a "fall on an outstretched hand." Shahady said he first tries to locate the exact source of the pain by clinical examination. "Shake the patient's hand to determine if he or she can wrap a thumb around your hand or if the thumb is held up to avoid pain," he said. Next, check for pain in the "anatomical snuff box," which is the area of the wrist just beneath the thumb. "Place your thumb in the 'snuff box' and ask the patient to rotate the hand to each side (ulnar deviation and radial deviation)," he said. If those movements increase pain, the most likely source of pain is a scaphoid injury.
Turning to anatomy, he pointed out that both dorsal and palmar views of the wrist illustrate that the scaphoid "butts directly up against the radius, so this makes sense as the site of injury." Finally, he considers epidemiology: in this case, age. "The patient is a 30-year-old. In that age group, scaphoid injury is the most likely diagnosis when the patient presents with these symptoms. But if the patient were 70 years old, the diagnosis is more likely to be injury to the humerus or the shoulder."
Treatment requires casting or splinting -- with finger immobilization -- for four to six weeks, he said.
Another common condition, de Quervain's tenosynovitis results from an injury associated with "forceful grasp coupled with ulnar deviation or repetitive use of the thumb -- the type of injury that fly fishermen, golfers or tennis players will get," he said. But also at risk are young mothers "who are constantly lifting up the baby," he said. A simple diagnostic test for this condition is Finkelstein's test: Have the patient make a fist with thumb tucked inside the fingers and then move the hand back and forth. If this causes increased pain, the most likely cause is de Quervain's, he said. He recommends treating the condition by injecting steroids plus lidocaine into the sheath surrounding the pollicis tendons.
Finally, he said the most common wrist-hand problem seen by family physicians is carpal tunnel syndrome. "With this condition, epidemiology is very important since carpal tunnel is more common in women -- especially middle-aged women -- than in men," he said. Since it is considered an overuse injury, initial treatment usually includes job modification, night splints and nonsteroidal anti-inflammatory drugs. Patients who don't respond to these measures often are good candidates for injection therapy, again with a steroid-lidocaine solution, he said.
He contended that injecting the carpal tunnel is easy with a simple trick: Have the patient flex the fingers so that they are curled into a loose fist; place the needle about 1 centimeter into the palmaris longus, keeping the needle at about a 30- to 45-degree angle; then ask the patient to open the hand and stretch the fingers. "Stretching the fingers will pull the needle into the right place," he said.
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Thanks to the AAFP 2004 Annual Clinical Focus: Caring for America's Aging Population, you can look forward to receiving a wealth of information on health care for elderly people throughout the coming year. The Academy officially launched the 2004 ACF at this year's Assembly.
Diverse and comprehensive, Caring for America's Aging Population will cover three age groups: those 50-65 years old, those 65-80, and those 80 and older. The initiative will address the psychosocial and physica
