BY SHERI PORTER
 "Can you imagine how inefficient it is to use this record when Mary comes in for her visits?" President Michael Fleming, M.D., below, says of paper records at the press event. At left, representatives of three of the AAFP's new EHR partners look on. |
Ten health care visionaries made history here Nov. 12. Meeting at the National Press Club, they announced a bold initiative to improve the efficiency, quality and safety of the health care family physicians deliver.
The press event, "Partners for Patients," was all about electronic health records and AAFP's push to make EHR systems available and affordable to all FPs by forging alliances with leaders in the field. Representatives of the Academy and its new EHR partners spoke at the press event.
What's all this mean to you as an AAFP member? You now can purchase hardware and software discounted 15 percent to 50 percent, depending on the product. And that means the thousands of small- to medium-size practices that have been frozen out of the move to EHRs because of prohibitive cost will now be able to move forward.
To date, the Academy's new partners are A4 Health Systems, GE Medical Systems Information Technologies, Hewlett-Packard, MedPlexus Inc., MedPlus Inc., NextGen Healthcare Information Systems Inc., Physician Micro Systems Inc., Siemens Medical Solutions Health Services Corp. and Welch Allyn Inc.
AAFP's alliances with these partners "place us clearly in the forefront of technological development among all other medical associations," AAFP President Michael Fleming, M.D., of Shreveport, La., said at the press event.
To illustrate just how the move to EHRs will help patients and physicians, Fleming held up a well-worn manila folder housing a patient's chart. "Can you imagine how inefficient it is to use this record when Mary comes in for her visits?" he asked. "What if all of Mary's health records were current, immediately accessible and updatable? And what if everything was at my fingertips every time I saw Mary?"
Mark Leavitt, M.D., GE's vice president for clinical initiatives, said it was no secret that the health care industry has fallen behind in implementing digital technology. "We're about the only ones not participating. We're lagging behind pizza parlors and video rental stores," Leavitt said.
What this initiative offers is not a new product, but rather a new network that will help every product work better, said Jon Zimmerman, Siemens' vice president for e.Health. "We're going to make all of those products talk together. It's time to get busy, because data in motion is data at work."
Each company has pledged to uphold the Academy's four guiding principles of affordability, compatibility, interoperability and data stewardship.
Get more information about the initiative at http://www.aafp.org/centerforhit.xml. Click on "Current Projects," then "Principled Group Purchasing Agreements." You'll find links to the partner organizations' Web sites, which provide product and pricing information. Enter your AAFP ID number to access the links.
This project is evolving at a breakneck pace; the Web sites will be updated as soon as new information becomes available, including possible additional partners.
To reach writer Sheri Porter, e-mail sporter@aafp.org.
WEB EXTRA!BY LESLIE CHAMPLIN
 A stream of white coats flows from Missouri to Kansas as FPs and other physicians symbolically flee Missouri's malpractice insurance crisis. The White Coat Flight was organized by the Missouri AFP. |
Malpractice premiums skyrocket. Underwriters drop coverage. Insurance companies abandon certain states. And, despite pleas from the medical community, some states' legislators turn a deaf ear to calls for resolution.
That inaction has spurred family physicians into action. They've gotten into their legislators' faces, as AAFP President Michael Fleming, M.D., of Shreveport, La., suggests (see "Q&A -- Michael Fleming, M.D.: 'I think it's time to get in some faces.'"). With help from their constituent chapters, FPs have begun turning to America's most powerful stimulus for change: the voters. In doing so, the FPs hope to intensify political pressure on legislators who have failed to respond to calls for legal reform.
Beginning to get noticed
Illinois legislators have consistently ignored skyrocketing malpractice insurance premiums. So Mark Macumber, M.D., a 35-year-old family physician, joined the ranks of the uninsured in order to provide services to the uninsured. His malpractice premium had escalated, so he cut costs by dropping malpractice insurance. In September, the Illinois AFP arranged a half-day media event, in which reporters toured Macumber's Patients First Clinic and grilled him about his decision to "go bare."
The tactic worked. In Chicago, three newspapers, five radio stations and the region's largest television station jumped at the chance to show Macumber caring for his patients and describing the negative effect of high malpractice insurance premiums on patients' access to care.
Before the Macumber story broke, the media had usually portrayed the malpractice insurance issue as rich physicians pitted against vulnerable patients, said Ginnie Flynn, Illinois AFP manager of public relations.
Response has been gratifying, said Macumber. Since the public learned of his position, an average of five new patients a week have called for appointments. A 20-minute stint on a call-in radio show ballooned to two hours because "the phones were full with callers," said Macumber. The news coverage spurred intense cyberdiscussion. Web logs -- individuals' online journals -- abound with references to Macumber. (See "Online journals discuss 'going bare.'")
Moreover, colleagues have offered to serve as attending physicians of record for Macumber's patients who may require hospitalization. An optometrist asked to join his practice to provide low-cost vision services to patients.
"I want to show people they could do something outside the system, and people would respond to it," said Macumber.
Taking it to the streets
Meanwhile, Missouri legislators failed this year to override the governor's veto of a tort reform bill.
"Our members just threw up their hands," said Diana Ewert, chapter executive of the Missouri AFP. "There's a sense (among the public and legislators) in the state that things aren't so bad that physicians are going to leave."
That's when the idea of a symbolic White Coat Flight developed. Well beyond the shadow of the Missouri statehouse, family physicians and their colleagues from other specialties from across the state converged on a Kansas City, Mo., neighborhood and took their message to the streets.
As neighbors watched and television cameras rolled, physicians donned white coats and marched from Missouri into Kansas. Drivers of passing vehicles honked their horns and their passengers flashed thumbs-up as a stream of white coats flowed across State Line Road.
"We have gotten a lot of positive support," Ewert said. "We framed the issue in a way that explains it's everyone who depends on a doctor in Missouri who is hurt (by the malpractice crisis). When you lose 700 doctors over five years, as Missouri has, you're creating an environment where health care is going to suffer."
Interested in learning more about the Illinois and Missouri activities and the potential to adapt them to your state? E-mail Flynn at gflynn@iafp.org; e-mail Ewert at dewert@mo-afp.org.
To reach writer Leslie Champlin, e-mail lchampli@aafp.org.
The Illinois AFP news event focusing on the decision by Mark Macumber, M.D., of Berwyn, to "go bare" -- practice without malpractice insurance -- touched a nerve in cyberspace. People who read or saw news about Macumber's decision generated additional coverage -- and, in general, support for physicians -- on their weblogs.
"If you are uncomfortable getting treated by a physician because you might not be able to sue them for enough money, then go find another physician," writes Bhavesh Patel at http://www.veshman.com/mt/archives/000048.php," he continues.
"HMOs won't deal with Macumber because he doesn't have liability insurance. And he doesn't want to deal with HMOs.
"Because he won't be billing insurance plans, submitting claims, appealing denials, etc., he can keep his fees low and have more time for patients.
"Wow, maybe Dr. Mark will actually have time for his patients and will be less likely to even make a mistake. And maybe his patients will like the care they receive. And maybe they will appreciate the fact that he is cutting his costs so that they can have affordable health care."
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The death was sudden. Virtually no symptoms appeared until just before the end. By then, Renee Miskimmin, M.D., and the 33 family medicine residents she oversaw could do nothing to prevent the demise.
Citing a decision to focus on cardiology care, leaders of Hamot Medical Center of Erie, Pa., withdrew life support from the Hamot Family Practice Residency.
News of its demise jolted Pennsylvania family medicine. Waning medical student interest had haunted the specialty for a half-decade. Now the institutions that trained future family physicians seemed to be deserting the specialty.
To shut down in June 2004, the Hamot Family Practice Residency program is the state's third to close in two years. The program at Geisinger Health System, Danville, Pa., has already closed; the Meadville Medical Center Family Practice Residency will close soon.
Taking action, making plans
But Pennsylvania's family physicians are acting to stem the losses. The Pennsylvania AFP convened a statewide summit Oct. 10 in Harrisburg. There, family medicine educators reviewed challenges to the specialty and possible ways to recruit students to family medicine and enhance the specialty's prestige.
Any recruitment plan, they said, must address perceptions that family medicine is too broad and too difficult, or too broad and too superficial; that it is a research-poor specialty that rarely uses technology; or that family physicians are plagued with uncontrollable work hours filled with paperwork and reimbursement hassles.
Strong research is key
Some solutions, said summit participants, lie in primary care research initiatives.
Speakers urged colleagues to seek increased research funding from the NIH and other sources. Research opportunities abound, said speakers, in issues family physicians address on a daily basis. Programs with a strong research presence see an increase in prestige and student interest, said Jeannette South-Paul, M.D., chair of the family medicine department at the University of Pittsburgh School of Medicine.
Participants also agreed that early, positive exposure to family medicine could be a key to a medical student's decision to select the specialty.
Linda Kanzleiter, associate program director for the Pennsylvania Area Health Education Center in Hershey, suggested stronger alliances between AHECs and family medicine programs. The two share medical schools' workforce development goals, focus on primary care and offer ideal locations for student rotations, she said. As such, AHECs provide excellent exposure to the joys of family medicine, she suggested. Moreover, the Pennsylvania AHEC program, which traditionally has served rural areas, could shift focus to include urban sites, she said.
Hospitals determine programs' futures
Academic medical leaders have long acknowledged that the end of the residency programs demonstrated a fact of medical education life: The continued existence of many family residencies depends on the interest of community hospitals in serving as the residencies' educational homes.
"Family practice residency programs are particularly vulnerable" as a result of economic changes, said Perry Pugno, M.D., M.P.H., director of the AAFP Division of Medical Education, in the June 2000 Family Practice Management. "More than 80 percent are based in community hospitals. … They typically serve disenfranchised patient populations and have little access to revenues from 'high-reimbursement' surgical procedures and specialty consultations that, for example, are available to surgical residency programs."
Because they don't generate as much income as residencies for high-tech specialties, family medicine programs may be seen as cost centers to hospitals. The danger: Hospital boards may opt to cut family medicine residencies in order to add or increase subspecialty slots, said John Jordan, chapter executive of the Pennsylvania AFP in Harrisburg.
"Hospitals may have different ideas, decide to go in different directions and develop different goals," he said. "In order to increase their residency slots in cardiology, they had to delete another program."
AAFP President Michael Fleming, M.D., of Shreveport, La., is leading the Academy at an exciting time for the specialty. Health issues are the subject of hot debate in presidential campaigns and in the halls of Congress. Organizations in "the family of family medicine" are examining the very nature of the specialty. In this interview, Fleming discusses student interest in the specialty, the Future of Family Medicine project, the new Americans in Motion initiative, and advocacy for and by family physicians and their patients.
Q: We've had six straight years of declining numbers of people coming into family medicine residencies. How can the Academy attract more students to the specialty?
A: Since this specialty began, medical students have been told -- whether they're at small state medical schools or large urban medical centers -- "You're too smart to go into family medicine." Family medicine is belittled within the academic community, from top to bottom.
I intend to work with the academic folks to try to bring them into the real world. In my world -- the private practice world -- my relationship with my subspecialty colleagues is excellent. In polls for the Future of Family Medicine project, other specialists and subspecialists said clearly, "We must have family physicians in order for us to do our work."
Q: How does the National Conference of Family Medicine Residents and Medical Students factor into this?
A: Students who come to the conference get turned on to the specialty in a major way. I have given a number of scholarships to students. Now, I don't know what our rate of capture is for those students -- getting them to go into family medicine -- but I would suggest to you that it is very high. I plan to encourage our family medicine departments to provide more scholarships to next year's conference (July 28 - 31 in Kansas City, Mo.).
Q. What progress has been made in the Future of Family Medicine project?
A. Reports from the project task forces have gone to the seven organizations participating in the project, and the project Web site (http://www.futurefamilymed.org/x13525.html) has research results.
The project's task forces have considered the research results and framed recommendations. It's now the collective job of the governing boards of the seven organizations to decide which of the recommendations they want to begin to address, and to prioritize the recommendations. In late January, the project leadership committee will meet and wrestle with responses from the governing boards.
Every family physician in the country is watching our leadership to see what comes from this project. So stay tuned!
Q: You're taking an active role in the Academy's new Americans in Motion program, vowing to lose weight and get more physically fit over the next year. What's drawn you to this program?
A: I always remember the story my grandfather told me about the doctor who told him to quit smoking while blowing smoke in his face. We family physicians have to walk the talk, or we won't be credible with our patients. I have a personal issue, a health problem -- and I have four grandchildren, and I want to be around for them.
Americans in Motion gives me an opportunity to respond to a serious challenge. I have changed my diet. I wear a pedometer and aim to walk 10,000 steps each day; I use a personal scale to monitor my body mass index; and I've enrolled in the Active Lifestyle Program, a program of the U.S. President's Council on Physical Fitness and Sports that urges people to take part in at least 30 minutes of physical activity five days a week for six consecutive weeks. By this time next year, I want to see a major difference. So far, I have lost 20 pounds. I encourage other family physicians to check out our Web site (http://www.aafp.org/flemingchallenge.xml) and join with me in the Americans in Motion program!
Q: You have said, "We are not the old AAFP. There's a new attitude. We are advocates for members and patients, and we are asking our members to be advocates as well." What does that mean?
A: We can't just expect a few to go out and be advocates for the whole specialty. It's time for everybody to be involved.
Take the Academy's Patient Voices in Washington program (at http://www.aafp.org/ptvoices.xml). In my office, our Patient Voices program has allowed our physicians to mobilize patients by giving them information on key issues that affect them and showing them how they can be involved in the political process. I haven't been able to keep the Patient Voices brochure holders full. I have not heard back from my legislators yet, but I know from past experience that legislators do listen to their constituencies when their voices are strong.
Q: How do we go about establishing the AAFP as the medical organization legislators turn to?
A: We're going to have to let people know that our opinion matters. And, topic after topic, our message has to be, "Here's what's best for our patients." Family physicians have about 100 million self-identified patients, who make 210 million patient visits a year. We have got to make that known. Family docs tend to be nice people. We don't get in anyone's face. I think it's time to get in some faces.
BY TONI LAPP
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 Iraqi health care professionals listen as Lt. Col. Mark Harris, M.D., discusses emergency obstetrical procedures during an ALSO course that has engendered an overwhelmingly positive response from participants. |
In post-war Iraq, an AAFP CME program is helping to rebuild the shattered medical system -- and response from Iraqi medical providers so far has been overwhelmingly positive.
The Advanced Life Support in Obstetrics, or ALSO, provider course teaches techniques for handling obstetric emergencies.
One need only look at statistics to recognize the need for such a program in Iraq. According to the CIA World Factbook, 55 Iraqi infants die for every 1,000 live births. By comparison, the infant mortality rate in the United States is 6.75 per 1,000.
That's why one FP in the U.S. military led the push to teach the ALSO in Iraq.
Lt. Col. Mark Harris, M.D., a family physician in the Army's 1st Armored Division, and other physicians presented the course to Iraqi medical professionals for the first time in late October. The seed of the idea was planted when Harris saw the course advertised in an AAFP catalog.
Presenting ALSO has been a gratifying experience, said Harris, who -- along with most other members of his division -- had been in Iraq about six months by late October. "This course was definitely a highlight for me, and was the best event in the deployment for many of our other physicians," he said in an e-mail interview recently.
Harris has encountered cultural barriers to teaching ALSO in Baghdad. "Language is the biggest," he said. Arabic is a difficult language for English-speakers to learn, he said, but most Iraqis receive their medical training in English. So the presenters teach the course in English, and the more fluent Iraqis help the less fluent.
Then there's the delicate issue of societal norms.
"Most providers of women's health care in Muslim countries are women because of cultural and religious concerns, so we weighted our faculty towards women, even though there are many more male physicians in the Army. Many Muslim women will not even touch -- even shake hands with -- a man," he said.
Thirty-two Iraqis, five U.S. Army instructors and two student facilitators attended the first course in Baghdad. The 1st Armored Division plans to offer the two-day course at least twice more, said Harris.
"The response was overwhelming," said Harris. "They invited us to their hospitals, their universities and even their homes. Many gave me their home phone numbers -- those who have phones -- and asked me to call them personally for further classes. We are planning to accept as many invitations as possible, but people are dying every day out here, so security is a major issue."
Harris said ALSO was his favored maternity care training program. "I learned these skills for the first time from ALSO," he said. "It is concentrated, systematic and comprehensive.
"It is a good way to learn and teach."
The notion that ALSO can spread American good will overseas is not new. ALSO has been presented in Canada, England, Scotland, Wales, Australia, New Zealand, Hong Kong, People's Republic of China, Denmark, Haiti, Nepal, Kenya, Pakistan, Greece, Brazil, Ecuador, Paraguay, Qatar, Ireland, Italy, Turkey, Gaza Strip/West Bank and Zambia. Plans are in the works for a course in the United Arab Emirates in February.
In addition, the latest Physicians With Heart airlift arrived in October in the former Soviet republic Kyrgyzstan, where airlift delegation members presented the ALSO courses and provided education about family medicine to Kyrgyz physicians. The delegation built on the success of the 2002 Physicians With Heart participants, who presented the courses in Uzbekistan. The Academy; AAFP Foundation; and Heart to Heart International of Olathe, Kan., are partners in Physicians With Heart, a humanitarian effort that brings needy countries donated pharmaceuticals and other medical supplies.
ALSO Manager Diana Winslow, R.N., is not surprised by the program's reach overseas.
"As the ALSO program is implemented internationally, it is clear that this type of education is adopted with great success," she said. "It is primarily the structured, evidence-based, multidisciplinary approach that seems to appeal to all, especially the interactive training."
For more information about ALSO, go to http://www.aafp.org/also.xml.
To reach writer Toni Lapp, e-mail tlapp@aafp.org.
 Environmental researcher/writer Sandra Steingraber, Ph.D., signs copies of her books at the Society of Teachers of Family Medicine Annual Conference. Steingraber was a featured speaker at the meeting. |
BY CINDY BORGMEYER
There's no denying the truth of the adage, "Good things come in small packages." One glance at the enrapt face of a woman cuddling her newborn proves that.
Unfortunately, bad things also can come in small packages. Take traces of mercury in the infant's bloodstream, for example. That's a reality family physician Stephanie Brundage, M.D., of Greenville, S.C., deals with daily. Brundage directs the Appalachia II Public Health District, which encompasses Greenville and Pickens counties in South Carolina.
"We issue warnings to people who go fishing in certain lakes that they shouldn't be eating more than X number of largemouth bass because of the mercury content," Brundage said. "If a patient is pregnant and I know she has a husband who goes fishing a lot, I can tell her that certain species of fish contain higher levels of mercury than others and that could pose a risk to the pregnancy."
FP Leigh Beasley, M.D., of Central, S.C., takes a similar tack with her patients. Beasley is associate director of the Appalachia II health district, overseeing the Pickens County Health Department. She, too, warns her pregnant patients about consuming the local "catch of the day" and advises against eating locally harvested deer meat because of toxoplasmosis concerns.
"Dose makes the poison"
Brundage and Beasley embody the environmental awareness Sandra Steingraber, Ph.D., Distinguished Visiting Scholar in Interdisciplinary and International Studies at Ithaca College in Ithaca, N.Y., hopes all physicians espouse.
Steingraber described in glittering detail some of the hazards posed by environmental toxins Sept. 21 during the 36th Society of Teachers of Family Medicine Annual Conference in Atlanta. Her remarks fit hand-in-glove with the conference's theme, "Healthy People, Healthy Communities: Defining Family Medicine's Role."
Sixteenth-century Swiss physician and alchemist Paracelsus laid down the guiding principle of toxicology, Steingraber told family medicine educators at the conference. That principle: "The dose makes the poison."
"Now the evidence shows that it's the timing that makes the poison, as much if not more than the dose," she said. "There are windows (during human development) in which we are exquisitely sensitive to the effects of toxins."
Research suggests that during breast development in young girls, for example, exposure to even tiny amounts of ionizing radiation presents a risk of subsequent breast cancer, said Steingraber. Therefore, some clinicians avoid giving dental X-rays to girls during this developmental period. But problems can begin much earlier, said Steingraber. (See "Preconception, prenatal exposures can have lasting effects.")
Know local health risks
The prospect of keeping up-to-date with all potential environmental threats may seem overwhelming. Best to start in your own backyard, said Brundage.
"Family physicians really have to know what the particular risks are in their own communities," Brundage said. "Their major role is to translate health information for their patients, to help them understand what might affect them."
Right questions, right answers
Beasley said she had little difficulty gauging her patients' environmental risk. Most of them work in the textile mills, industrial plants or fast-food joints that form the lion's share of the local economy. A few well-considered questions about work and diet typically are all that's needed to elucidate potential toxic exposures. "I'm not saying we're all going to become occupational doctors," she said. "I'm just saying we need to know what mills or plants are in the area and know what the hazards are."
Providing reassurance and education can go a long way toward allaying patients' fears, Beasley has found. For example, patients frequently misunderstand the concept of possible versus probable risk, she said. "People are scared to get an epidural, for example, because the consent form lists 'death' as a possible side effect. I break it down by talking about the risks of driving, of being injured or killed in a car accident. Everybody understands about those risks and yet we're all going to go outside, get in our cars and drive home."
Some of this misunderstanding may stem from a paucity of reliable patient information about the risks posed by environmental pollutants. What's needed, Beasley mused, is a way to translate existing technical resources -- such as the material safety data sheets developed by the Occupational Safety & Health Administration on hundreds of hazardous substances -- into patient-friendly materials ready for posting online or handing out to patients.
Any takers?
To reach writer Cindy Borgmeyer, e-mail cborgmey@aafp.org.
Family medicine educators recently got an earful about the impact of some common environmental toxins on human development. Infants born to fathers routinely exposed to kerosene or diesel fuel -- even before the children were conceived -- have an increased incidence of neuroblastoma, Sandra Steingraber, Ph.D., told participants Sept. 21 at the Society of Teachers of Family Medicine Annual Conference in Atlanta. A mother's exposure to pesticides at 3 to 5 weeks' gestation -- before she realizes she's pregnant -- can lead to spontaneous abortion, Steingraber warned.
Slightly later in the fetal developmental process, "the amazing opera that we know as organogenesis" takes place, she said. During this critical window, maternal exposure to pesticides can lead to limb reduction deficits. State birth defect registries clearly show this correlation: By examining Minnesota's records of infants born with missing digits or limbs, for example, Steingraber confirmed that organogenesis occurred during the spring planting months, when pesticide use was at its highest.
Neurogenesis, a process Steingraber likened to a "quilting bee done by spiders," is also susceptible to the effects of environmental toxins. Fetal exposure to lead or mercury inhibits dendrite formation and can result in mental retardation.
Polychlorinated biphenyls, or PCBs, are some of the most well-studied environmental contaminants. PCBs were used in hundreds of industrial and commercial applications until the practice was outlawed in 1977. But they still contaminate the water supply in many areas, said Steingraber.
By binding to protein receptors in the brain, PCBs interfere with the supply of thyroid hormone essential for nervous system development. "It's like trying to flag down a thyroid taxi that already has a passenger on board," Steingraber explained.
BY J. MICHAEL BRODIE
If you want to sit at the political policy table, sometimes you have to bring your own chair. Speakers shared this message repeatedly with AAFP leaders during the State Legislative Conference, held here Oct. 31 - Nov. 1.
"Either you will shape the debate and shape the policy, or those you disagree with will," former Kansas Lt. Gov. Gary Sherrer told the more than 100 conferees from 32 states; Washington, D.C.; and the Virgin Islands.
Sherrer also advised patience in dealing with the political process. "We have this microwave way of thinking in a crock pot system," Sherrer said. "The problems are often so complex that you have to be very patient as you come up with a solution."
Several family physicians and chapter staff members shared strategies for addressing issues from Medicaid eligibility to medical liability reform to funding for family physicians' education. Chapter members have conducted marches, held White Coat Days in state capitols, visited legislators and written to local newspapers.
The legislative process "starts at home," said speaker Don Gilbert, former Texas HHS commissioner, who discussed the role of family physicians in state health care debates. "If you wait until the start of a legislative session to speak out, you have waited too long," he advised.
FP legislators
Three FP legislators had this message: Join the fray!
State Sen. Robert Deuell, M.D., a Republican from Greenville, Texas, said he was heartened to see so many colleagues taking active political roles. "For a long time I felt that physicians were turning health policy over to nonphysicians," said Deuell. "We need more physicians involved at all levels. Will history look back in dismay that those who had the most to do did the least?"
State Assemblyman Joseph Hardy, M.D., a Republican from Boulder City, Nev., agreed. "As a family physician, you do politics every day," he said. "You talk to people every day who have opinions. You don't have to go very far before you understand what people think. You have the ability -- as a physician -- to get in where no one else can."
State Rep. Lisa Marraché, M.D., a Democrat from Waterville, Maine, also stressed the importance of having FPs share their views with lawmakers.
"Testify. Be there. It is so important that they hear from someone directly affected by their legislation," said Marraché. She sits on the Maine House Transportation Committee, has served in elected office since 1997 and was reportedly the first medical resident to hold office while completing her training.
Chapter activism
Constituent chapter leaders described their legislative battles and, in some cases, victories. (See "Liability crisis: Family physicians take their case to the people.")
Oklahoma FPs recently celebrated the passage of a tort reform bill that placed a $300,000 cap on noneconomic damages.
Ohio FPs are targeting next year's state Supreme Court election, with four of the seven judicial seats up for grabs. The election could determine whether liability reforms and other health-related legislation will be upheld when challenged in court.
Wisconsin offers a medical liability success story, said Wisconsin AFP Past President Brad Fedderly, M.D., of Milwaukee. In 1975, the state created a patients' compensation fund that provides excess medical malpractice coverage for Wisconsin health professionals. The fund requires health care providers to obtain primary medical malpractice insurance from private companies in an amount required by statute.Since July 1, 1997, that amount has been $1 million per occurrence and $3 million annual aggregate. Coverage in excess of the primary insurance is provided by the fund.
Over the years, the fund has made Wisconsin an attractive place to practice, said Fedderly. "We are one of the states that does not have a medical malpractice crisis."
Family physician and U.S. Rep. Ernest Fletcher, M.D., R-Ky., won his state's gubernatorial race on Nov. 4. Prior to Fletcher's foray into politics, he worked as a family physician for 12 years. He is one of 17 family physicians holding either state or federal elected positions. Many of those seats will be up for re-election next November.
At press time, it was feared that Congress would adjourn for the year without sending Medicare legislation to President Bush to sign. The hoped-for legislation included a 1.5 percent minimum increase in Medicare reimbursement for the next two years, instead of the 4.5 percent cut slated to take effect Jan. 1.
Want regular updates from the Academy on topics such as Medicare reimbursement? Go to http://www.aafp.org, log in with your member ID number, open "My Subscriptions," and then open "Publications Delivery Options." You can choose AAFP This Week, a weekly e-mailed newsletter, and AAFP Direct, the biweekly source of "insider" news for AAFP members.
• The specialty declared victory Feb. 13 when Congress appropriated about $92 million for 2003 funding of the Public Health Service Act, Title VII, Section 747 -- funds crucial to training in family medicine and other areas. However, during the year, the administration and Congress hacked away at the Title VII funds proposed for 2004, and family physicians peppered Congress with requests to maintain the funding level. At press time, the specialty's best hope was for Congress to pass an omnibus appropriations act that would go with the status quo -- sustain the 2003 funding level for next year.
• Swayed by heavy lobbying, including contacts by FPs, Congress averted a 4.4 percent cut in Medicare physician fees Feb. 13 and allowed the fees to rise 1.6 percent. This fall, AAFP launched an unprecedented drive to enlist patients in contacting Congress, accenting the connection between Medicare reimbursement and access to care. On Oct. 30, the Centers for Medicare & Medicaid Services announced a 4.5 percent drop in fees for 2004 if Congress did not prevent the cut. At press time, however, Congress' work on Medicare legislation (including a possible call to revise the fee formula) bogged down in battles among congressional leaders.
• The AAFP had a place at the table at the Department of Veterans
Affairs Chiropractic Advisory Committee meeting in March in Washington. (Then)
Board Chair Warren Jones, M.D., one of 11 committee members, reiterated AAFP's
position that chiropractors should not be viewed as primary care providers in
the VA.
• AAFP members rallied to the cause during 2003 as
the medical liability crisis reached a crescendo. Constituent chapter members
testified before state and federal legislative committees. FPs also contacted
federal lawmakers in support of the Help Efficient, Accessible, Low-Cost,
Timely Healthcare Act, H.R. 5, through AAFP's online service, "Speak Out:
Legislative Action Center." Some FPs took to the airwaves and marched in the
streets to educate the public (see "Liability crisis: Family
physicians take their case to the people").
• AAFP's Colonoscopy Pilot Project, begun in 2002, posted new data online this fall that could help members improve their ability to obtain colonoscopy privileges.
• The AAFP Congress of Delegates, meeting in October in New Orleans, called on the Academy to form a "SWAT" team to help members fight privileging battles. The Academy is to develop a list of FPs willing to travel and testify in privileging disputes.
• AAFP's National Network for Family Practice and
Primary Care Research continued a study this year on pneumococcal immunizations
among older adults and conducted a survey on FPs' clinical practices concerning
hepatitis C.
• Wonca, the World Organization of Family Doctors, organized a March meeting in Kingston, Ontario, where representatives from more than 30 countries reached consensus that family medicine research was important to the health of nations and that Wonca had a critical role in promoting that research.
• Annals of Family Medicine, full of peer-reviewed family medicine research, premiered May 30. Rave reviews erupted from the public press, including this from Newsweek: "There are 30,000 scientific journals in the world and most of them are unreadable. Do we really need another? Yes, yes, yes, at least in the case of Annals of Family Medicine."
• The Future of Family Medicine project, launched in 2001, began to bear fruit. Preliminary data released in March "indicated the American people still want a personal relationship with a listening, caring physician," said (then) President James Martin, M.D.
• The National Resident Matching Program results in March showed family medicine continued to struggle to position itself as the specialty of choice among medical students. This year's overall fill rate for family medicine residencies through the match was 76.2 percent.
• The Congress of Delegates in October directed the Academy to replace the term family practice with family medicine when referring to the specialty. Also, those who specialize in family medicine are family physicians, not practitioners, delegates affirmed.
• Delegates confirmed that women had "arrived" in the Academy and in the specialty when they elected Mary Frank, M.D., the Academy's first woman president-elect.
• Delegates voted to establish six delegate seats and six alternate seats in the Congress for international medical graduates; women physicians; minority physicians; and the gay, lesbian, bisexual and transgender constituency.
• AAFP collaborated with the CDC Office on Smoking and Health in sending stop-smoking patient education materials to selected FPs in February. "Got a minute? Give it to your kid," say the materials, urging parents to be active in the stop-smoking effort.
• In March, the CDC reported on a mysterious disease, SARS, or
severe acute respiratory syndrome, and AAFP posted the CDC health alert on
aafp.org. AAFP added patient information -- "SARS: What Parents Need to Know"
-- to the KidsHealth section at familydoctor.org.
• In May, the Asthma Collaborative, organized by the AAFP and the National Initiative for Children's Health Care Quality, finished its work -- finding ways to improve asthma care in 13 family practice settings. Participants are sharing their results through presentations at medical meetings and via documents on AAFP's Web site.
• The budget prioritization process in 2002 gave Tar Wars® a mid-2003 deadline to secure full external funding. AAFP's anti-tobacco education program has received support from Schering, AAFP Foundation and Janssen Pharmaceutica and is seeking more funding.
• In September, the CDC announced a three-year, $390,805 agreement to work with AAFP on an immunization project, focusing on increasing family physicians' awareness of the need to immunize.
• The Congress of Delegates in October called for Academy support of a proposal -- under FDA consideration -- to make progesterone-only emergency contraception available over the counter. The measure also urged the FDA to approve product labeling that would encourage patients to seek guidance from their primary care physicians on use of all OTC contraceptives.
• Throughout 2003, the AAFP helped members gain
compliance with multiple rules for the Health Insurance Portability and
Accountability Act. AAFP initiatives included a Web site dedicated to HIPAA
resources for members, a "President's Letter" urging active members to test
claims transactions before the Oct. 16 deadline to comply with transactions and
code sets standards, and constant AAFP pressure on the Centers for Medicare
& Medicaid Services to develop a contingency plan before the deadline. A
reprieve came in September when CMS said it would give physicians more time to
come into compliance with the transactions standards.
• The Academy established a Center for Health
Information Technology at AAFP's Leawood, Kan., headquarters in September.
• The Academy hosted a press event at the National Press Club in Washington in November to announce strategic business alliances with nine companies that will provide electronic health record technology to medical practices at an affordable price (see " Academy forges alliances, clears path for EHR implementation").
• In 2002, AAFP spearheaded development of a
health care coalition that, by this summer, asked the U.S. Congress to endorse
"health care coverage for all persons in the United States by Jan. 1,
2009."
• During the March Patient Safety Awareness Week, AAFP leaders briefed congressional aides about the need for a medical error reporting system that would be voluntary and confidential. (Then) AAFP President James Martin, M.D., said much information was available on medical errors in hospitals. "But the majority of health care in this country takes place in an outpatient setting," he said, calling for improving patient safety in primary care.
• National, regional, local and medical news media turned to the Academy during 2003. A leading indicator: In August, ABC's Good Morning America solicited an interview with (then) President-elect Michael Fleming, M.D., about whether healthy people need annual check-ups.
• A September conference on patient safety assembled more than
100 participants. It was organized by the AAFP Developmental Center for
Research and Evaluation in Patient Safety in Primary Care with a $50,000 grant
from the Agency for Healthcare Research and Quality.
• In September, FP Jonathan Temte, M.D., Ph.D., took AAFP's message on bioterrorism to Congress by testifying before the Subcommittee on Emergency Preparedness and Response of the House Select Committee on Homeland Security. Throughout the year, AAFP continued to post information on bioterrorism and public health threats on aafp.org.
• In September, AAFP and CDC launched "Get Smart: Know When Antibiotics Work," a national education campaign about appropriate use of antibiotics.
• The 2003 Annual Clinical Focus on prevention
enjoyed unprecedented media coverage; results of a nationwide health behaviors
poll drew national news attention this summer.
• Washington-based political commentator Morton Kondracke delivered the keynote address during the Scientific Assembly Oct. 1 - 5 in New Orleans, exhorting family physicians, "Lobby like crazy." In all, 12,529 people registered for the Scientific Assembly, including 4,377 physicians. The event featured hundreds of educational sessions, allowing FPs to rack up as many as 45.5 Prescribed CME credits.
• The American Board of Family Practice's Maintenance of Certification for Family Physicians program has generated much controversy since it was announced in the summer. AAFP members critiqued the plan at a town hall meeting during the Annual Assembly, and the Congress of Delegates referred resolutions on the matter to the AAFP Board of Directors for further scrutiny.
• The AAFP Congress voted to change the terminology used to refer to members' CME activities. The change from CME hours to CME credits allows AAFP to recognize 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.
• The Advanced Life Support in Obstetrics program expanded its international efforts in 2003, traveling for the first time to the former Soviet republic of Kyrgyzstan and to Baghdad, Iraq, this fall (see "AAFP program boosts Iraqi maternity care"). Several dozen ALSO® instructors and hundreds of ALSO providers were trained during the program's visits overseas to these and other destinations.
Family medicine residents in the Kansas City area have the opportunity to complete their specialty training and earn a master's degree in business administration simultaneously -- a breakthrough for the specialty. Rockhurst University, Kansas City, Mo., is developing the pilot program with support from the AAFP Foundation.
From 36 to 45 family medicine residents are expected to begin the first business course in the dual program in June. They will earn their MBAs and complete their residencies in 2007.
The MBA curriculum will require 51 hours of course work with an emphasis on leadership in health care. Classes will be scheduled to accommodate residents' training demands.
"The idea is to give family physicians administrative expertise and leadership skills as well as a recognized credential to facilitate their becoming leaders in health care," said Perry Pugno, M.D., M.P.H., director of the AAFP Medical Education Division.
Physicians' need for business acumen has grown with the spiraling complexity of reimbursement regulations, employment law and business tax rules, according to Myles Gartland, Ph.D., assistant professor of economics and health care leadership curriculum coordinator at Rockhurst.
Their training often pushes them into top leadership roles within the health care community, but their medical education doesn't train them to handle the stress and burdens that accompany such roles, he added.
Today's medical students are acutely aware of the need for business savvy, said Pugno. He foresees as many as 200 applicants to family medicine residencies in the Kansas City area as a result of the dual program.
The Academy worked with Rockhurst University to establish the dual program, and the AAFP Foundation provided $55,000 in support of its development. Rockhurst has already offered a successful dual MBA/doctor of osteopathy degree with the University of Health Sciences for four years.
"The characteristics that make a good family doctor are also suited to leadership positions in health care," said Pugno. "They have excellent communication skills, a broad perspective and comfort with complexity. They are good at collaborative decision-making, and they take care of patients in all kinds of settings: medical, surgical, emotional health. That gives them a perspective on what other disciplines in health care are dealing with."
The Academy and Rockhurst University have begun groundwork for expanding the program to FP preceptors and -- through intensive online classes and other mechanisms -- to family physicians who live outside the Kansas City region.
The MBA will be offered to residents in the Baptist-Lutheran Family Practice Residency, University of Health Sciences/Medical Center of Independence Family Medicine Residency Program and University of Missouri-Kansas City Family Practice Residency.
To reach writer Leslie Champlin, e-mail lchampli@aafp.org.
WEB EXTRA!
Virtually everyone talks about osteoporosis. But is anyone doing anything about it?
Well, yes. More than 400 family medicine residents, residency directors and faculty members have taken advantage of Better Bones Osteoporosis Workshops designed specifically for them. The workshops focus on:
The Association of Family Practice Residency Directors is sponsoring the workshops through an unrestricted educational grant from the Alliance for Better Bone Health. Program directors select workshop participants from among their residents. However, word about the program has spread, and several residents have called AFRPD directly to ask about registration, said Amanda Hanova, AFPRD program manager.
If you're a resident wanting to bone up on osteoporosis, call Hanova at (800) 274-2237, Ext. 6738, or visit http://www.afprd.org/bones/ for more information.
The program has two formats: one for residents, one for residency directors and faculty.
"The benefit of this program is that we can offer a high-quality educational program to residents in a subject area where there's an academic need," said Robin Winter, M.D. of Edison, N.J., president of the AFPRD. "The faculty development component provides ongoing materials that faculty can share with the residents who have not attended" the workshops.
Having both formats helps ensure the delivery of diagnostic and treatment information that has not yet reached medical school curricula, said Todd Shaffer, M.D., director of the Lee's Summit Family Medicine Residency program, Lee's Summit, Mo. Shaffer attended a July session.
Why family medicine residents?
"We're the ones on the cutting edge," said Shaffer., "Family physicians are the ones who are diagnosing and treating the majority of these patients."
Shaffer noted that the new bone mineral density test is a much more reliable tool for diagnosis than earlier tests. Besides, he said, "Most of the medications for treatment came out in the last five years, so there's not a lot about them in the medical school curriculum yet."
Through the AFPRD, the Alliance for Better Bone Health grant reimburses participants for air or rail travel, hotel, registration and meals. The faculty offer the sessions throughout the year and across the country to accommodate residents' schedules. Each session begins with an evening reception and features one and a half days of didactic and small group training.
The Alliance for Better Bone Health, which markets the osteoporosis medication risedronate sodium (Actonel®), is a collaboration between Procter & Gamble Pharmaceuticals and Aventis Pharmaceuticals. Other osteoporosis medications include alendronate sodium (Fosamax®), produced by Merck and Company; calcitonin (Miacalcin®), produced by Novartis; and raloxifene (Evista®), produced by Eli Lilly and Company.
Winter emphasized that the workshops are devoid of any drug marketing.
To the editor:
Let's get down to the difficult business of solving the malpractice insurance crisis. I propose reform in five equally important areas:
I am fairly certain my proposal will alienate most of the groups involved. This possibility alone suggests it may be a reasonable start!
Mary Jo Groves, M.D.
Springfield, Ohio
To the editor:
Is this where our medical system is going?
I recently wrote a managed care system regarding the poor care my late grandfather received. He was primarily treated for heart failure by a cardiology nurse practitioner, whose evaluation and treatment were limited. No cardiologist saw him despite his failing health. The primary care physician who referred him to the NP did only problem-focused visits. He had scheduled no regular follow-ups and didn't do preventive care (i.e., complete physicals).
Consequently, my grandfather's hypothyroidism was undiagnosed and neglected until it was too late. He was hospitalized three times in his last month of life, each time by different hospitalists, causing disjointed care and medical errors. Social workers pressured staff to discharge him quickly despite his failing condition. He died in a nursing home the morning after the final discharge.
I am concerned that more medical care problems will occur as health systems try to cut costs. Already, physicians are underpaid for their level of education, skill and responsibility. They are pressured to see more patients for less reimbursement. It would not be surprising if their quality of care were declining. However, replacing physician care with that of less-trained providers isn't necessarily helpful for quality of care.
Hopefully society will recognize this trend and re-evaluate its priorities.
Cheryl Regalia, M.D.
South San
Francisco, Calif.
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It's not too early to clear your calendar for the 2004 AAFP Scientific Assembly Oct. 13 - 17 in Orlando, Fla. You won't want to miss this event. It will be held in conjunction with the 17th World Conference of Family Doctors, sponsored by the World Organization of Family Doctors, or Wonca. The Academy's Web site for this two-in-one event is up and running. Go to http://www.aafp.org/x24594.xml to catch the excitement. Stay tuned -- online registration begins in February. |
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Proven value: Three timely AAFP Family Health Facts patient education brochures are available for you to distribute to your patients. Brochures are written at a seventh grade reading level and take a family medicine perspective. Check out “Diabetes: Taking charge of your diabetes” (#1530), “Diabetes & your body: How to take care of your eyes and feet” (#1553) and, just in time for the holidays, “Depression: You don't have to feel this way” (#1547). Brochures are packaged by title and cost $12.50 for a bundle of 50. Order more than 250 brochures and receive a discount. |
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Proven value: Take advantage of online CME with the latest in a series of evidence-based CME enduring materials called CME Bulletins. Go to http://www.aafp.org/cmebulletin.xml to find “Gastroesophageal Reflux Disease: Diagnosis and Medical Management.” Read the article, complete the quiz and then click on “Submit for Credit” to report your CME. Five previously released CME Bulletins are also available at the site. |
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Proven value: Look for a new topic in the AAFP video CME library -- now in DVD format. The video/monograph CME program, “Pathways to Controlling Hepatitis A & B: Prevention, Vaccination and Treatment,” provides an update on the prevention of hepatitis A virus and hepatitis B virus infection. Active members will receive a free copy in the mail soon. To order additional copies of this program (#1890, $17.95) or the entire AAFP Video CME series, visit http://www.aafp.org/shop/2800. Online video programs can be viewed at no charge at http://www.aafp.org/videocme.xml. CME credit is available for a fee. |
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A shipping fee may apply; Kansas residents pay a 7.525 percent tax. |
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FP Report is published by the
AAFP News Department.
Copyright © 2003 by
American Academy of Family Physicians.
