 The guitar-strumming finale of Francis Collins, M.D., Ph.D., brought people to their feet at the AAFP Assembly/Wonca 2004 keynote address on genomics. To the tune of "Runaway," he led attendees in "DNA," beginning, "I'm a-walkin' through the genes. I don't know what all this means." |
If anyone listening had misgivings that the field of genomics was some dry topic with little application in the real world, those misgivings were laid to rest by crooning keynoter Francis Collins, M.D., Ph.D., Oct. 13. He spoke at the opening ceremony for AAFP's Scientific Assembly and the 17th World Conference of Family Doctors, held Oct. 13 – 17 in Orlando, Fla.
Yes, at the end of his lecture, Collins -- the researcher who led the Human Genome Project, which mapped and sequenced human DNA -- whipped out an acoustic guitar and gamely led more than 6,000 participants in song: "Runaway" rewritten into "DNA."
The importance of knowing one's family health portrait has become one of the outcomes of the Human Genome Project. Collins announced the development of a Web site where patients can enter three generations of their family medical history -- a "paper pedigree," which they can take to their family doctor. The site was scheduled to be launched Nov. 8, allowing time to prepare patients for the First Annual National Family History Day, coinciding with Thanksgiving. After all, family gatherings present a ripe opportunity to learn from relatives, Collins noted.
Many people left Collins' lecture saying they were convinced that genomic information will become increasingly important to the care of patients and that family physicians can and should play a key role in applying genomics in primary care.
In fact, Collins made the case for genomics' relevance to family medicine with a force that had some in the audience murmuring. He encouraged FPs to think strategically.
"The rate of future progress depends not only upon technological advances but upon physician expertise," he said in an interview. "Translation of genomic advances into improved clinical outcomes can only occur if family physicians are well-informed."
All diseases have a genetic component -- a "misspelling" in the body's instruction book, or DNA -- Collins explained. Having knowledge of family history will change the management of disease.
Collins presented a scenario that could play out in any family physician's practice: "Peter D., age 52, comes to your office complaining of fatigue, arthralgias and loss of libido," he said. Many physicians would think "bipolar" and treat accordingly. But family history reveals a brother with congestive heart failure, liver disease and diabetes. A clinical workup shows transaminases mildly elevated, lab evidence of borderline anterior pituitary dysfunction and transferrin saturation of 52 percent. Hemochromatosis is diagnosed; both Peter and his brother are homozygous for the C282Y mutation in the HFE gene.
The keynote speech created good buzz for the AAFP Annual Clinical Focus 2005: Genomics, which Collins plugged during his presentation.
ACF coordinator LeAnn Carl, who staffed the Assembly ACF booth, said that following Collins' keynote, she'd been busy filling requests for information about the program, which will offer online CME about genetics and its relationship to clinical issues.
One person to visit the booth was Robert Christensen, M.D., of Carroll, Iowa, who declared himself "genomically challenged." Although he is retired from practice, he said he could appreciate the implications of Collins' talk and would be able to use the information when former patients came to him for advice. One piece of advice he shared: "We should all be getting a more thorough medical history from our relatives while they are alive."
But some FPs remained only guardedly enthused about how a family health history could be used in family medicine.
"That step from identifying a cluster of disease in the family history to the actual genetic testing is a huge leap," said Maryjean Schenk, M.D., M.P.H., chair of the family medicine department at Wayne State University, Detroit. "This isn't something you can write on the encounter form and get a test."
But nevertheless, she said it's good to get a dialogue started. "It has inspired me to go back to my medical school and look at how we're teaching genomics," she said.
This, no doubt, would be music to Collins' ears.
To reach writer Toni Lapp, e-mail tlapp@aafp.org.
The human genome has come to your office. No longer limited to scientific inquiry, genomics has moved into patient care. So when patients ask questions about the possibility of developing a genetically linked disease or the cause of a child's condition, be prepared to respond, said four genetics experts at the Assembly.
The panelists -- Nancy Stevens, M.D., associate professor of family medicine at the University of Washington, Seattle; Louise Acheson, M.D., family medicine researcher at Case Western Reserve University, Cleveland; Joseph McInerney, M.A., M.S., of Lutherville, Md., director of the National Coalition for Health Professional Education in Genetics; and Susie Ball, M.S., genetic counselor and founder of the Central Washington Genetics Program at Yakima Valley Memorial Hospital -- reviewed case studies of patient concerns Oct. 14 during "Genomics: Answering Patients' Questions."
Patient questions generally follow the birth of a child with a congenital condition or the development of an illness in a relative. You should respond with solid understanding of the presenting condition, the family history and the community's resources, the panel advised.
Step one: Determine whether researchers have identified a genetic component to the condition in question, said Ball. Despite progress in the human genome, scientists have not identified genetic links to all conditions. Moreover, many conditions have either a genetic or an environmental cause.
"A congenital condition is not necessarily a genetic condition," she said. "Congenital only means the condition was present a birth."
Cystic fibrosis has a definite genetic link, but prelingual deafness could be inherited or could be caused by a prenatal complication, lack of oxygen during delivery or a postdelivery infection.
Step two: If the condition of concern to the patient is genetically linked, identify whether it develops from a dominant or recessive gene. Then develop a genetic map from family history. The patterns that emerge will help determine whether your patient inherited the suspect gene and will help identify the likelihood the illness will occur. The genetic map also will calculate the likelihood of passing the gene to offspring, said Ball.
Step three: Discuss genetic counseling. Most patients won't need genetic testing, which can cost thousands of dollars and has implications for health insurance, family dynamics and other issues, said Ball. She reminded the audience that a positive genetic test doesn't predict disease; for most illnesses, a positive test provides risk information.
"Genetics are not determinism," she said.
In addition, a test may reveal a patient's risk for developing an illness, but its value is limited if physicians have no option to prevent onset of the disorder.
For example, medicine has no guaranteed prevention for breast and ovarian cancer, said Acheson. Preventive mastectomy, oophorectomy and chemotherapy don't prevent all breast or ovarian cancers. Interventions for Alzheimer's disease have limited impact on illness progression. However, early intervention is highly successful and vital if prelingually deaf children are to grow into happy, productive adults.
Genetic counselors can help patients decide whether to proceed with genetic testing, said McInerney. See a related article (below) for online help identifying qualified genetic counselors.
Regardless of the decision on genetic testing, family doctors play an integral role in helping patients understand and respond to a genetically related condition, said Stevens. Family physicians should be prepared to educate patients about the illness or condition, the likelihood that children will inherit the illness, and the community resources that help patients and families cope with the condition.
To reach writer Leslie Champlin, e-mail lchampli@aafp.org.
For information about genetically related conditions and illnesses, go to these sites:
On Oct. 13, Francis Collins, M.D., Ph.D., director of NIH's National Human Genome Research Institute, voiced his conviction that family physicians could play a key role in deciphering the mysteries of genetics and genomics for their patients (see story, page 1). Giving the keynote address at the joint AAFP Assembly/Wonca (World Organization of Family Doctors) world conference opening ceremony, Collins challenged FPs to learn more about genomics' powerful potential by tapping into educational resources now offered by various professional organizations, including the Academy.
Enter the AAFP's 2005 Annual Clinical Focus: Genomics.
In keeping with the cutting-edge topic, this will be the first ACF offered as a series of Web-based, curriculum-driven modules. The modules will use physician-patient vignettes and guided Web tours to answer questions about the role of genomics in practice. Each topic module will incorporate relevant evidence-based clinical guidelines or practice recommendations supported by evidence. At the conclusion of each module, learners will be asked to complete a clinical quiz to help them gauge what they've learned and to identify areas for further study.
Topics for modules under development include taking a family history and exploring the genetic components of breast and colon cancers, bipolar disorder, and Alzheimer's disease. Future modules will cover, for example, single-gene disorders, newborn screening and developmental disorders.
It is expected that family physicians will play a major role in the future of medical genomics, particularly as it relates to preventive, diagnostic and therapeutic medicine. It will be important for physicians to be able to communicate accurately and effectively with patients and the public about the clinical, legal, social and ethical issues involved in this burgeoning area of medicine.
For more information about ACF 2005, visit http://www.aafp.org/acfgenomics.xml. Beginning in January, you'll be able to access the clinical modules at the site.
The 2005 ACF program on genomics is being made possible by the generous support and participation of the National Human Genome Research Institute; Maternal and Child Health Bureau of the Health Resources and Services Administration; National Coalition for Health Professional Education in Genetics; GlaxoSmithKline; Roche; National Heart, Lung and Blood Institute; and the Susan G. Komen Breast Cancer Foundation.
Other participating partners are the American Academy of Nurse Practitioners, American Academy of Pediatrics, American Academy of Physician Assistants, American Cancer Society, American College of Medical Genetics, American College of Physicians, American Heart Association, American Society of Human Genetics, CDC, March of Dimes and National Society of Genetic Counselors Inc.
This list may change; additional supporters were still being sought at press time.
Drawn to the Intelligent Medical
PracticeSM exhibit to learn more about electronic health records,
attendees such as William Gilkison, M.D., of Indianapolis, standing at right,
came away impressed. After seeing a demonstration of one program, he said, "It
was an incredibly impressive system with interesting and useful features." He
added, "I've been using the same thermometers and blood pressure cuffs for 20
years -- it's time to upgrade to newer technology."
The Congress of Delegates kicked the Academy's national advocacy efforts into high gear Oct. 12, calling for the Academy to create a federal political action committee and to have it up and running by June 2005.
Adopting recommendations in a Board of Directors' report, delegates affirmed the Board's contention that it's time the AAFP availed itself of this political tool to help take the message of family medicine to Washington. The delegates met Oct. 11 – 13 in Orlando, Fla.
In reference committee testimony, (then) AAFP President Michael Fleming, M.D., of Shreveport, La., assured members that the Board's deliberations on the matter had been lengthy and inclusive.
In the end, Fleming said, "The advantages outweighed the disadvantages. If we're to move to the next level in our advocacy -- if we want to be successful in our endeavors -- this is what we need to do."
Take advocacy to next level
Mississippi delegate Timothy Alford, M.D., of Kosciusko, chair of the Commission on Legislation and Governmental Affairs, agreed. "It's my hope the Academy has reached the maturation point where we are prepared to take this to the next level," he testified. "You can only go so far with words and a good argument. Even the grassroots efforts of our constituencies can only take it so far."
In its report, the Board stated it would shoulder the responsibility of creating and approving bylaws governing the PAC, to include the following points:
Texas delegate Roland Goertz, M.D., of Waco spoke in favor of the measure at a reference committee hearing, drawing on his experience with PACs in his state. "If it's created correctly and the right people are on it, they will make the decisions ethically, and any candidate from any party who represents the principles we believe in will be supported," said Goertz.
It's about the issues
Some members voiced concerns to the reference committee about the potential to alienate those the PAC chose not to support.
Keep in mind, Florida delegate Thomas Hicks, M.D., of Tallahassee advised his colleagues, it's not about the people -- it's about the issues. Politicians know that.
"We as leaders of medicine are here to represent our constituents and their patients. And through a PAC, we ask our politicians to represent those constituencies," he said. "We purchase our seat at the table so we can at least be heard."
Jeffrey Bachtel, M.D., of Tallmadge, Ohio, past president of the Ohio AFP, noted advantages beyond simply securing a place at the legislative table. "Our PAC has afforded us the ability to disseminate political information to our membership without jeopardizing our tax-exempt status and to endorse political candidates -- also without jeopardizing that status."
Ohio has had tort reform measures struck down twice by the state's Supreme Court, Bachtel explained. In response, the OAFP endorsed three of four candidates up for election to the court. "Without our PAC, we would have much more difficulty making those endorsements and getting that message out to our members," he said.
Show us the money
Michigan delegate William Gifford, M.D., of Williamston, a member of the AAFP Commission on Finance and Insurance, raised the issue of the $360,000 fiscal note attached to the Board's plan.
"We have two other organizations -- radiologists and physical therapists -- who are raising about $800,000 (for their respective PACs). That $360,000 (proposed for the Academy's PAC) is the operational component; we're still going to have to have a tangible amount of money from members to achieve our goal."
And that, said Utah delegate Brian Zehnder, M.D., of Salt Lake City, begs the question of how such a fiscal note might affect the AAFP's bottom line. "If we're adding this cost to the Academy, what are we taking away?" he asked.
Fleming explained the $360,000 start-up amount would come out of the Academy's operating budget. It's the Board's responsibility, he added, to make changes to offset that amount and maintain a balanced budget.
Warren Jones, M.D., of Ridgeland, Miss., an AAFP past president and current administrator of Mississippi's Medicaid system, summarized key issues in his testimony.
"If we're going to establish a PAC, it needs to be substantial, so that we make a difference," he said. "Once we establish that PAC, we're no longer just the guys with the white hats. What separates us now is the fact that we go there and we haven't bought access to anyone -- it is our ideas and our concern for our patients that have secured that access."
Jones urged his colleagues to continue to engage policy-makers at the grassroots level. "When people want to know what's going on in Mississippi, Warren Jones is one of a hundred people they talk to. But it's not because I gave them a ton of money," he said. "If it's time for a PAC, then make it a substantial one. But if not, let's find a way that we don't lose our grassroots effort and we don't lose the white hat."
To reach writer Cindy Borgmeyer, e-mail cborgmey@aafp.org.
While exploring the Assembly Exposition Hall,
Martin Schear, M.D., of Dayton, Ohio, right, stopped by the METRIC exhibit in
the AAFP Marketplace. He discussed the Academy's Measuring, Evaluating and
Translating Research Into Care initiative with Bruce Bagley, M.D., AAFP medical
director of quality improvement. Within minutes, Schear became one of the FPs
who have signed up as beta-testers. They will give feedback to the Academy
before the system launches in January.
 Jubilation: AAFP President Mary Frank, M.D., the Academy's first woman president, celebrates after receiving the presidential medal from outgoing President Michael Fleming, M.D. |
Embrace the power of one," incoming AAFP President Mary Frank, M.D., of Mill Valley, Calif., invited her family physician colleagues Oct. 15. "I need each and every one of you. I need you to realize -- and to embrace -- the value of ‘the power of one.'"
In her president's address, Frank called on FPs to join her in a quest for change -- change in how patients are treated, change in how FPs are valued, change in how care is delivered throughout the health system.
"My goal is -- in some small way -- to help create a world where all people are treated with fairness, decency and respect," said Frank. "Note that I said ‘all people' -- not just the highly educated, not just the wealthy and upper-middle class, not just people with the same color of skin, the same belief systems, the same hopes and dreams. All people."
"What is fair about a system where nearly 45 million people -- one in six Americans -- don't have access to health care?" Frank asked. In her own Sonoma County, she said, only one surgeon and one ear, nose and throat physician still accept Medicaid patients -- aside from the family doctors.
"And what would common decency say to a country where children begin their precious life without proper nutrition and where every fourth person is denied access to the kind of health care that we all expect for our families?" Frank asked. "What is decent about a community that doesn't have an adequate physician workforce -- where the only care is either miles away or available only through an emergency room?"
Finally, she queried, "Are we respecting our patients -- those with health care coverage and those without? Have we ever changed a treatment plan because an insurance company told us to? Have we ever failed to talk with a patient about all the treatment options? Have we ever ordered a test to buy time, because we were just too frazzled to fully explain a diagnosis or a prognosis?"
Fairness, decency, respect -- these are values family physicians must embrace without reservation, Frank said.
"Throughout the year," Frank said, "I will be working with the Academy and others to strive to bring health care coverage to all -- and to change a system that is neither fair nor just to many people in this country.
"Please join me. Please help me make change happen."
When a patient presents with a soft-tissue infection and claims it is due to a spider bite, perhaps you don't want to go there. "Spiders are getting a bad rap. Get a culture because what you are seeing is probably community-acquired MRSA (methicillin-resistant staphylococcus aureus)," says Tom Frank, Pharm.D., B.C.P.S., an associate professor of pharmacy practice and assistant professor of family and community medicine at the University of Arkansas for Medical Sciences, Jonesboro, Ark.
Frank, who conducted the Dialogue session "Antimicrobial Therapy: New Challenges, Few Tools" at the Assembly, says that "77 percent of patients presenting with soft-tissue infections are showing up with MRSA on culture." Most of these patients attribute the infection to spider bites, he says. This observation was confirmed during the discussion when several physicians noted that they, too, were seeing a surge in spider bite complaints.
One unique aspect of these "spider bites" is that "the wound abscesses and needs to be drained," Frank says. In a typical case report, a woman presented with progressive swelling of an index finger. She was admitted to the hospital and treated with IV cefazolin. When the finger was incised, a deep abscess was drained, but two days later she required a second surgery because drainage persisted. A culture obtained at the original surgery grew MRSA resistant to erythromycin. She was treated with IV vancomycin followed by oral trimethoprim-sulfamethoxazole and recovered.
Since resistance is a significant problem, Frank advises "holding off on vancomycin treatment. Instead, I am recommending some old weapons from the arsenal: bactrim, clindamycin and doxycycline as a simple first step in treating these soft-tissue infections." He cautions, however, that these agents may take three to four weeks.
Frank favors a fast, aggressive treatment for strep: "I say be aggressive, be short and be gone. In the majority of patients, if there is no improvement with the initial dose of amoxicillin or augmentin at day three, increase the dose."
Finally, Frank says that "this year when we've just found out that we have an insufficient supply of influenza vaccine, your mother's advice is more important than ever -- wash your hands, wash your hands."
Here's a simple solution for family physicians who are stressed by patient overload, worried about declining revenues and unable to remember the last time they took a vacation. Hire a physician assistant, says family physician Keith White, M.D., of Independence, Ore.
"A PA is essential for any family physician who wants to improve practice revenue, improve patient quality of care and improve quality of life," says White, presenter at an Assembly core practice management and professional development course titled "Enhancing Practice Revenue, Productivity & Lifestyle Utilizing Team Practice With PAs."
White says that his PA costs the practice $78,095 a year, an amount composed of salary ($50,000) and a generous benefits package including pension, 401K and health insurance. "But the annual profit generated by my PA is $65,682, which works out to $5,474 a month that is added to my income," he says.
While some practices encourage PAs to develop their own patients, White says that he prefers a team approach in which "we each see the same patients, which means that the patients know both of us and we know all the patients." For new patients, White does the initial physical and takes time to explain that he works with a PA, who may be the provider that the patient sees on the next visit.
In White's practice, the PA participates at every level. For example, White says, "When I'm on call, she takes first calls." This top-to-bottom integration of the PA "keeps me happy, keeps my staff happy and keeps my family happy," he says. "Plus it improves my cash, and when I return from vacation, there is no flood of patients or paperwork greeting me."
Likewise, when the PA is on vacation, White is at the office.
White's co-presenters were Lynn Caton, P.A.-C., an assistant professor at Oregon Health Sciences University in Portland, and Michael Powe, director of health systems and reimbursement policy at the American Academy of Physician Assistants in Alexandria, Va. They discussed the PA-physician team from the PA's viewpoint.
Caton says PA training takes roughly 26 months, with "nine to 12 months devoted to classroom work and 55 weeks rotating through 11 specialties." He says the most popular PA specialty is family medicine, with 31 percent of PAs practicing in that area. As a group, PAs are the third-fastest-growing profession, says Caton, who added, "the number of PAs is expected to increase by 50 percent in the next five years."
Powe says that most insurers will reimburse PAs directly, although at a lower rate than payment to physicians. For Medicare billing, PAs need a separate Medicare provider number. Medicare reimburses PAs at 85 percent of the physician reimbursement, he says.
For physicians who are anxious for a quick fix to an overburdened practice, Powe says that an experienced PA can "almost hit the ground running. My wife is an internal medicine PA, and she can be up to speed in a new practice in about three weeks."
They may look like they're
wrestling at left, but FPs Eve Patton, M.D., of Humble, Texas, left, and Julie
Bonilla Camacho, M.D., of Arecibo, Puerto Rico, are practicing a manipulation
technique during a clinical procedures workshop. Above, during a workshop on
women's health procedures, Miriam Nolte, M.D., of Anchorage, Alaska, uses a
chicken breast and a needle to perfect her technique as she simulates
aspiration of a breast cyst.
Diabetes kills one American every three minutes, causing more deaths than AIDS and breast cancer combined. This progressive disease affects more than 150 million people worldwide, and that number is expected to rise to 300 million by 2025.
According to FP Jeffrey Unger, M.D., director of the Chino Medical Group Diabetes Intervention Center in Chino, Calif., "primary care physicians manage 90 percent of all diabetes patients in the United States, but on average physicians receive only four hours of diabetes training while in medical school."
Unger led an Assembly two-hour seminar, "Intensive Management of Type 1 and Type 2 Diabetes." He urged FPs to be aggressive in managing patients who have diabetes or risk factors for the disease. "Aggressive control of hyperglycemia and diabetes risk factors reduces micro- and macrovascular complications and decreases endothelial cell inflammation," Unger said. "Your patients will live longer with less morbidity!"
It's the micro- and macrovascular complications of diabetes -- cardiovascular disease; peripheral artery disease; and diabetic retinopathy, nephropathy and neuropathy -- that usually kill people rather than the disease itself, he added.
Screening patients
Unger suggested family physicians begin screening low-risk patients every three years after patients turn 45. "A two-hour glucose challenge test is indicated if their fasting plasma glucose is between 110 mg/dL and 126 mg/dL, indicating impaired fasting glucose," he said.
Early screening, beginning at age 30, is warranted for patients with multiple risk factors for diabetes, such as those with a family history of diabetes or coronary artery disease, overweight or obese patients, those who lead a sedentary lifestyle, and minorities.
FPs should also be aware of the insulin resistance syndrome, a cluster of metabolic abnormalities headed by insulin resistance that significantly increases a patient's risk of developing cardiovascular disease. "Fifteen percent of patients with insulin resistance syndrome will develop type 2 diabetes mellitus," Unger said.
To help prevent patients from developing diabetes, family physicians can recommend lifestyle interventions, such as exercise, weight loss and a healthy diet. This especially applies, said Unger, to those with impaired glucose tolerance, as indicated by two-hour postprandial blood glucose levels between 140 mg/dL and 200 mg/dL.
Lifestyle interventions are also critical in the treatment of those who develop diabetes. "Behavior modification is key to successful intervention," Unger said. "Set reasonable goals for weight loss and exercise for your patients. A seven-pound weight loss is a good start. Ten percent of starting weight is a good weight-reduction goal. Exercise improves glycemic control and enhances weight loss." Diabetic patients should also stop smoking cigarettes and drinking alcohol.
Medical interventions
Unger asked FPs to consider prescribing statins and aspirin therapy for all diabetic patients at high risk of cardiovascular disease, regardless of their lipid levels. Hemoglobin A1c levels should be below 7 percent. Prescribe angiotensin-receptor blockers to prevent diabetic nephropathy and treat hypertension.
"Think insulin early in treatment," Unger said. "Diabetes is a progressive disease characterized by persistent insulin resistance and deterioration of beta-cell function. Over time, most patients will need insulin to control glucose."
Family physicians should start type 2 diabetes patients on insulin therapy when the patient has these characteristics:
 "If you haven't done the SAMs, please do them. Give me some objective feedback," David Price, M.D., a member of the ABFP Board of Directors, told the delegates. |
For the third year in a row, family physicians brought their concerns about the American Board of Family Practice's Maintenance of Certification Program for Family Physicians to the AAFP Congress of Delegates. And for the third year in a row, the Academy will respond by urging the ABFP to modify its plans for implementing the MC-FP.
A flurry of resolutions considered by delegates Oct. 11 – 13 in Orlando, Fla., covered MC-FP-related issues -- from providing AAFP members more chance for input on MC-FP to calling for delayed implementation of some of its processes.
In testimony to a reference committee Oct. 12, many members recounted -- in great detail -- their experiences with portions of the process, most notably the self-assessment modules, or SAMs, that make up Part II of MC-FP.
District of Columbia alternate delegate Jeffrey Weinfield, M.D., of Silver Spring, Md., said he was currently working through one of the SAMs offered for 2004 and found it "extremely burdensome" in terms of both time and the computer resources needed to download and complete the associated forms.
"In my humble opinion, the product needs more user testing," Weinfield testified. He urged that members up for recertification be given the option of delaying at least that portion of the process until the problems could be addressed.
FP Russell Breish, M.D., of Philadelphia also spoke in favor of a delay to allow additional beta testing of the system. He said he's had to call ABFP for technical support numerous times while working through a SAM and has had difficulty getting his calls returned in a timely manner. He also noted that rather than taking the Web site down to work on it, for example, "at 3 o'clock on Monday morning, they take it down -- without sending an e-mail first to let you know it's down -- in the middle of the workday."
Delegates testified that information about MC-FP, its components and its processes has been inadequately communicated and that even today, some members are unaware of the new recertification requirements.
The Academy has taken numerous steps to address the communication issue, pointed out (then) Board Chair James Martin, M.D., of San Antonio, citing as an example a memorandum of understanding between the AAFP and ABFP signed last spring. That memo states, among other things, the two organizations are committed to a collaborative approach to discerning and responding to physicians' information needs about MC-FP.
Alain Montegut, M.D., of Portland, Maine, a former member of the AAFP Commission on Education and newly elected finalist for the AAFP seat on the ABFP Board of Directors, testified that both ABFP Executive Director James Puffer, M.D., and Deputy Executive Director Joseph Tollison, M.D., have become "regulars" at COE meetings. Communication between the two organizations continues to improve, he asserted.
Speaking on the floor of the Congress Oct. 13, Colorado delegate David Price, M.D., of Broomfield, a member of the ABFP Board of Directors, acknowledged that MC-FP is a work in progress but cautioned delegates not to, in effect, throw the baby out with the bath water. After all, he noted, the endpoint of MC-FP is to enhance patient care and outcomes.
Price urged his FP colleagues in the Congress to try their hand at one of the ABFP's MC-FP Part II self-assessment modules and let him know -- personally -- their thoughts on how the process could be improved. "If you haven't done the SAMs, please do them. Give me some objective feedback," Price said, promising to take that feedback to the ABFP board.
On Oct. 13, delegates adopted two resolutions on MC-FP. The first resolution calls for the Academy to collaborate with the ABFP to develop a plan to educate members about "the process and importance" of MC-FP. The second directs the AAFP to urge the ABFP to suspend the SAMs as an MC-FP requirement "until technical and clinical problems are adequately resolved," to recommend that the ABFP develop a better beta-testing mechanism "to gather and disseminate evidence of effectiveness," and to "develop an alternative mechanism for those members who have unreliable access to the Internet."
As headlines nationwide trumpeted news of a critical shortage of flu vaccine, AAFP members at the Assembly debated a resolution calling for the Academy to work with federal health policy-makers to find better ways to respond to vaccine shortages.
According to testimony in an Oct. 11 reference committee hearing and on the floor of the Congress of Delegates the next day, current flu vaccine prioritization recommendations leave little for physicians' clinical judgment. Moreover, physicians exercising that judgment have no liability protection when forced to make tough decisions about who should receive the scarce vaccine.
The upshot: The Congress approved a late resolution from the Rhode Island AFP directing the AAFP to "work with the CDC to create alternative recommendations and risk stratifications to be used in states and localities where there is a shortage of vaccine." Delegates also called on the Academy to work with federal legislators to create "a short-term liability shield" for physicians employing such alternative recommendations.
The AAFP, through its liaison to the CDC's Advisory Committee on Immunization Practices, worked feverishly in early October to create prioritization recommendations following word that British regulators had temporarily shut down flu vaccine manufacturer Chiron's Liverpool, England, plant. Chiron, one of only two manufacturers of flu vaccine for the United States, had been scheduled to produce about 48 million doses for the 2004 – 2005 flu season.
But, as Herbert Young, M.D., director of the AAFP Scientific Activities Division, pointed out in an interview, "the ‘A' stands for ‘Advisory,'" and the committee can only go so far in promoting community-based physicians' interests -- the CDC makes the final call.
Add to that the CDC's decision in mid-October to have the second vaccine manufacturer, Aventis Pasteur, divert shipment of some 22.4 million doses to areas identified as serving high-risk patients and those deemed to have the most severe shortages -- and many FPs find themselves with no vaccine to offer patients.
Debate on the vaccine issue was heated in the reference committee hearing. Doug Campos-Outcalt, M.D., of Phoenix, a member of the AAFP Commission on Clinical Policies and Research, decried a system that leaves so much responsibility for the health of the American public in the hands of overseas manufacturers.
"How we've let our situation come to this -- how we've allowed ourselves to become so dependent on this foreign manufacturer -- is hard to believe," said Campos-Outcalt. "What this issue has brought to light is the entire larger issue of flu prevention."
An anecdote Wisconsin alternate delegate Susan Kinast-Porter, M.D., of Monroe relayed in the Congress aptly summarized the issue. "We're supposed to use the CDC-AAFP stratification, which wants to treat everybody over 65 the same," she said. "We don't have enough (flu vaccine) for our whole country, with all the people who qualify.
"I wanted to put a patient with COPD who's on oxygen and prednisone and living in a nursing home ahead of healthy 66-, 67- or 70-year-olds who are out playing golf and living alone in their own homes. I was told (by local health officials) I couldn't withhold any vaccine from the healthy 66-year-old to give to the 66-year-old with COPD, O2 and prednisone if the healthy person came to me first."
Academy, CDC post flu vaccine infoA number of resources are online to guide physicians through the vaccine shortage:
|
The Congress also acted on other public health measures. Among them:
To reach writer Cindy Borgmeyer, e-mail cborgmey@aafp.org.
 Georgia delegate Tanya Jones, M.D., of Atlanta calls for "more aggressive" pursuit of reimbursement for paperwork. |
Family physicians have been giving away too much for too long. But thanks to two resolutions passed during the AAFP Congress of Delegates Oct. 12, the big giveaway may be coming to an end.
The resolutions call on the Academy to develop information to help doctors collect previously uncompensated administrative services, to work toward garnering third-party payment for administrative costs that insurers could bear, and to advocate a system that allows family doctors to collect for managing care of hospitalized patients who require subspecialists' services.
At the heart of delegates' call for action on reimbursement for paperwork costs are the ongoing -- and growing -- demands from managed care, Medicaid, Medicare and pharmaceutical companies. Third-party payers demand proof of patients' need for medical or assistance services.
Delegates contended collecting that information should rest with the organizations that demand it, not the physician who provides care. Added to patient requests for new prescriptions due to changing insurance formularies or for free help completing school physical forms, the financial burden of paperwork becomes overwhelming, delegates said.
Family physicians "are screaming for relief from paperwork," George Shannon, M.D., of Columbus, Ga., a member of the Commission on Continuing Medical Education, said during a reference committee hearing.
Georgia delegate Tanya Jones, M.D., of Atlanta agreed with Shannon. Noting that attorneys, accountants and other professionals charge clients for telephone calls and paperwork, she called on family medicine to "become more aggressive." In response, the Congress directed the Academy to "provide family physicians with information on how to bill and collect for clinical and administrative services not covered by insurance, and advocate with public and private insurers to recognize the value of, and to appropriately pay for, these services."
Moreover, delegates called on the Academy to help ensure physicians receive payment for managing and coordinating the care of hospitalized patients. Hospitals and subspecialists rely on family physicians for the continuity of care needed by hospitalized patients whose conditions require intervention by multiple specialists, said Wisconsin delegate Bradley Fedderly, M.D., of Milwaukee. However, most insurers refuse to pay two physicians for the same diagnosis under the same code. Most often, he added, they deny reimbursement to family doctors for their coordination and management expertise.
"There's a clear value to them (hospitals, specialists and insurers) to have us manage these cases, and it's something we should receive reimbursement for," said Fedderly.
The delegates concurred, calling on AAFP to "address adequate reimbursement of physicians providing management and coordination of complex hospital care and concurrent care utilizing the same diagnosis code, using strategies that may include coding and benefit and contractual design."
To reach writer Leslie Champlin, e-mail lchampli@aafp.org.
Universal
Studios® was the scene of much fun and revelry for the
Assembly/Wonca Celebration. While some were lured by carnival games, left,
others sought thrills on the "Back
to the Future" ride, right.
With the enormous popularity of cosmetic surgery and TV shows like Extreme Makeover, the multibillion-dollar industry surrounding aesthetic medical procedures is growing exponentially, and some family physicians are adding aesthetic procedures to their practice.
At the Assembly, FP Greta McLaren, M.D., described the most common cosmetic procedures FPs perform. McLaren is an assistant professor of family practice at the University of Colorado, Boulder, and medical director of Park Meadows Center for Cosmetic Procedures in Lonetree, Colo.
Among the top procedures are Botox® injections, chemical peels, microdermabrasion, collagen injections, laser and light-source photofacials, and photodynamic therapy.
McLaren characterized photodynamic therapy as "the newest and most exciting" cosmetic procedure for family practice. It offers acne patients a nontoxic alternative to Accutane®.
"Why should family physicians do cosmetic procedures?" McLaren asked. "Why not? We have training in dermatology. We perform multiple dermatologic procedures daily. We already have our patients' confidence because we are their primary care providers. And patients like one-stop shopping."
Botox causes a temporary block in facial nerve signals, preventing muscle contractions, she said. The injections decrease the appearance of facial wrinkles for about three months.
Chemical peels involve the application of a caustic chemical, such as glycolic or salicylic acid, to produce a controlled-partial thickness burn of the top layers of facial skin, McLaren explained. Peels destroy and peel away sun-damaged skin, providing a younger look. Superficial peels can be performed by a nurse or aesthetician in a family practice, freeing the physician for other patient care, she said.
Microdermabrasion can be performed along with chemical peels to remove fine lines and refine large pores. The procedure shoots micronized crystals of aluminum oxide or sodium at the skin to sandblast it and improve its texture, she said.
So-called filler agents, including collagen, hyaluronic acid and autologous fat, are used to fill in static facial lines not caused by muscle contractions and to add volume, McLaren said. Commercial agents are formulated with an anesthetic to minimize patient discomfort.
Lasers and intense pulsed light devices are valuable in treating age spots, telangiectasias, rosacea, port-wine stains, acne and benign brown spots, McLaren said. Pulsed light devices are popular for photofacials to lighten age spots, improve the appearance of rosacea and melasma, and stimulate collagen formation, she said.
Leading an Assembly discussion of hypertension and evidence-based medicine, Robert Raspa, M.D., of Orange Park, Fla., had a habit of talking about the "old days" and the "new days."
There used to be four categories of hypertension, and now there are two, "not too bad" and "bad," Raspa quipped during the two-hour seminar "Hypertension and Evidence-based Treatment."
The "new days" refers to findings in the wake of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure, or JNC-7.
So what is hypertension? The simple answer is a blood pressure of 140/90 mm Hg and above. But part of the new approach is to aggressively treat the condition and designate patients whose blood pressure is higher than 120/80 mm Hg as "prehypertensive," said Raspa. At the prehypertensive stage, the physician should counsel the patient about lifestyle modifications, because these patients have greater than twice the risk of developing hypertension than patients with normal blood pressure.
Raspa prefaced the lecture by talking about one of his own patients, a woman whose high blood pressure was unresponsive to changes despite repeated visits to address it. He counseled her about lifestyle changes. Still high. She took a diuretic. Still high. She took an angiotensin-converting enzyme inhibitor. Still high. Beta blocker. Still high. Again, he asked about her diet. Raspa commented, "She said, ‘I swear I'm not eating too much salt.'" Try as he might to help her lower it, her blood pressure remained stubbornly elevated.
"We slipped into an antagonistic relationship," Raspa said. But with the potential to extend a person's life by up to two years by controlling blood pressure, patients and physicians both are becoming more motivated.
"Why be more aggressive?" he asked rhetorically. "If you can keep people in the normal range when they're very young, that's where you get the most benefit, the most prevention."
The vast majority of patients with hypertension remain inadequately treated, he said.
"The good news is pharmacologic treatment works," said Raspa.
Diuretics are unsurpassed and remain the first line of treatment, he said. He challenged attendees to go back and look at their patient records to ensure that diuretics were their first line of treatment when indicated. In fact, he called his mother's physician when he learned she wasn't on a diuretic for hypertension, he told attendees.
However, pharmacologic therapy is complex, and there are always exceptions, he noted. One study showed that white males do better with an ACE inhibitor first, for instance.
He went into further detail, discussing use of particular agents with specific conditions. Finally, a small number of patients have secondary causes of hypertension and should be treated accordingly, he said.
After the lecture, physicians were able to discuss their own patients, asking advice on prevention, prescribing, complicating factors and education.
Testosterone replacement therapy has become a more than $400 million-a-year business in the United States, up from $18 million in 1988 and still rising. Because of increased advertising in magazines, on TV and elsewhere, more and more patients are asking about it. But is testosterone replacement therapy safe or a repeat of the estrogen replacement therapy fiasco?
A two-hour seminar explored that question and gave Assembly attendees advice on which patients to treat with TRT. The seminar leader was Douglas Kamerow, M.D., M.P.H., clinical professor of family medicine at Georgetown University and chief scientist with Research Triangle Institute (RTI) International, Washington, D.C.
Whom to treat
"Hypogonadal men should be on testosterone replacement therapy, no question about it," Kamerow said. But for others, there are no clear answers.
"For men with symptoms and low to low-normal testosterone levels, cautious use of testosterone replacement on a trial basis is a reasonable strategy at this time, while monitoring for side effects and adverse reactions," he added.
Monitoring of men who are on TRT should include blood tests for serum testosterone levels, hemoglobin, prostate-specific antigen and lipids, and liver function tests, he said.
An estimated 4 million to 5 million men in America are hypogonadal, Kamerow noted, but only about 5 percent of them receive testosterone therapy. The FDA has listed primary or secondary hypogonadism caused by surgery, radiation therapy, infections or genetic disorders as the main indications for TRT.
Clinicians can diagnose hypogonadism if the patient's total testosterone level is approximately 200 ng/dL, "although others use 300 to 350 ng/dL as the cutoff," he said.
Normal levels of testosterone may range from 300 to 1,000 ng/dL. They peak in men at age 17 and decline gradually over time, falling about 1 percent per year for men in their 30s and 40s -- making diagnosing older men difficult.
Treat symptoms
"Treat symptoms, not levels," Kamerow advised. For men who are not clearly hypogonadal, symptoms can include low sex drive and declining muscle mass and fat-free body mass. Studies have shown that replacement therapy probably does improve libido, especially for men with low testosterone levels at baseline, but not erectile dysfunction. It also has been shown to increase muscle mass and lean body mass.
"There are now easy-to-use, effective testosterone products available," he said. Until recently, only intramuscular injections were on the market, but now the choices include patches, gels and buccal tablets. Each has its own pros and cons for patient use, but all are effective, he said.
Kamerow was part of a group that reviewed studies of the effects of TRT for the Institute of Medicine. The studies found no direct evidence of increased prostate cancer rates in men who take TRT, although PSA levels may rise.
There is also no direct evidence of increases in coronary artery disease, although effects on lipid levels have been mixed -- lipids have worsened in some men and improved in others, he said.
 Medical student Clay Josephy, left, and Richard Paris, M.D., fly over the Idaho mountains from Hailey to the Challis clinic. |
Richard Paris, M.D., of Hailey, Idaho, was acclaimed AAFP's 2005 Family Physician of the Year during the Congress of Delegates Oct. 11 in Orlando, Fla.
"The honor is pretty overwhelming," says Paris, who has spent almost a quarter century treating patients in Wood River Valley, home to Hailey. This award, he says, "means being able to represent what all my colleagues do every day. It's a real recognition."
Paris, a native of North Dakota, graduated from the University of Rochester School of Medicine and Dentistry, Rochester, N.Y., in 1976. After completing the University of Arizona (Tucson) family practice residency program, he moved to Idaho, where he has been a fixture in the scenic Rocky Mountain community since 1980.
When he arrived, Hailey's health system consisted of an 11-bed hospital and two other doctors. "We were the entire staff," he recalls. "By my second year, I was chief of staff. That happened so many times I lost count."
Today, Paris' practice boasts seven family physicians, including Paris' wife, FP Kathryn Woods, M.D.
Going the distance
In addition to being a primary care physician to Hailey's 4,250 residents, Paris also provides patient care to Challis, a distant mountain outpost 130 miles from Hailey. This requires him to pilot his small plane over the mountains. He and Challis' physician assistant serve a population of about 1,000 scattered over a 100-mile radius.
"Dr. Paris has served as medical director of our rural health clinic since August 1999," says Kate Taylor, administrator for the Challis Area Health Center. "He came when our clinic was in turmoil, financially and professionally. His clinical oversight helped move our facility past that state into a more stable mode of operation."
Paris' medical beat also includes trekking even further into the Rockies to the isolated town of Stanley, where he provides clinical support to the midlevel provider working with the 100 residents.
Reflecting on physician distribution in America, Paris says, "You have a lot of physicians practicing in small towns, but not many have to cover such a large area. You end up having a lot of responsibilities in a community like this."
Many of Paris' patients face distance challenges as they seek out care. "There was a kid in the Pahsimori Valley - about 200 miles away from us - who had an emergency. His family had to drive an hour to get to the clinic in Challis. When they realized they needed to get to a hospital, they had another two-and-a-half-hour drive to be with us," Paris says. "It's amazing how isolated some of these people are."
Pushing progress
As chief of the medical staff for Blaine County Hospital in Hailey, Paris was key in merging two small regional hospitals into one state-of-the-art facility that houses a 24-hour emergency department, inpatient and outpatient surgery, diagnostics, maternity services, and intensive care and surgical units.
"Dr. Paris was instrumental in bringing together a group of excellent family physicians interested in high-quality patient care," says James Blackman, M.D., assistant dean and Idaho clinical coordinator for the University of Washington School of Medicine, Seattle. The university houses the medical school for Washington students, as well as students from four other states with no medical schools of their own, through the Washington-Wyoming-Alaska-Montana-Idaho (or WWAMI) program.
"Idaho gets 16 positions each year in the WWAMI program," explains Paris, who served on the medical school's admissions committee to participate in selecting the Idaho students from 1992 to 2001. "A number of years ago, they decided that they wanted more than the academicians in Seattle to decide who goes to school," he says.
On several occasions, Paris participated in interviewing and selecting students who came to Hailey during their first year, came back as third-year students and returned as residents. "Being a part of someone's entire (educational) career is unique," he says.
Paris now teaches in the university's Rural/Underserved Opportunities Program, or RUOP, a four-week program for medical students transitioning between their first and second year, and the WWAMI Rural Integrated Training Experience program, or WRITE, a six-month rural program for third-year students.
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"Hailey was one of several sites in Idaho the first year of RUOP," he says. "And based on our success with RUOP, we were selected to be the first site for the WRITE program in the five-state region in 1997."
Healing the ills, living the life
Over the past 24 years, Paris' patients have come to depend on his healing touch. Says Tom Bowman, a long-time Paris patient, "He has seen me through a leg that was severely broken while skiing, numerous illnesses, a misdiagnosed heart murmur, a few broken ribs and the complicated births of both my little girls. The kids like to go to him and refer to him as 'Doctor Rich.'"
Paris is regarded as an impassioned advocate for the family physician in rural settings. It is a life he's chosen, one that reaches far beyond the exam room. He's also right at home in the great outdoors.
"I get to live in God's country. I get to live with elk in my back yard, go kayaking and still do interesting work," he says. "I have always wanted to be a doctor in a small town in the mountains."
From Nov. 15 to Dec. 31, beneficiaries can change their Medicare-approved drug discount card or enroll for the first time. Patients may be asking you for help with their choices, and help is available.
The National Council on Aging offers assistance on an array of topics, including how to choose a card, at http://www.ncoa.org/content.cfm?sectionID=214.
CMS has information at http://www.medicare.gov on drug discount cards, public and private programs that offer discounted or free medications, and Medicare health plans that include prescription drug coverage. The agency also provides information on even more ways patients can reduce their prescription drug costs, such as by using generic alternatives.
More news about patient assistance programs: Many drug companies are collaborating in the Partnership for Prescription Assistance, offering helpful materials at https://www.helpingpatients.org. The program helps low-income, uninsured people get free or inexpensive medicines. The Web site has a short questionnaire patients can take to determine the best program for them.
In addition, several drug companies in the U Share Prescription Drug Discount Card program are offering copays of $10 to $30 on drugs to low-income Medicare beneficiaries for 30-day supplies. Go to http://www.usharerx.com.
At right: Julian Steele, 9,
left, and his brother Brandon, 5, of Santa Rosa, Calif., are all smiles as they
begin their day with the AAFP/Wonca Youth Program at SeaWorld®
Adventure Park.
Below: Sea creatures, including endangered manatees, entrance children and adults alike.
Wonca 2004
|
Family doctors from 96 countries converged on Orlando, Fla., to hold the 17th World Conference of Family Doctors (sponsored by Wonca, the World Organization of Family Doctors) in tandem with the AAFP Annual Assembly. Stories in this Special Section catch the flavor of the international exchange among almost 7,000 FPs and GPs. "Colleagues from around the world, despite many challenges, you are here," Daniel Ostergaard, M.D., AAFP vice president for international and interprofessional activities, said during the opening cerenomy. "Now more than ever, there is a need for international cooperation toward the betterment of our specialty and our patients' health -- international cooperation that transcends national policital issues." |
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Wonca 2004
By every accepted epidemiological measure -- birth weight, infant mortality, life expectancy, to name a few -- primary care-oriented health systems are associated with healthier populations that live longer. That's the contention of Barbara Starfield, M.D., M.P.H., professor of health policy and management at the Johns Hopkins University Bloomberg School of Public Health, Baltimore.
Starfield, who was introduced as the "grand lady of public health," addressed worldwide issues in primary care in an Oct. 13 session.
Citing international studies, Starfield said increasing the number of primary care physicians is positively associated with improved health outcomes, while increasing the number of specialty physicians appears to have the opposite effect.
For example, in the United States, a "20 percent increase in the number of primary care physicians is associated with a 5 percent decrease in mortality (40 fewer deaths per 100,000)," she said. But the benefit is even greater if the primary care physician is a family physician. Adding one more FP per 10,000 people "is associated with 70 fewer deaths per 100,000, which is a 9 percent reduction in mortality," she said.
Moreover, she said that when specialists practice outside their area of specialization, the result is an increase in mortality rates for "acquired pneumonia, acute myocardial infarction, congestive heart failure and upper GI hemorrhage." Noting that specialists are "trained to look for zebras instead of horses," she said specialty care usually means more "tests, which lead to a cascade effect and consequently greater likelihood of adverse effects, including death."
The reality of medical practice, Starfield said, is that while "specialists may, and in fact do, follow guidelines better than primary care physicians, specialists cannot deal with comorbidities. And guidelines don't account for comorbidities." This observation triggered a burst of applause from the audience at the 17th World Conference of Family Doctors.
Primary care, Starfield said, "is more effective, efficient and more equitable" than specialty care. For example, a 1994 study of the major determinants of health outcomes in all 50 U.S. states found that when the number of "specialty physicians increased, all outcomes were worse." Likewise, worse outcomes were directly related to a decline in the supply of primary care physicians.
During the discussion period, Starfield was asked why her data have failed to move Congress to increase funding for primary care. "If you are asking what is in the heads of congressmen, I think you know," she said. They are thinking: ‘What will this mean for big pharma? What will this mean for the medical device companies? What will this mean for insurance companies?' Those are the powerful forces in Congress. If primary care is to grow, it needs to find powerful allies in the population, which is difficult because the population is brainwashed to believe the best care comes from specialists. The only ally of primary care is business because business pays the bills."
Finally, Starfield challenged Wonca to support research in three key areas: the impact of comorbidity on the development of clinical and preventive care guidelines; new strategies to develop a better relationship between primary care and specialty physicians; and cross-country and cross-area variations in referral rates to serve as a basis for a better definition of the roles of primary care and specialty physicians.
Wonca 2004
Family physicians, said Joseph Scherger, M.D., M.P.H., are reinventing the practice of family medicine. They're moving from the acute care model of the 20th century into a new, patient-centered model that will rely heavily on technology and teamwork while reinvigorating the high-touch, caring family medicine that has always been the number one core value of family physicians.
Scherger, clinical professor of family medicine at the University of California, San Diego, spoke as part of a plenary panel, "Young Physicians and Future Practice." He described the Future of Family Medicine project cosponsored by North American groups including AAFP.
As representatives of the future of family medicine in the United States, three newly minted family physicians joined Scherger on the panel.
"I'm truly a solo doc," said Saria Carter Saccocio, M.D., of Fort Lauderdale, Fla. "My mother is my receptionist and office manager, and I'm the nurse and the doctor. I answer all calls myself, and my mother and I take turns cleaning the office toilet."
But all is not low-tech in Saccocio's office, which has an electronic health record system. Saccocio said the future of medical practice is the EHR that will allow physicians to access complete medical records via secure Internet connections.
Erika Bliss, M.D. -- like Saccocio and the third young physician on the panel, Michael Coffey, M.D. -- completed residency training less than two years ago. Bliss works at a community clinic in Seattle. "Many of our patients are uninsured or underinsured, and our community clinic plays an important role in providing health care to this population," she said. "As a family physician, I am committing to the culture of inquiry. I believe that we can all be researchers in our own right." She said she works with a network of community clinics to develop databases and clinical research.
Coffey told the Wonca 2004 audience that he joined the Boston practice of an elderly "GP surgeon who is so well-known and well-regarded that he has a square in town named after him." Brandishing a PDA, Coffey said that his goal is to practice "high-touch, high-tech, high-teach" family medicine. Hitting a nostalgic note, he said, "Back in the 1970s, there was a television show about the ideal family doctor: Marcus Welby, M.D. Well, my goal is to be Marcus Welby with a Palm Pilot."
Wonca 2004
 Professor Pham Huy Dung of Hanoi Medical University, left, tells U.S. and foreign physicians about family medicine in his native Vietnam. Above, Hassan Hadi Baker, M.D., head of Iraq's Family Physician Society, talks with FP Kelly Murray, M.D., about international activities resources offered by the Academy. |
To become an international consultant, you need excellent communication skills, impeccable diplomatic talents and an inspiring teaching style. But there also are some particular personal qualities you'll need, said Brian Jack, M.D., associate professor and vice chair for academic affairs for the department of family medicine at Boston University.
"If you don't like the heat, don't go to Saudi Arabia," Jack advised during a Wonca 2004 workshop highlighting the AAFP's International Family Practice Development Assistance Program. And if you're put off by "mean" bathrooms, he said, international consulting may not be your calling.
Those challenges couldn't dissuade the family physicians, generalists and others who gathered to hear success stories from Jack and others involved in IFPDAP and similar programs.
Strong start in Vietnam
Professor Pham Huy Dung, vice director of the Health Strategy and Policy Institute at Hanoi Medical University, presented an overview of how an international consultation project helped catapult family medicine to the forefront of primary care in his native Vietnam. Alain Montegut, M.D., of Portland, Maine, and his colleagues consulted with Vietnamese physicians for several years to make family medicine a reality there. Although the collaboration Dung described predated IFPDAP, beginning in 1995, it served as a model for the AAFP program.
Traditionally, Vietnamese medicine -- like that in many foreign countries -- has centered on care provided by subspecialists, Dung explained. Patients would visit one of the country's large hospitals for all types of care; there was no history of community-based primary care.
That's all changed in just eight years, Dung said. A series of "commune health stations" now stretches across Vietnam, with each station staffed by physicians specifically trained in family medicine and providing full-spectrum care modeled on that offered by FPs in the United States.
And, Dung noted, the Vietnamese Ministry of Health has recognized family medicine as a new form of medical training -- Level 1 Specialization in Family Medicine. Most recently, he said, the ministry has called on all Vietnamese universities providing medical education to include family medicine curriculum.
Of course, sustainability is key to this development process. A Physicians With Heart airlift to Vietnam in 2001 proved invaluable in maintaining a high level of interest -- and visibility -- for family medicine, said Daniel Ostergaard, M.D., AAFP vice president for international and interprofessional activities. The visit, which included delivery of donated medical supplies, drugs and educational support, helped lend "credibility and prestige" to Vietnam's family medicine training program, he said.
"It was a heavy-duty assist," Ostergaard said. "We had the U.S. ambassador with us for three days -- that's big."
Response to Iraqi request
The IFPDAP session held hope for FPs trying to nurture family medicine against heavy odds. Hassan Hadi Baker, M.D., head of Iraq's Family Physician Society, told Ostergaard after the session, "I came to this Wonca meeting to ask for help from the AAFP -- to see if we can start some sort of collaboration between our two societies."
Iraq has had a fledgling family medicine training program for 10 years and has about 50 physicians in the Iraq Family Physician Society. But the curriculum falls short on family and community aspects of care, Hassan admitted. Obtaining resources from abroad has been difficult, he said: "Until this spring, for about 35 years, no one entered my country or went out" without government approval. "Our doctors have been isolated. We'd like some to get training abroad, and when they return, they can teach in Baghdad University," Hassan said. The society wants to revise the curriculum and set up a board recertification process, he added.
FP Kelly Murray, M.D., now of Fort Polk, La., a member of the Uniformed Services AFP, served in Iraq for 15 months recently and joined the Iraq Family Physician Society. She urged Hassan to attend Wonca 2004 and seek resources.
"We probably gave him more materials than he could carry back to Iraq," said Ostergaard.
Among Hassan's new tools are the Society of Teachers of Family Medicine medical school curriculum information, AAFP materials and Residency Assistance Program criteria for residencies, six years of AAFP Home Study CME offerings on a CD-ROM, and the audiocassette series from AAFP's Family Practice Board Review course. And more help is in the offing.
"We can't send our IFPDAP consultants into danger, but we're going to explore a meeting with some of the family medicine faculty, perhaps in a safe area in northern Iraq or in a nearby country," said Ostergaard.
To reach writer Cindy Borgmeyer, e-mail cborgmey@aafp.org.
Wonca 2004
There are 500 million people alive today who will die tobacco-related deaths. Thus began the presentation Oct. 13 at Wonca 2004 by Sean David, M.D., assistant professor of family medicine at Brown Medical School in Providence, R.I.
The 500 million is "equivalent to all the deaths in the Vietnam War occurring every single day for 25 years," said David. "And if anyone were kind enough to build a memorial to those who will die a tobacco death in the first half of this century, and patterned it after the well-known Vietnam Memorial, it would start in Washington, D.C., travel west for six states, 1,100 miles, and end in Kansas City."
"Some of the names on that wall would be your patients. And, if you smoke, some of the names on that wall would be yours," he told attendees. "With all due respect to AIDS, malaria and other infectious diseases, tobacco is the greatest public health menace in the world today."
The message was well-targeted to the audience. After all, at the last Wonca world conference in 2001, the Wonca Executive Committee declared its "Call to Action on Tobacco Cessation" to encourage a global effort against the tobacco scourge.
David told attendees about his own research studying genetic influences on nicotine addiction using functional magnetic resonance imaging and positron emission tomography. In addition, he is studying how genetics influences smoking cessation with nicotine replacement therapy and bupropion in three randomized clinical trials. Environmental factors play a major role in why people smoke. This is why policy interventions can have a major impact on preventing tobacco-related deaths, he told the Wonca attendees, encouraging them to bring their influence to bear on the powers that be.
"We're at the crossroads of the greatest public health crisis of our time," he said. "We can win this war."
To reach writer Toni Lapp, e-mail tlapp@aafp.org.
Wonca 2004
The only way to successfully halt chronic diseases across the globe is to implement preventive health programs across the street. Those programs must reside in the markets of Kampala, Uganda, as well as in the heart of New York City.
That's because lifestyle behaviors -- unhealthy diets, inactivity and tobacco use -- have crept throughout the world. Changing those behaviors requires intensive local action that focuses on both individual choices and the sociopolitical environment in which people live, said a renowned health leader Oct. 14 at Wonca 2004.
Chronic diseases: top killers worldwide
Chronic disease has skyrocketed worldwide, said Dr. Pekka Puska, director general of the National Public Health Institute of Finland and former director of Noncommunicable Disease Prevention and Health Promotion at the World Health Organization.
"Sixty percent of all premature deaths in the world are from chronic disease, not communicable disease," Puska said. His plenary session, "Health Behavior and Disease Prevention: Primary Care and Community Perspectives," focused on program elements that change individual behavior and, in turn, improve community health.
"Global public health depends on what happens with the growing incidence of chronic disease," said Puska. "The risk factors for chronic disease are moving to poorer and poorer countries."
World Health Organization data show that, worldwide, more than 5 million people die prematurely from chronic disease each year. In 25 years, that number will rise to 10 million premature deaths a year "as the tobacco industry moves its products to developing nations," he added.
National program succeeds
Puska pointed to a program in Finland, through which mortality from cardiovascular disease plummeted by 75 percent. The effort demonstrated that successful disease prevention depends on several factors, including well-defined health targets; solid monitoring of patient behaviors and progress; flexible interventions; strong community involvement; ability to influence national political processes and health policy, including integration with the public health system; and long-term leadership and commitment.
Act locally, think globally
"The cultures are different in different parts of the world, so the action we take must be tailor-made to what works in the local traditions," Puska said. "The risk factors are the same throughout the world. Tobacco kills everywhere, high blood pressure kills everywhere."
Moreover, primary care doctors assume leadership because they reach the most people and because they lend medical prestige to preventive messages.
"Our challenge is to make healthy choices easier, which relates to (changing) public health policies. Our work is to influence policy-makers, but even more, to mobilize the people to make changes in society."
To reach writer Leslie Champlin, e-mail lchampli@aafp.org.
Wonca 2004
When Wonca's World Council last met in 2001, Wonca represented 65 countries. At the World Council meeting Oct. 12, Wonca's (then) President Michael Boland, M.D., of Ireland told attendees that the organization now comprises 100 member organizations, representing 83 countries.
Not only that, but a new region has been formed since 2001 -- Wonca Iberoamericana -- to represent Latin America, the Spanish-speaking Caribbean and the Iberian Peninsula.
Such growth presents a challenge for an organization with a mission to improve the standing of primary care worldwide. "The concern is," Boland explained, "how do we increase resources to improve the position of family medicine in countries joining us -- especially developing countries?"
Wonca regional representatives worked on initiatives such as the following:
Sparks said the mandate to disseminate pharmaceutical education to the developing world will address the need to better use medical resources.
Wonca 2004
Bringing together
health care professionals from all corners of the world, Wonca 2004 provided a
week of education and camaraderie. At left, (then) President Michael Boland,
M.D., of Ireland addressed the Wonca World Council. Below, participants pored
over programs to complete their schedules for the week to come. At right, Dr.
Ue Kyong Hwang from Korea and, at far right, Joon Hyung Lee, M.D., of Hershey,
Pa., exchanged business cards after reconnecting for the first time since
medical school, nearly five years ago.
The AAFP Congress of Delegates Oct. 13 chose Larry Fields, M.D., of Ashland, Ky., to be the Academy's new president-elect.
"Raising the bottom line for family physicians is the linchpin of the future," said Fields in a subsequent interview. "It's the key to student interest, to keeping people satisfied in practice, to keeping the doors open, to access."
Others elected or chosen by acclamation for the following positions are: speaker of the Congress -- Thomas Weida, M.D., of Hershey, Pa.; vice speaker -- Leah Raye Mabry, M.D., R.Ph., of San Antonio; directors -- Judith Chamberlain, M.D., of Brunswick, Maine, Ted Epperly, M.D., of Boise, Idaho, and Virgilio Licona, M.D., of Fort Lupton, Colo.; new physician Board member -- Maureen O'Hara Padden, M.D., of Camp Lejeune, N.C. (Uniformed Services); resident Board member -- Michael King, M.D., of Lexington, Ky.; and student Board member -- Gretchen Dickson of Pittsburgh.
Finalists for the AAFP position on the board of directors of the American Board of Family Practice are Craig Czarsty, M.D., of Oakville, Conn.; Barbara Hughes Kostick, M.D., of Fremont, Calif.; and Alain Montegut, M.D., of Brunswick, Maine. The ABFP will select one finalist next spring to serve a five-year term on its board.
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President
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President-elect
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Board chair
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Speaker
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Vice speaker
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Executive vice president
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 Mary Frank, M.D. Mill Valley, Calif. |
 Larry Fields, M.D. Ashland, Ky. |
 Michael Fleming, M.D. Shreveport, La. |
 Thomas Weida, M.D. Hershey, Pa. |
 Leah Raye Mabry, M.D. San Antonio, Texas |
 Douglas Henley, M.D. Leawood, Kan. |
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Directors
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 Rick Kellerman, M.D. Wichita, Kan. |
 John Sattenspiel, M.D. Salem, Ore. |
 Mary Jo Welker, M.D. Columbus, Ohio |
 James King, M.D. Selmer, Tenn. |
 Thomas Kintanar, M.D. Fort Wayne, Ind. |
 Timothy Komoto, M.D. Mendota Heights, Minn. |
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Directors
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New physician director
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Resident director
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Student director
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 Judith Chamberlain, M.D. Brunswick, Maine |
 Ted Epperly, M.D. Boise, Idaho |
 Virgilio Licona, M.D. Brighton, Colo. |
 Maureen O'Hara Padden, M.D. Camp Lejeune, N.C. |
 Michael King, M.D. Lexington, Ky. |
 Gretchen Dickson Pittsburgh, Pa. |
Academy members who could not attend this year's Scientific Assembly can still reap CME benefit from the sessions. Access complete versions of 19 lectures presented during the Assembly at http://www.aafp.org/2004lectures.xml. Among the highlights of the online offerings: four Annual Clinical Focus sessions, including the keynote lecture "Genomics and the Family Physician: Realizing the Potential" by Francis Collins, M.D., Ph.D., director of NIH's National Human Genome Research Institute.
Other topics include "Asthma in Children," "Hypertension Update," "End-of-Life Issues" and "Perspectives in Pain Management."
The online taped lectures are accompanied by speakers' biographies, handouts and slide presentations. Each is acceptable for up to 1.5 Prescribed CME credits for a possible total of 28.5 credits that are free to AAFP members. Completed credits will be quickly processed electronically.
A word of caution: Members who attended and obtained CME credit for the lectures in Orlando, Fla., cannot apply for additional credit for the same course online.
The 2004 Scientific Assembly and 17th World Conference of Family Doctors was the largest gathering of FPs in more than a decade. The meetings drew 20,773 physicians, health care professionals and others to Orlando, Fla., Oct. 13 – 17.
As of Oct. 17, the total registration for the Scientific Assembly was 13,465, which included 5,180 physicians, 202 other health care professionals, 214 speakers and 8,083 guests. The total registration for the world conference -- sponsored by the World Organization of Family Doctors, or Wonca -- was 2,668, including 1,813 physicians. In addition, 4,640 exhibitors displayed their products for registrants for the two meetings.
Now's the time to mark your calendars for the 2005 Scientific Assembly Sept. 28 – Oct. 2 in San Francisco.
This financial summary has been prepared to present an overall picture of AAFP's financial condition and operations.
| CONSOLIDATED STATEMENTS OF FINANCIAL POSITION | ||||
| May 31, 2004 | May 31, 2003 | |||
| Assets | ||||
| Cash and cash equivalents | $8,884,808 | $13,522,129 | ||
| Receivables, net of allowance for doubtful accounts of $682,833 in 2004 and $745,112 in 2003 | 8,923,248 | 8,393,638 | ||
| Inventories | 47,110 | 50,108 | ||
| Prepaid expenses and other assets | 2,733,463 | 2,178,124 | ||
| Marketable securities | 51,489,053 | 44,317,171 | ||
| Property and equipment, at cost | ||||
| Land | 5,781,848 | 5,781,848 | ||
| Office buildings | 30,647,873 | 30,638,272 | ||
| Office equipment, furniture and fixtures | 11,576,369 | 11,203,942 | ||
48,006,090 |
47,624,062 |
|||
| Less accumulated depreciation | 12,706,679 | 10,857,609 | ||
35,299,411 |
36,766,453 |
|||
| Investments in deferred compensation plan, at fair value | 1,759,403 | 1,367,957 | ||
$109,136,496 |
$106,595,580 |
|||
| Liabilities and net assets | ||||
| Liabilities | ||||
| Accounts payable | 2,964,311 | 2,322,822 | ||
| Accrued expenses | 6,901,102 | 6,365,230 | ||
| Unearned revenue | 21,843,208 | 21,894,759 | ||
| Income taxes payable | 2,176,086 | 2,217,508 | ||
| Mortgage note payable | 19,290,308 | 20,461,654 | ||
| Liability for deferred compensation plan | 1,759,403 | 1,367,957 | ||
54,934,418 |
54,629,930 |
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| Net assets | ||||
| Unrestricted | 54,202,078 | 51,965,650 | ||
$109,136,496 |
$106,595,580 |
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| CONSOLIDATED STATEMENTS OF ACTIVITIES | ||||
| Revenue | ||||
| Membership dues and fees | $16,607,732 | $15,344,100 | ||
| Publishing activities | 23,738,304 | 20,548,867 | ||
| Programs and miscellaneous | 27,684,639 | 28,297,161 | ||
| Investment income | 1,531,721 | 223,207 | ||
69,562,396 |
64,413,335 |
|||
| Expenses | ||||
| Membership services and programs | 41,517,791 | 36,735,860 | ||
| Publishing activities | 15,009,913 | 12,041,957 | ||
| Organizational business services | 10,871,312 | 15,602,427 | ||
| Income taxes | 2,323,578 | 1,830,994 | ||
69,722,594 |
66,211,238 |
|||
| Other income (expense) | ||||
| Interest on income tax refunds | -- | 248 | ||
| Other | (340,000) | -- | ||
| Net unrealized gains (losses) on marketable securities | 2,736,626 | (251,920) | ||
2,396,626 |
(251,672) |
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| Change in net assets | 2,236,428 | (2,049,575) | ||
| Net assets, beginning of year | 51,965,650 | 54,015,225 | ||
| Net assets, end of year | $54,202,078 |
$51,965,650 |
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The above data are only a part of the complete financial statements examined by Grant Thornton LLP, certified public accountants.
WEB EXTRA!
Family physicians peppered AAFP leaders with questions about reimbursement at a town hall meeting on the Future of Family Medicine project Oct. 10. The questioners were delegates and others in Orlando, Fla., for the AAFP Congress of Delegates.
AAFP officers reviewed the FFM project and its recommendations. The leaders highlighted the new model of care, which includes giving patients a personal medical home, using advanced information systems and offering family medicine's basket of services. "If no one in your practice does obstetrics, ask your patient who calls in and says she's pregnant to come in for a visit, and talk to her about prenatal care," said (then) President-elect Mary Frank, M.D., of Mill Valley, Calif. "Don't just turn her loose in the system; don't just give her a list of OB-Gyns. Get her an appointment with one."
The AAFP leaders discussed the impact of the report from the FFM project's sixth task force. The report, to be printed in the November/December Annals of Family Medicine, focuses on reimbursement and shows how using the new model could help FPs increase their productivity. That would give FPs more time for patients or, if
