BY J. MICHAEL BRODIE
 |
Family medicine training programs seem to have kept most of their federal support -- for now. But the funding dance continues.
Congressional leaders reached a tentative agreement in November on an omnibus appropriations bill that included funding for Title VII, Section 747, of the Public Health Service Act. Section 747 supports training in family medicine, other primary care specialties and dentistry. The House of Representatives passed the omnibus bill Dec. 8, and the Senate was expected to vote on it in late January. The bill contains an $82.2 million Section 747 allocation for fiscal year 2004, a decrease of $10.2 million from 2003.
At one point last year, it appeared the Section 747 funding would be cut entirely, an action the specialty fought for months and managed to prevent.
The threat of losing Title VII is nothing new for family medicine programs, many of which are financially strapped. The administration often zeroes the funds out of the federal budget only to have Congress restore them at the 11th hour.
"There was always a dance," said Patrick Tranmer, M.D., M.P.H., professor of clinical family medicine and chair of the family medicine department at the University of Illinois College of Medicine, Chicago. "We had a history of our funding being restored."
Commenting on the effort to save the 2004 funds, he said, "This feels different (from the past). We have a president and possibly a Congress that are not committed to primary care education. This time we are getting a different message."
What if Title VII dies?
What would happen if Congress one day decided not to step in and support Title VII, and the specialty's federal funds disappeared?
It could be devastating, according to an Association of Departments of Family Medicine survey of its members in January 2003. Sixty departments reported that their very survival would be in jeopardy without the funding. Many also reported experiencing financial difficulties, even with Title VII dollars: Only 22 percent said they broke even, 73 percent said expenses exceeded revenue, and only 5 percent reported operating in the black.
Confirming the dire message the survey results sent, academic leaders talked recently about the possible demise of Title VII funds.
"We've been worried every year for a long time," said Harold Williamson, M.D., M.S.P.H., professor and chair of the family and community medicine department at the University of Missouri, Columbia. He said a total cut in Title VII funding could damage the department's standing within the academic medical community. Williamson said the fellowship program, which gets much of the department's Title VII funding, would be hardest hit if there were no Title VII support.
"We've produced 60 graduates in this fellowship program since it began in 1982. Many serve in academic roles, and six are department chairs," he said. "That program would be shut down."
Jeannette South-Paul, M.D., professor and chair of the family medicine department at the University of Pittsburgh, said, "Loss of all Title VII funds would destroy our faculty development program and seriously affect the quality of teaching programs in our three residencies. Several nonclinical faculty are funded almost entirely through Title VII."
The family medicine program at Ohio State University, Columbus, could lose as many as three full-time faculty positions and several staffers without Title VII support, said AAFP Director Mary Jo Welker, M.D., chair of Ohio State's family medicine department.
Eventually, the dance will end, and the numbers 747 and Title VII will be relegated to memory, Welker said. "Will I keep writing grants in the meanwhile? Yes. Do I think they will last forever? No."
Losing all Title VII funds "would cut $450,000 a year from a $6 million budget -- that would be an 8 percent to 9 percent cut," said John Saultz, M.D., professor of family medicine and assistant dean of the Oregon Health & Science University, Portland, medical school.
OHSU uses the funds to help pay for faculty development activities, residencies and predoctoral programs, Saultz said. One program takes family medicine residents into underserved communities.
"The government doesn't value family medicine education, society doesn't value it. There is a pervasive attitude," Saultz said. "They don't see it as their problem. A lot of people in government see health care as a personal service commodity. They are saying, 'We believe it is not in our best interest for you to have medical care.'"
University of Illinois' Tranmer said government disdain for primary care also exists on the state level, where funds for the Illinois Department of Public Health's Family Practice Resident Training Act were zeroed out by the governor and restored by the state legislature at the last moment. "It took a heartfelt and significant effort to get those funds restored," he said.
Call to action
The department heads interviewed for this article agreed more needs to be done to make the case to legislators that family medicine is a valued component in medical care. For Williamson, it will mean going back to what he does every year -- writing letters to his representatives in Congress, pleading the case for family medicine.
"That's what I'd like to see all FPs do," he said. "This money isn't our only source of funding, but it helps give us a leg up. It's meant for building up our programs."
To reach writer J. Michael Brodie, e-mail mbrodie@aafp.org.
WEB
EXTRA!The University of California, Los Angeles, has three of the four available types of Title VII grants. One grant supports residency training in urban areas. The program would not survive without the federal support.
"Our clinic is located in a federally designated health professional shortage area and serves an immigrant population of which 70 percent are uninsured," said Patrick Dowling, M.D., M.P.H., professor and chair of the family medicine department at UCLA's David Geffen School of Medicine.
"Funding in predoctoral programs allows us to place students in underserved settings, including two to three homeless shelters," said Dowling. "It also allowed us to build a Web-based teaching curriculum of dermatology cases that could be used all over the country."
Dowling said an administrative academic unit grant supports UCLA's research infrastructure unit, particularly for junior faculty. It also allowed the department to develop a practice-based network with a large consortium of community clinics that serve the underserved.
"According to the Census Bureau, LA County is now the poverty capital of the country," said Dowling. "It is also one of the wealthiest areas, which means we have a widening gap between the haves and have-nots."
Dowling said the grants allow the department to reach beyond the West Side of Los Angeles and expose residents and students to the needs of the underserved.
"The loss of such funds would have a devastating impact on our ability to recruit and train residents and students to work with underserved and multicultural populations," he said.
BY LESLIE CHAMPLIN
| FPs work fewer hours than many other specialists
|
Shorter hours. Lower liability premiums than for many other specialists. A bump in take-home pay. Perhaps family medicine is on the upswing.
Family medicine has weathered a deep professional winter, but the specialty may be feeling the warmer breezes of spring, according to national surveys. The survey results imply family physicians have increasingly controllable hours, lower overall medical liability premiums than many other specialists and somewhat higher take-home pay than FPs had in the past.
Not every family physician feels these effects, but good news is blooming for many family physicians.
For example, the Medical Economics Continuing Survey reported family physicians worked an average of 50 hours a week in patient-related activities in 2003. That was three hours fewer than internists worked; two hours fewer than orthopedic surgeons put in; and 10 hours fewer than cardiologists, gastroenterologists, general surgeons and OB-Gyns worked.
The Medical Economics findings for FPs echo AAFP's 2003 Practice Profile Survey. In that, respondents said they spent an average of 40 hours seeing patients in the office, emergency department, hospitals or nursing homes or providing follow-up, referral or other telephone calls. Additional tasks, such as meetings or administrative work, claimed another 10 hours a week, on average. The total of 50 work hours was 10 hours fewer than in 1989.
FP incomes grow
Meanwhile, family physicians' incomes may be coming in from the cold. Though not as lucrative as procedure-driven subspecialties, family medicine has seen income growth. Family physicians earned an average income (after expenses) of $150,000 in 2002, according to the Medical Economics Continuing Survey. AAFP's 2003 Practice Profile Survey found FPs had an average income (after expenses) of $142,400 in 2002, up from $134,000 in 2001.
By comparison, Medical Economics reported average 2002 incomes (after expenses) of $150,000 for internists, $130,000 for pediatricians, $300,000 for gastroenterologists and orthopedic surgeons, and $230,000 for general surgeons.
Premiums less daunting
Likewise, family physicians face less daunting medical liability premiums than many other specialists. According to AAFP's 2003 survey, members paid a median of $9,600 -- a 21 percent increase since 1998 -- for basic liability coverage in 2002.
From 1999 to 2002, general surgeons' and internists' premiums billowed by as much as 130 percent, according to a study of seven states by the U.S. General Accounting Office. Surgeons paid between $28,000 and $111,000, and internists forked over between $10,000 and $39,000 in 2001 for basic liability insurance coverage, reported the Medical Liability Monitor.
The medical liability crisis has come home to medical students, according to the American Medical Association. Survey results released in November showed that 50 percent of medical student respondents said the medical liability situation was a factor in their specialty choice.
However, the lower cost of liability coverage doesn't automatically mean more students will opt for family medicine, said Jay Fetter, manager of student interest at AAFP. In a preliminary inquiry, the AAFP found no clear indication that liability costs would encourage students to opt for family medicine over high-risk specialties, he said.
To reach writer Leslie Champlin, e-mail lchampli@aafp.org.
BY LESLIE CHAMPLIN
Recent national surveys point to better days for family physicians. The surveys indicate family doctors work fewer hours than their counterparts, their liability insurance costs haven't risen as fast, and their incomes are improving (see related story).
The survey results drew mixed reviews from FPs across the country. Many saw no change in long days, erratic schedules and stagnant reimbursement.
"I average approximately 60 hours a week, and the stress and hassle level of dealing with the hospital and patient expectations have increased 100 percent plus," said Gary Bevill, M.D., of El Dorado, Ark. "In our community, the specialists work less hours than those of us in primary care and definitely make more money."
Others found the survey results to be on target. Pennie Marchetti, M.D., of Stow, Ohio, said she worked an average of 50 hours a week while her peers in surgery, cardiology and obstetrics logged more hours. She noted, however, that subspecialists handled more emergency and higher-risk cases and were compensated "a lot more than we are. But if you compare us to other primary care physicians, we probably all work about the same."
Practice setting plays role
Others said the work hours, liability costs and income derive from individuals' choices, not the nature of the specialty itself.
"Several studies have indicated family medicine is not considered one of those specialties that's controllable," said Doug Campos-Outcalt, M.D., of Phoenix, a member of the AAFP Commission on Clinical Policies and Research. "I've always disagreed. Controlling your practice does limit where you go and the type of setting where you practice, but that's true of any specialty. A neurosurgeon in a large geographic area will also have less control over his time.
"How controllable family medicine is depends on where you practice. If you practice in a rural area, you may have less control. But it's not necessarily a rural versus urban issue, because you can work in a (rural) community health center with an agreement that stipulates when you work."
That's just what Keith Davis, M.D., of Shoshone, Idaho, did. He changed his practice to a rural health clinic and saw an improved financial return for his time.
Acknowledging his aversion to "feeding at the government trough in what is essentially a subsidized program to keep rural health care available," Davis said, "I probably should have just done it years ago. The program exists for a reason!"
Business decisions have influence
Location isn't alone in determining demand on a physician's time. Other business decisions, such as office size and structure, professional obligations beyond clinical practice, and relationships with medical peers can influence the workweek.
Physicians can lighten the load by sharing, said Dennis Perry, M.D., of Okemos, Mich. "Doing family practice involves controlling the uncontrollable. There are certainly ways to make it more tenable. Group practices, call sharing, job sharing are all ways to ease the burden of a 60-hour workweek."
Service mix affects hours, insurance rates
Moreover, many FPs have changed their clinical mix.
"It is my surmise -- read educated guess -- that a significant number of family physicians are fleeing inpatient medicine, and decreased hours are due to this," said Arthur Freeland, M.D., of Kirksville, Mo. "All of medicine is intrusive to physicians' private lives. Family medicine is less so than most. In fact, the only real reason that my practice is not controllable is that I still do -- and love -- maternity care."
Unlike some specialists, family physicians can tailor clinical services. That flexibility could contribute to the relatively mild increases in liability premiums.
In fact, family physicians across the country have dropped obstetrical or hospital care in response to malpractice premium spikes. Such a decision, though made under duress, isn't available to many other specialists. OB-Gyns who drop obstetrics or cardiologists who drop hospital care can dramatically cut into their patient loads.
"Our blessing and our curse"
Much of family medicine's angst probably stems from the perceived lack of respect by other specialties, despite FPs' dedication to high-quality care, several observed.
"I believe that those who choose family practice genuinely care for their patients and strive to make a difference in their lives," said Perry. "Not that the subspecialists don't do so, but unlike the subspecialists, we become ingrained in the lives of our practice families. That is our blessing and our curse.
"Those of us that love what we do are secure in the sense that we will always have a job. Sometimes we have to remind ourselves that even though we are one of the lowest-paid specialties, in the eyes of those we care for, we are the highest. I never -- in reflection -- regret the hours I spend or the decisions I made."
Visit http://www.aafp.org/fpr/ with your AAFP ID number handy, click on "Reader Survey," tell us your opinion about FP Report -- and you'll be entered in a drawing for your choice of a personal digital assistant or items from the AAFP catalog, worth up to $300. The survey questionnaire will be available online until the end of February.
By sharing your thoughts, you'll help FP Report do an even better job of meeting your information needs. Thanks in advance for your input!
BY SHERI PORTER
 |
Sometimes a great idea needs time and tweaking before it comes to fruition. Such is the case with the continuity-of-care record, an idea initiated by the Massachusetts Medical Society several years ago. The CCR is poised to become available to physicians and their patients this spring.
The CCR is an ongoing record of a patient's care, "a summary at any one point in time," said MMS President Tom Sullivan, M.D., who co-chairs the society's CCR work group. The record can be updated after every health care visit and be made available to the next health professional or facility. The CCR's purpose is to provide current and accurate information to each health care provider down the chain. Whereas the electronic health record contains the patient's entire health record, the CCR incorporates basic information and can become part of the EHR.
"I would say that the CCR standard, once adopted, represents a major step toward achieving some of the aims of the Institute of Medicine in improving health care in this country," said Sullivan. "This will have a big impact on patient care, patient safety and health care efficiency."
Early evolution
A Massachusetts Department of Public Health document a patient care referral form in use for 30 years provided Sullivan with a CCR starting point. He simply put the document into an electronic format.
Next, ASTM International, a not-for-profit, nongovernmental organization that develops standards, was brought in to facilitate the standard-setting process.
That step gave the project steam and credibility, and in August, AAFP threw in its support. The Healthcare Information and Management Systems Society also backs the effort.
"AAFP is the first physician organization to join us," said Sullivan. "AAFP saw the light, and I give credit to its leadership in getting information technology to the real world of practicing physicians."
CCR components
According to a CCR concept paper on the ASTM Web site (a link to the site is noted below), a portable patient record must incorporate specific elements, including:
What makes the CCR stand out is its simplicity. "This is something that's never been done before," said Kathleen Bellisle, a Massachusetts Medical Society manager who has been working on the project for more than a year.
She said other proposed solutions to the portable patient record dilemma were too complex. "People were trying to create interfaces to disparate systems. What we've done is create something in a standard XML format, making it easy to transmit information back and forth between systems."
Close to fruition
For months, stakeholders in the CCR project have held meetings (including an Oct. 23 meeting at AAFP headquarters in Leawood, Kan.) and invited all interested parties to comment on the evolving document.
"You don't have to be a member of ASTM to provide input," said Dan Smith, an ASTM manager who's been involved with the CCR project. "You do have to be an ASTM member to cast a vote when the ballot opens."
At press time, the ballot for the proposed CCR standard had yet to be posted on the ASTM Web site. If it went live in mid-January as planned, the next step would be a 30-day period for voting and then a probable March meeting to discuss final feedback. "If everything goes well, my guess would be we're talking about sometime in March for the approval date for the standard," Smith said.
However, implementation of the CCR is up to the health care industry. "From everything I'm hearing, there are many physicians who are anxious to implement this standard in their work," said Smith.
Patients will benefit as well. "Informed patients are better patients," said David C. Kibbe, M.D., director of the AAFP's Center for Health Information Technology. "This is one route to self-management and an essential component of care coordination."
The final standard, available in an electronic or hard-copy format, will consist of a seven- to eight-page document and a spread sheet. ASTM members will be able to download the document free from the ASTM Web site. If you are not an ASTM member, the standard will be available for a small fee, probably less than $50, said Smith.
To read more about the CCR, go to http://www.aafp.org/x24962.xml on the AAFP's Web site. Click on the link to ASTM's Web site for additional details.
To reach writer Sheri Porter, e-mail sporter@aafp.org.
BY LESLIE CHAMPLIN
Today's patients like the computer. They'll tell it secrets never divulged to a person. They grant computers an educational authority not often given to a person. And the physician who capitalizes on patients' affinity for the keyboard and screen will enhance not only office efficiency and patient care but also the quality of patient education efforts.
Why? Because computerized records completed by the patient enable the physician to gather information in greater detail with less time and fewer staff, said FP John Bachman, M.D., the Sanders Professor of Primary Care at the Mayo Clinic in Rochester, Minn.
 Invaluable tool -- FP Tim Dudley, M.D., right, demonstrates use of a PDA in teaching "patient" John Nagle of Denver during the recent Conference on Patient Education. |
"The patient does data entry," Bachman said at the recent Conference on Patient Education here. "The computer collects more data than the clinician. It obtains better-quality information on socially sensitive topics because it's completely impersonal. And it's faster for the patient." Using computers eliminates the need for patients to repeat their medical history and complaint to the receptionist, the nurse and the physician during each visit.
Patient education starts when the patient enters health information or a chief medical complaint on a home computer or in the waiting room before the doctor's appointment. From that moment forward, an integrated system can begin searching for educational materials that will meet the patient's needs, Bachman said.
By the time the physician examines the patient; enters a diagnosis; and, if needed, writes a prescription into the computer, much of the patient education footwork has been completed. Options flash on the screen. The physician selects the most appropriate material to print and gives the patient tailored information.
Meanwhile, the computer has stored all the information -- including the type of educational materials -- provided during the visit. At the next visit, the electronic record will display previous patient education materials with other data.
Establishing a patient education database is not complex. Bachman recommended Web sites such as AAFP's http://familydoctor.org, a library of patient education materials in English and Spanish. Another site, MEDLINEplus (http://www.nlm.nih.gov/medlineplus/healthtopics.html), offers interactive tutorials and, under "Directories," lists other medical sites approved by the National Library of Medicine.
Physicians can add personal digital assistants to their repertoire with interactive educational programs that demonstrate, for example, patient risk for an illness or possible outcomes of treatment choices, said FP Tim Dudley, M.D., of Denver.
Equally powerful are search engines that surf the Web for sites with patient information.
"Clinicians don't have time to surf the Web," Bachman told participants at the Nov. 20 23 meeting. "But you don't need hundreds of Web sites. You need a search engine.
"Digital tools make patient education a part of the workflow."
The outcome: They enhance office efficiency, improve patient care and ensure patient education, he said.
To reach writer Leslie Champlin, e-mail lchampli@aafp.org.
BY J. MICHAEL BRODIE
Plan B® -- the emergency contraception pill, or "morning after" pill -- should be available over the counter, two FDA panels advised the FDA recently. The Academy also weighed in on the issue.
The FDA Nonprescription
Drugs Advisory Committee and Reproductive Health Drugs Advisory Committee
voted 23 to 4 for the OTC status Dec. 16.
On the same day, AAFP Board Chair James Martin, M.D., of San Antonio wrote one of the panels to concur with the advisers' vote.
"The AAFP supports the change to OTC status because of emergency contraception's reported long-term safety record, its ease of use for our patients, the time-sensitive element of therapy and increased access to the medication for the uninsured in this country," Martin wrote.
Plan B consists of two progesterone pills to be taken 12 hours apart. For maximum effectiveness, Plan B should be taken within 24 hours after intercourse.
An FDA public affairs officer said Dec. 19 that the advisers had conducted several votes. For example, they voted 28 to 0 that there was evidence Plan B would be safe.
The 2003 AAFP Congress of Delegates voted for the OTC status for progesterone-only emergency contraceptives and recommended that information on safe sexual practices, birth control options and the advantage of having a personal physician should be included with such OTC products.
Wanda Filer, M.D., of York, Pa., was among the delegates who spoke in favor of the measure. "Emergency contraception has been underutilized, especially for sexual assault victims, even in emergency department settings," Filer, president of the Pennsylvania AFP, said last month. "The awareness of emergency contraceptives as an option to physicians and our patients has been very low."
The possible move to OTC status, accompanied by a strong educational component, could be a strong benefit to patients when time is of the essence, said Filer. "It will be vital for family physicians to be familiar with emergency contraceptives and to know how to counsel their patients about the many issues likely to surround its usage."
To reach writer J. Michael Brodie, e-mail mbrodie@aafp.org.
When AAFP's fitness initiative -- Americans in Motion, or AIM -- kicked off at the 2003 Scientific Assembly, organizers launched a study to determine how fit family physicians are. That study was aptly titled, "How Fit Is Our Specialty?"
Now chapters will be able to participate in fact-gathering for AIM. Investigators in December received local institutional review board approval to extend the study from the original population of FPs who signed up at Assembly to FPs in constituent chapters.
At the Assembly, researchers gathered baseline body mass index levels for the 839 FPs who volunteered for the study, and the FPs self-reported their physical activity. Participants received a pedometer, compliments of Tanita, and were encouraged to enroll in the Active Lifestyle Award, a program of the President's Challenge (http://www.presidentschallenge.org/) that recognizes persons for achieving fitness goals. Pending funding, this cohort of FPs will be followed and the project will be replicated at the 2004 Assembly.
So far, 21 chapters have expressed interest in participating in the study. Having chapters participate will strengthen the study and allow investigators to stratify results geographically, says principal investigator Angela DeJulius, M.D., of Northeastern Ohio University College of Medicine, Rootstown.
"The key to AIM is that doctors will bring the message to patients," says DeJulius. "Bringing it to the state chapters will get more members involved."
Constituent chapters that agree to replicate the research project will begin data collection at their annual meetings in 2004. The Nevada AFP, at its meeting this month, hopes to be the first to enroll FPs in the study.
Chapters may still enter the "How Fit Is Our Specialty?" study. Contact Sarah McMullen at (800) 274-2237, Ext. 3136, or e-mail smcmulle@aafp.org to learn more.
To reach writer Toni Lapp, e-mail tlapp@aafp.org.
 Michael Fleming, M.D. |
For those keeping score, AAFP President Michael Fleming, M.D., of Shreveport, La., who announced his decision to take the Americans in Motion challenge in late September, by press time had lost 21 pounds.
Fleming, who pledged to wear a pedometer and work toward amassing 10,000 steps a day, challenged other FPs to follow in his footsteps.
"The most heartening thing is that I have heard from family docs around the country who are supportive and joining in, and at every state meeting I go to, our members respond," says Fleming. Using a pedometer is working well, he says, and he walks between 9,800 and 11,000 steps a day.
Media attention for the AIM initiative has been strong. The Los Angeles Times reported on Fleming's progress in a November article, "Doctors Who Lose Gain Credibility."
An article about the initiative in the Nov. 3 American Medical News set off a spate of letters questioning the role of patient responsibility in the initiative's premise. Fleming wrote a response printed in the Dec. 15 issue of the publication: "Contrary to what was written in one of the letters, we are not asking family physicians to look 'buff.' We simply want them to lead healthier lives. In some cases, a byproduct of improved physical activity, nutrition and emotional well-being will be weight loss, but that is not our end goal. This is about following our own advice to lead a healthy lifestyle."
Some members have asked why the AAFP supports the Medicare Prescription Drug, Improvement and Modernization Act, passed by Congress late last year. Read online the answer to that question, a message from AAFP President Michael Fleming, M.D., of Shreveport, La.
In addition, Fleming indicates which parts of the new Medicare law cause concern -- areas the Academy will address with lawmakers.
Fleming's message is at http://www.aafp.org/medicareletter.xml.
BY LESLIE CHAMPLIN
Bring together about 20 patients with diabetes. Add two family medicine residents. Provide clinical and educational goals. Mix for several months.
Then watch everyone learn.
That's the goal of combining group medical visits and residency training, said Sean Gaskie, M.D., associate clinical professor of family medicine at the University of California, San Francisco, and faculty supervisor for group visits at Sutter Medical Center Family Practice Residency Program.
Family medicine residency programs, such as Sutter and the Duluth (Minn.) Family Practice Residency Program, are beginning to experiment with group visits, which are part of residents'rotations.
A pioneer in pairing group visits with residency training, Gaskie said the combination sparks enthusiasm among participants, broadens residents' clinical skills and enhances the quality of patient care.
Patient-centered focus
Group visits can occur monthly or bimonthly and last up to two hours. They include a brief social time, a presentation on a health topic of interest to the group and review of patients' action plans. Some incorporate one-on-one physician encounters during group time, while others offer individual visits after the meeting.
Research shows that key elements of group visits -- social support, self-management, health education and routine primary care -- provide significant benefit to patients with chronic conditions such as diabetes. However, said Gaskie, those elements also require attitudes that differ dramatically from those learned in medical school.
"The group medical visit puts the patient first and makes the doctor secondary," said Gaskie. "These visits recognize that patients are more expert at coping with their illness than the doctors are."
William Byrd, M.D., a resident at the Duluth program, agreed. Commenting on a recent group visit for patients with diabetes, he said, "The most important thing that I walked away with in regard to that meeting was that each person did not feel alone and was more candid about their health issues.They exchanged ideas that could be useful in maintenance of their diabetic control."
In-depth preparation, active listening
In contrast to the grab-and-read chart reviews and jam-packed 15-minute encounters of traditional one-on-one patient visits, group medical visits require more preparation.
"If you're not prepared to address the patients' medical condition, you can't take care of them," said Gaskie.
Residents must review charts for up to 20 patients and order preliminary lab work. During the meeting, residents must facilitate discussion among participants. Success depends on developing active listening and negotiation skills, said Gaskie.
Brian Niskanen, M.D., a resident with the Duluth program, said most physicians come to group visits with strong examination and diagnostic skills. However, he added, "What has improved considerably is my ability to communicate the complexities of diabetes and facilitate group discussion. The topics presented have increased my understanding of the physiology of diabetes and its complications. This understanding has certainly improved my clinical decision-making skills."
Medical students can gain firsthand knowledge about the Step 2 Clinical Skills examination by participating in a preimplementation pilot examination, or PIPE. The exam will be available this year to students who have registered for the U.S. Medical Licensing Examination Step 2 Clinical Skills exam. Each clinical skills test center -- in Atlanta, Chicago, Los Angeles and Houston -- will accommodate 400 participants for PIPE.
The pilot tests will closely resemble actual exam situations by presenting a series of encounters with standardized patients. Though the number and mix of cases may differ for live examinations, PIPE will enable participants to see what the test centers are like and how the testing day will unfold, said the USMLE announcement. In addition, students will receive limited feedback on their examination performance.
Contact information on registering for the Step 2 Clinical Skills exam is at http://www.usmle.org/applicationmaterials/default.htm#contact. USMLE will direct registrants to a Web site or a telephone contact that will give them more information about PIPE, test locations and dates. Participation in PIPE is free, but participants must pay for travel and lodging expenses.
Caring for America's aging population
The
full weight of the post-World War II baby boom is beginning to settle onto
America's demographic landscape. According to the National Center for Health
Statistics, the number of U.S. residents 65 and older will double by 2030
to more than 70 million.
Thanks in part to two decades of reduced mortality rates among those 65 to 84, a person born in 2001 could expect to live 77.2 years, about 30 years longer than someone born in 1900, says the Administration on Aging. Moreover, persons turning 65 in 2001 could expect to live to 83 -- an additional 18 years. Acknowledging FPs' key role in caring for these patients, the AAFP has selected "Caring for America's Aging Population" as its 2004 Annual Clinical Focus topic. The Academy received members' input about areas in which they'd like more information. This FP Report Special Section takes a look at some of those areas.
BY LESLIE CHAMPLIN
 |
The aging of America promises a sea change in the way family physicians practice medicine. The first ripples have already arrived. Americans 65 and older made more than 20 percent of all the office visits to family physicians in 1999, according to the National Center for Health Statistics. In a few decades, the ripples will be a gray tsunami. As noted in the story at left, this age group is expected to double from 35 million to more than 70 million by 2030. Then, say researchers, seniors will make 30 percent of the office visits to family physicians and constitute 60 percent of FPs' hospitalized patients.
Knowing how to care for older adults is an essential skill for FPs, and communication is the key, says Robert Parker, M.D., assistant clinical professor of geriatrics and family medicine at the University of Texas Health Science Center at San Antonio.
Numerous studies have demonstrated that poor communication results in missed diagnoses, patient noncompliance, potentially toxic drug interactions, unnecessary hospitalizations and overall poor health.
Offer respect, empathy
Caring for the elderly comes with a few ground rules, according to Parker, who has lectured at the American Geriatrics Society annual meetings and the Conference on Patient Education sponsored by the Academy and the Society of Teachers of Family Medicine. The first ground rule: Establish a respectful relationship. Most older patients grew up when addressing adults by first names was taboo.
"It's important with elders to address them as Mr. Jones or Mrs. Smith until they tell you otherwise," Parker advises. "If you use their first names, ask their permission. They will think it's impertinent to do otherwise."
More difficult is developing empathy. Young physicians can't always relate to the losses in abilities and quality of life that can accompany aging, says Parker.
Help patients "get it"
Geriatricians have some advice: When elderly patients nod with understanding, doubt their comprehension. When they list their health concerns, pry. When they accept a written handout, assume they can't understand it.
Why? Because, when caring for older patients, family physicians swim against a tide of challenges -- from undetected dementia, to multiple "chief complaints," to die-hard myths and cultural beliefs.
Studies indicate that physicians frequently miss cognitive impairment in elderly patients, says Parker. The result: Patients nod as if they understand what the doctor tells them; in fact, they absorb none of the information or confuse its details.
"Frequently, patients who are demented have social skills that are very well-preserved," he says. "But they don't understand or comprehend the information they are given."
In addition, family physicians must determine their patients' health literacy.
"The illiteracy rate in the general population is about 5 percent," says Parker. "But it's much higher in the elderly. Many older patients read at the sixth-grade level." However, most health literature is written at an eighth-grade level or higher.
Combat myths
Most difficult to address are long-held beliefs, Parker adds.
Elderly people may be ignorant about advances in preventive care. When patients refuse a flu shot, they may hearken back to early vaccines "and tell you the vaccine made them sick," Parker says. "Many older patients believe that cancer is always fatal, so they delay getting a diagnosis or treatment. And some cultures believe it's fate, so the patients will do nothing to intervene."
Equally damaging myths: Memory loss, chronic pain, depression, incontinence and other conditions are part of aging. These beliefs can prevent patients from even mentioning such topics. So the family physician should. When patients realize such problems can often be treated, they -- or their family members -- may request help.
"That is what is so gratifying about family medicine and working with the elderly," says Parker. "In no other specialty can you do such small things for people and make such a huge change in their lives. When you listen and provide information, they are genuinely thankful."
To reach writer Leslie Champlin, e-mail lchampli@aafp.org.
BY CINDY BORGMEYER
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"It's a family affair," Sly and the Family Stone sang in the group's 1971 hit. For more than 22.4 million Americans, providing day-to-day care for an older loved one is often just that -- a family affair.
According to Administration on Aging statistics, it's spouses, adult children, other relatives and friends who provide the yeoman's share of informal, unpaid but keenly needed care for older patients in the community -- care worth about $257 billion each year.
Those are some of the numbers. To find the faces, family physicians may have to do some digging, says FP Susan Parks, M.D., of Philadelphia.
In her experience with patients, she explains, "You have to discover that they're caregivers; they're not going to necessarily offer that information to you. Exploring the social history and finding out that they're in that role are important things for you to do as a family doc."
Parks is clinical assistant professor of family medicine and director of the geriatrics fellowship program at Thomas Jefferson University in Philadelphia. She's also medical director for Chandler Hall, an assisted-living and skilled nursing facility in Newton, Pa., and sees elderly outpatients in her practice at the Philadelphia Senior Center.
Specific roles, challenges
Once you know a patient is a caregiver, Parks says, "You have to find out what type of caregiving role it is. Is the person's loved one suffering from advanced dementia, or from congestive heart failure? There's a specific set of challenges that go with different types of caregiving."
Dealing with a loved one with Alzheimer's disease, for example, can be especially trying. "People who are caring for someone with dementia go through an ongoing grief process as the dementia advances," she says, particularly as that loved one becomes unable to recognize the caregiver.
It's essential for family physicians to identify that grief and to empathize with what caregivers and their families are going through, Parks says.
Realize, too, that what goes up one day can easily come crashing down the next, advises Gregg Warshaw, M.D., professor of family medicine-geriatrics at the University of Cincinnati and director of the school's Office of Geriatric Medicine.
"These caregivers need help," says Warshaw. "You need to routinely ask them -- on a scale of one to 10, with one being everything's great, and 10 being they're ready to shoot themselves -- how they're handling things at home. When they say, 'I'm an eight,' you have to start looking at what to do."
Know available resources
"You don't have to be a social worker," says Warshaw, "but you have to know social workers. You have to have a phone number on your desk you can give people, and you need to know what resources in your community to steer them to."
At a national town hall meeting held last December to focus attention on the issue, HHS Secretary Tommy Thompson acknowledged the burden of caregiving, saying, "Too often, caregivers put their own health on the back burner." He highlighted federal efforts to ease the strain on caregivers and their families, especially the National Family Caregiver Support Program.
Under the 2-year-old program operated by the Administration on Aging, states partner with local area agencies on aging and faith- and community-based service providers to offer caregivers information and hands-on support, including counseling and respite care.
Families typically come to their family doctors for information on available support resources, Warshaw notes. "Medicare services are mostly related to management of illness, but most communities have some sort of community support systems.
"The role of family doctors is to help make those connections."
To reach writer Cindy Borgmeyer, e-mail cborgmey@aafp.org.
Find out more about the National Family Caregiver Support Program at http://www.aoa.gov/prof/aoaprog/caregiver/caregiver.asp. You can download a toolkit produced by the Administration on Aging to mark November as National Family Caregivers Month at http://www.aoa.gov/press/nfc_month/nfc_month.asp. The kit contains resources to help you educate your patients about caring for an ailing family member, as well as tips to help caregivers maintain their own health.
Go to http://familydoctor.org/645.xml to download a patient education handout that teaches caregivers how to recognize and cope with stress. The site includes links to related handouts and other resources.
BY TONI LAPP
One size does not fit all when it comes to hospice-based palliative care. In fact, the prevailing model of care often fails many elderly patients, says a group of researchers.
That's because older patients typically suffer from multiple chronic illnesses, making an accurate prognosis difficult and leading to either lack of eligibility for or very late entry into hospice.
In fact, palliative care -- care that makes the patient feel better and function better -- should be a priority throughout the aging process, regardless of whether death is imminent, according to family physician Anthony Jerant, M.D., of Sacramento, Calif.
Jerant leads a team of four researchers from the University of California, Davis, School of Medicine who have proposed a new framework for palliative care.
According to the Institute of Medicine and the World Health Organization, palliative care is the active, total care of patients whose disease does not respond to curative care. But in the framework proposed by Jerant's group, palliative care should be offered while curative care is ongoing -- well before the attempt to cure is abandoned and the patient is eligible for hospice.
Jerant's team calls the new framework the "TLC" model. TLC means timely and team-oriented, longitudinal (care evolves as a balance between palliative and curative measures), and collaborative and comprehensive.
"I wouldn't even use the term palliative when initially meeting an older patient," says Jerant, "but would say, 'I want to talk about your symptoms, how you're feeling and functioning.'"
Too often, he adds, physicians offer curative care to the exclusion of palliative care. Part of the blame lies with payment models that delay palliative measures.
But physicians can and should still talk with their elderly patients to determine those patients' goals, says Jerant.
Preliminary results from the study of the TLC model appear in the January/February Annals of Family Medicine, online at http://www.annfammed.org/.
The study participants were not terminally ill and, therefore, they were not hospice candidates, says Jerant. Yet all were approaching the end of life and were found to have unmet palliative needs such as pain, mobility problems, depression and incontinence.
While Jerant concedes it was a fairly small study (data were presented on 50 subjects at two facilities) and the model was used in an assisted-living facility, he says the principles might be adaptable for use in ambulatory care.
A fundamental concept of the model is that palliative care should be a focus of care throughout the aging process, regardless of whether death is imminent.
That's profound, because it would change the way doctors relate to their older patients, says Jerant. It's all about being proactive, he says.
For instance, writing out prescriptions and going over lab results often fill the time for a patient visit. Physicians can miss opportunities to improve that person's quality of life. To avoid repeatedly neglecting palliation, schedule a follow-up visit to talk about what symptoms may be limiting the person's potential, Jerant suggests.
"Most older people get to a point where they perceive that they're nearing the end of life," Jerant says. "We should also talk about that explicitly with elderly patients.
"We can pursue many goals with our medical care; we can't necessarily lengthen life, but we can ask older patients what their main goal is in seeking care -- to live longer or maximize how well they feel."
For an online resource on palliative care, visit http://www.palliativecare-la.org/.
To reach writer Toni Lapp, e-mail tlapp@aafp.org.
BY J. MICHAEL BRODIE
As the senior population increases, American medicine faces a disease management problem that cuts to the heart of how care is organized.
The term disease state management has become a buzzword when applied to care of patients with multiple chronic conditions. It is a multi-step, coordinated systems approach to managing care processes for a specific high-cost and/or high-volume diagnosis, according to an AAFP position paper at http://www.aafp.org/x6710.xml. The idea is to improve outcomes and lower overall costs. This system requires a primary care physician, such as a family physician, as an overall care manager, says the Academy.
But two chronic care management demonstration projects included in the Medicare reform package passed by Congress late last year failed to recognize primary care physicians -- family physicians -- as essential care coordinators for these complex patients. One project focuses chiefly on shifting care to disease management organizations, while the other involves a "pay-for-performance" approach to providing chronic care.
The Partnership for Solutions, led by Johns Hopkins University and the Robert Wood Johnson Foundation, has estimated that about two-thirds of Medicare dollars -- nearly $170 billion -- are spent on participants with five or more long-standing conditions. Not surprisingly, many of those participants are elderly.
Commenting on the cost factor, AAFP Board Chair James Martin, M.D., of San Antonio said, "This is a startling figure for a program that not only costs taxpayers billions of dollars, but also is not geared toward chronic care management." He put this comment in a November letter to Rep. Nancy Johnson, R-Conn. She chairs the House Ways and Means Subcommittee on Health, which was studying the topic. She is also author of the provisions concerning chronic care programs.
The letter, available at http://www.aafp.org/x24988.xml, formed the basis of written testimony to the Senate Special Committee on Aging, which also held a hearing on the topic in November. "Examining 'what works' for chronic care is crucial as Medicare costs spiral upward and budget pressures to hold down spending increase," the Academy said in its statement to the Senate committee. Go to http://www.aafp.org/x25296.xml to read the statement.
The Academy is in the second generation of its quality enhancement program, Martin said in his letter to Johnson. The program was originally based on a chronic care model developed by Edward Wagner, M.D., Ph.D., director of the W.A. MacColl Institute for Healthcare Innovation at the Center for Health Studies, Group Health Cooperative of Puget Sound (in Washington).
The statement to the Senate committee noted that in November, the Academy convened an advisory committee to discuss specific initiatives to help family physicians design systems enabling them to enhance the quality of health care they deliver -- including care for chronic conditions -- as well as to document and be recognized for quality care.
Options discussed during the two-day session included offering family physician training through Web-based information, one-on-one interventions and innovative residency curricula. A newly created AAFP task force took up the concept again during the January cluster meeting in San Francisco.
"While a significant activity for a private organization, our focus on improving chronic care management for our members is only a fraction of what federal support could do to support disease care in the U.S. health care system," said Martin in his letter to Johnson.
The Academy’s concern is "that legislation focusing primarily on disease management companies, absent the integral role of an integrating physician, is counterproductive," he said. "We believe that federal support of disease management entities will take chronic care in the wrong direction."
What works, Martin offered, is a focus on improving chronic illness care within family physicians’ offices.
"If disease state management is ‘carved out’ by the managed care company and the family physician is not involved, then the patient loses the benefit of the family physician's knowledge of the patient's overall health status and problems," said Stephen Spann, M.D., professor and chair of the family medicine department at Baylor University in Houston. Spann is also medical director of the AAFP Annual Clinical Focus. The 2004 ACF topic is "Caring for America's Aging Population."
Spann said the more problems a patient has, the greater the complexity of care the patient needs. Managing some chronic diseases entails certain common elements, such as controlling blood pressure and lipid levels and maintaining a healthy weight.
"The family physician manages the multiple diseases and appropriate medical therapies, cognizant of potential drug-drug interactions," he said. "When specialists are consulted, they should report their opinion to the family physician, allowing the family physician to make the final decision regarding medication management."
To reach writer J. Michael Brodie, e-mail mbrodie@aafp.org.
BY SHERI PORTER
Even folks who have been driving for decades eventually experience a decline in their ability to drive safely. Chalk it up to changes in vision, hearing and general physical ability -- unwelcome gifts that come with longevity.
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Family physicians who've had long-standing, close relationships with patients may be in the best position to broach the topic of when a driver should relinquish the car keys.
It's an important subject for family physicians to discuss with older patients and their families, said AAFP President Michael Fleming, M.D., of Shreveport, La. "Telling a loved parent that he or she can no longer drive is one of the most difficult issues a family faces. I tell my families to let me be the bad guy."
Fleming talks to patients about the real possibility of injuring themselves or others, and he explains the liability risk of losing everything after a lifetime of hard work should an accident occur.
A free patient education resource on this topic is available from the AAFP. "Decisions About Driving: A Toolkit for Older Drivers and Their Families" consists of five handouts that include information on how to get by without driving, checkslists allowing both patients and their families to assess driving skills, and tips on how to help a loved one make the transition from driver to passenger.
The kit was developed through a cooperative agreement with the National Highway Traffic Safety Administration. Kits are available in packages of 10. Order online at http://www.aafp.org/shop/978 or call the AAFP order department at (800) 944-0000 and ask for item #978. Expect a small shipping charge.
The handouts in the tool kit are also available as PDF files on the AAFP Web site at http://www.aafp.org/x23744.xml. Help using PDF documents is available at the site.
To reach writer Sheri Porter, e-mail sporter@aafp.org.
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| Enjoy two meetings for the price of one
-- and save $50 if you register by |
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| AAFP'S National Research Network recruitment project is searching for minority and nonacademic family physician participants. The network is specifically recruiting physicians with underserved and minority patient populations so that its studies can better represent these patient groups. The network wants to recruit 500 physicians who meet this criteria by December 2004 and is nearly to the halfway mark. Would you like to join? Contact Tom Stewart, network coordinator, at tstewart@aafp.org, or call (800) 274-2237, Ext. 3172. For additional information, go to http://www.aafp.org/x3201.xml. |
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| Proven value: Is board certification or recertification on your "to do" list in 2004? If so, plan to attend one of three AAFP Family Practice Board Review courses. Choose the course that works best for you: April 18 - 24 in Kansas City, Mo; May 9 - 15 in Seattle; or June 6 - 12 in Greensboro, N.C. The course features pre- and post-tests to help participants improve test preparedness and retention of the material. These courses often fill, so go to http://www.aafp.org/x15036.xml today, and click on the city of your choice for easy online registration. |
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| Proven value: Do you have patients who have added "stop smoking" to their list of New Year's resolutions? Help them quit the tobacco habit with an AAFP resource, the Patient Stop Smoking Guide. You can purchase a pack of five booklets for $10 through the AAFP's online catalog at http://www.aafp.org/shop/915. A free sample pack of additional stop-smoking materials is also available at the site. Just scroll down to item #901 and add it to your order. |  |
| A shipping fee may apply; Kansas residents pay a 7.525 percent tax. |
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You might want to post some of these deadlines on your calendar. For details, call (800) 274-2237 and the extensions noted below, contact staff via e-mail, or check the Web sites.
Encourage your constituent chapter to nominate a physician or another individual for the AAFP Public Health Award. The chapter should e-mail jhaas@AAFP.org or call Ext. 3140 for a nomination form, to be submitted by March 1.
March 15 is the deadline for proposals for workshops, seminars, lectures, papers, poster displays and special interest discussions at the 2004 Conference on Patient Education Nov. 11 - 14 in San Francisco. Submit your proposals online at http://www.stfm.org/calendar/cal_pe.htm.
Want to present your research or a scientific exhibit at the AAFP Scientific Assembly Oct. 13 - 17 in Orlando, Fla.? Go to http://www.AAFP.org/assembly.xml for applications to make family medicine research presentations and to present scientific exhibits. Submit those applications by April 2.
The World Organization of Family Doctors, or Wonca, is holding its 17th World Conference of Family Doctors in conjunction with the AAFP Scientific Assembly. Go to http://www.wonca2004.org/x14653.xml to access applications to give an oral presentation, lead a workshop or symposium, or present an international poster. Those applications are due by March 15.
Two deadlines are near for Tar Wars®, AAFP's tobacco-free education effort aimed at fourth- and fifth-graders. Nominations for the Star Award, which honors individuals or groups that have significantly contributed to the Tar Wars effort, are due by April 15. Applications for scholarships to attend the Coordinator Leadership Conference July 20 - 22 in Alexandria, Va., are due by April 30. The Star Award nomination form is at http://www.tarwars.org/PreBuilt/2004StarForm.pdf, and the scholarship application is at http://www.tarwars.org/PreBuilt/2004ScholarshipApplication.pdf. For help using PDF files, go to http://www.aafp.org/pdf.xml.
AAFP President Michael Fleming, M.D., of Shreveport, La., has called on FPs to encourage medical students to attend the National Conference of Family Medicine Residents and Medical Students July 28 - 31 in Kansas City, Mo. -- a way to get students fired up about the specialty. Consider these possibilities, some for students, some for students and residents: Family Medicine Interest Group Leadership Award, Student Community Outreach Award, Resident Community Outreach Award, Tomorrow's Leader Award, and First-time Attendees and Resident/Student Minority Scholarships. The application deadline is May 3. For information, go to http://www.aafp.org/conference.xml.
The Joint AAFP Foundation-AAFP Grant Awards Program is accepting requests for support of research in family medicine. Applications must be postmarked by June 1. Go to http://www.aafpfoundation.org/x270.xml for more information.
FP Report is published by the
AAFP News Department.
Copyright © 2004 by
American Academy of Family Physicians.
