Entire Issue - March 1998

March 1998
News for members of the American Academy of Family Physicians

Family physician David Satcher becomes America's

'First Doc'

Victory at last: The Senate finally confirmed family physician David Satcher, M.D., Ph.D., as surgeon general and assistant secretary of health Feb. 10. The confirmation came five months after his nomination to the posts and more than nine months after plans for the nomination were announced.

"This is an American dream come true -- to go from a humble farm in Anniston, Ala., to the office of the surgeon general," said Satcher Feb. 10.

AAFP President Neil H. Brooks, M.D., of Rockville, Conn., said, "We are thrilled and honored that the nation's 'first doctor' is a family physician." Satcher, 56, an AAFP member, is the first family physician to be surgeon general.

The Academy recommended to the White House that Satcher be considered a candidate for surgeon general. After the nomination, many Academy members urged their senators to vote for him. AAFP's staff and leaders campaigned for him, countering criticism of Sen. John Ashcroft, R-Mo., and others.

Satcher expressed his gratitude Feb. 10 "to all those strong voices and helping hands, my family, friends and colleagues who have spoken out and worked so hard on my behalf."

When Satcher was sworn into office Feb. 13 in the Oval Office, both he and President Bill Clinton formally thanked the American Academy of Family Physicians. AAFP President-elect Lanny Copeland, M.D., of Albany, Ga., and Executive Vice President Robert Graham, M.D., attended the ceremony.

Satcher promised to try to engage all Americans in an ongoing conversation about physical activity, good nutrition, responsible behavior and other passports to good health and long life.

During the contentious debate on the nomination, senators recounted details of Satcher's life:

He is one of 10 children raised in rural Alabama by his mother, a homemaker, and his father, a foundry worker, neither of whom completed grade school.

Certain vaccines were not available in the rural south, and at 2, Satcher's life was threatened by whooping cough. His father talked an African-American physician into caring for the boy at the Satchers' house -- and the physician became Satcher's inspiration for entering medicine. As director of the Centers for Disease Control and Prevention in Atlanta since 1993, Satcher spearheaded efforts that increased childhood immunization rates from 55 percent in 1992 to 78 percent in 1996.

He began his career serving low-income patients in neighborhood health centers and urban hospitals. He developed and chaired the King/Drew Medical Center's family medicine department in Los Angeles, chaired Morehouse's family and community medicine department, and was president of Meharry Medical College in Nashville, Tenn., from 1982 to 1993.

Ashcroft criticized Satcher for concurring with the president's refusal to sign a bill banning late-term abortions because exceptions were not made for the health of the mother. Ashcroft assailed Satcher's support for free-needle programs for drug addicts and approval of a Third World azathioprine (AZT -- zidovudine) study criticized in a New England Journal of Medicine editorial. Senators including Sen. Bill Frist, M.D., R-Tenn., countered with Satcher's statement that he would not promote issues related to abortion but would focus on issues that can unify the nation.

Sen. Jim Jeffords, R-Vt., chair of the Labor and Human Resources Commit-tee that voted 12-5 in favor of the nomination last fall, said the free-needle programs were a matter of AIDS prevention and that two members of the NEJM editorial board resigned in protest of the NEJM editorial.

Sen. Ted Kennedy, D-Mass., the ranking minority member, reminded senators of one of Satcher's comments to the committee -- that he has wanted to make the greatest difference to people he thought had the greatest need.

When the Senate voted 63-35 to confirm the nomination, Clinton expressed pleasure at the overwhelming bipartisan support. After Satcher was sworn into office, Clinton said, "Stunning medical breakthroughs, new treatments for deadly diseases, and a rapidly changing health care system make it more important than ever that our surgeon general truly be America's family doctor and guide us through this time of change."

By Jane Stoever, Associate Editor

"I, David Satcher, do solemnly swear ..." Participants in the historic moment at the Oval Office Feb. 13: Satcher; his wife, Nola; President Clinton; and Vice President Gore.
(White House Photo)

April 1998 space shuttle mission includes two family physicians

Forgive Alex Dunlap, D.V.M., M.D., and Dafydd "Dave" Williams, M.D., if they're gazing at the stars a little bit more than usual these days.

Dafydd "Dave" Williams, M.D. Alex Dunlap, D.V.M., M.D.

Dunlap, 37, and Williams, 43, are both FPs and are both part of "STS 90," the 90th mission of NASA's space shuttle program. As as astronaut, Williams will find himself a little bit closer to those stars very soon while Dunlap, his backup, will be at Johnson Space Center in Houston with an eye on the shuttle. The mission is called "Neurolab," it's dedicated to research on the nervous system and behavior, and it will most likely blast off April 16.

During the 16-day mission, Dunlap, on leave from the Baptist Health-Plex Family Practice Residency in Memphis, Tenn., will be working long hours in Houston. He'll be helping Wil-liams and the other astronauts with more than two dozen scheduled experiments.

"The experience has been incredible," said Dunlap, an AAFP member. "Working with these experiments has been like going on 26 mini-sabbaticals. It's been incredible to work with this level of scientists on a one-to-one basis."

That work started about two years ago, when Dunlap left his residency and Williams left Toronto, where he is an emergency physician/family physician and a member of the College of Family Physicians of Canada (CFPC). As FPs, Dunlap and Williams received "crew medical officer" training to allow them to act as physicians in space. Neurolab will also be the first-ever shuttle mission to carry a defibrillator, so the two have learned to resuscitate in space.

They also did work here and in Europe on the 26 experiments, endured centrifuge training, experienced freefall in NASA aircraft, and even did water survival training at Pensacola, Fla.

Mementos in space

The FP scheduled to blast off into space April 16 is Canadian, but he'll carry at least two AAFP mementos with him.

Dafydd "Dave" Williams, M.D., will carry an AAFP "I Deliver" button, courtesy of the University of Tennessee Department of Family Medicine, where Alex Dunlap, M.D., the other FP working on the mission, is a resident. He'll also carry an AAFP lapel pin, which he received from Academy headquarters in Kansas City, Mo.

Williams, who grew up along with the U.S. space program in the '50s and '60s but saw his own country send only satellites into space, was already familiar with the ocean. Rather than explore "outer space," Williams says, he turned to "inner space" when he started scuba diving in 1967.

Twenty-five years later, in 1992, Williams' application was accepted by the Canadian Space Agency, and he soon found himself at Houston.

"I never thought as a youth, growing up in Canada, that I'd have the chance to fly in space," Williams said. "I'd had it in the back of my mind, but never thought it was possible to have a dream like that come true."

Dunlap took a slightly different route to NASA. He received his medical degree from the University of Tennessee College of Medicine in Memphis in 1996, and he also holds a veterinary medicine degree from the Louisiana State University School of Veterinary Medicine in Baton Rouge. As such, he is valuable to the Neurolab mission.

"They felt it was important to have someone who knows science, and knows the experiments, communicate between the ground and the shuttle," Dunlap said. "This is the opportunity of a lifetime."

Dunlap is not the first AAFP member to be involved in a space shuttle flight. Charles Brady, M.D., of Robbins, N.C., took part in the (then) longest-ever space shuttle mission between June 20 and July 7, 1996.

By Todd Simchuk, Managing Editor

News from Headquarters

Grant application process is under way

$2.7 million to be awarded to family practice research centers

The AAFP has announced a call for proposals that will end with the selection of three family practice research centers. The centers will receive a total of $2.7 million in grants.

This Research Center Grant Program, one of four grant programs in the overall AAFP research initiative plan, is designed to build an augmented family practice research infrastructure which will improve the research environment.

Eligible institutions should have received information by mail by now. If not, contact Tom Stewart at (800) 274-2237, Ext. 5538.

The deadline to submit grant letters of intent to the AAFP is April 3, 1998. AAFP Director Joseph Scherger, M.D., M.P.H., of Irvine, Calif., said the Academy's Task Force to Enhance Family Practice Research will award the grants Sept. 1 of this year.

The three institutions will receive up to $450,000 during the first two years of the four-year program, and up to $450,000 during a subsequent two-year period.

Further inquiries about the grant program and task force can be directed to Herbert F. Young, M.D., director of the Academy's Scientific Activities Division, at (800) 274-2237, Ext. 5500, or at AAFP, 8880 Ward Parkway, Kansas City, MO 64114.

The call for proposals and the instructions are also listed at http://www.aafp.org/research/index.html on the Academy Web site.

AAFP leaders address national committees

Two AAFP Board members took Academy concerns to committees in the nation's capital recently.

Bruce Bagley, M.D., of Albany, N.Y., testified before the House Appropriations Committee's Subcommittee on Labor, Health and Human Services, and Education Jan. 29. Bagley asked for a fiscal year 1999 funding level of $87 million for family practice training programs, compared with the current funding of about $49 million. He noted this is the first time in recent years that the president's budget calls for level funding for the programs (about $49 million for family practice) instead of drastic cuts.

Bagley also sought a $50 million increase in funding (over the current $146 million) for the Agency for Health Care Policy and Research, particularly for its Center for Primary Care Research, and he called for continued support for rural health activities.

Ronald Christensen, M.D., of Anchorage, Alaska, presented testimony Feb. 3 to the National Advisory Committee on Rural Health, a committee of the Department of Health and Human Services. He addressed rural America's shortage of primary care physicians and the need to remedy problems created for graduate medical education in the Balanced Budget Act of 1997.

Family physicians on the advisory committee supported Christensen's presentation, and the committee made recommendations in line with AAFP's positions. The recommendations will be sent to the HHS secretary and relevant congressional committees.

Both AAFP statements are available at http://www.aafp.org/gov on the Web.

Fellowship criteria will change in '99

This is the last year for AAFP members to receive the degree of AAFP Fellow under the old criteria. Starting in 1999, a new and broader pathway to earning Fellowship will replace it.

Until Dec. 31 of this year, you may use either the old or new criteria to apply for Fellowship. Some distinctions: The old pathway confers Fellowship for board certification or completion of 600 hours of postgraduate study as an AAFP active member. The new pathway requires experience in areas such as academic training and CME, publishing and research, volunteer teaching, public service and service to the specialty.

If you'd like to receive the degree of Fellow during the convocation ceremony this fall at the Scientific Assembly in San Francisco, apply by July 31. For more information, call Jay Fetter in the AAFP Membership Division at (800) 274-2237, Ext. 4130.

Upcoming events include ALF, NCWMNP

The Annual Leadership Forum and National Conference of Women, Minority and New Physicians are coming up.

ALF is slated for Friday and Saturday, May 1 and 2, while the NCWMNP will take place April 30 through May 2.

For the first time, persons who take part in the Annual Leadership Forum will be able to earn CME credit. For more information, contact Donna Fletcher at AAFP, (800) 274-2237, Ext. 3216.

McCall's, Family Circle publish AAFP special section in their current issues

The March issues of McCall's and Family Circle feature a "Healthy Living" section developed in cooperation with the Academy.

The combined circulation of the magazines is about 12.3 million -- close to one in three American women. "Healthy Living" appears in two versions, the longer one in Family Circle.

The section explores how women's lifestyle decisions may relate to health problems such as melanoma, osteoporosis and stress. The section also discusses the yo-yo effect of dieting for only a week or stopping smoking for only a month.

In a passage on motivation, Pamela Kushner, M.D., of Long Beach, Calif., chair of the AAFP Communications Committee, mentions a patient who needed to lose 100 pounds. "I tried to find what was important to Mary," says Kushner. "Issues such as heart disease did not move her as much as the fact that she was tired all of the time and that she needed to maintain her health in order to help a divorced daughter with young children."

This year marks the second year the Academy has cooperated with McCall's and Family Circle in developing the section and recommending Academy members to be interviewed.

On a first-come, first-served basis, you may request complimentary copies of each magazine for your office reception area by calling Barbara Decker at AAFP, (800) 274-2237, Ext. 4234.

Past Treasurer Robert S. Young, M.D., dies

Robert S. Young, M.D., of Johnstown, Ohio, died Feb. 14 from prostate cancer at age 74. He served as AAFP treasurer from 1983 to 1987 and was a director from 1978 to 1981. He served as the 1970-71 Ohio AFP president.

Young's legacy includes state line-item funding for family practice departments and residencies. According to the Ohio AFP, he was the key force in convincing the 1973-74 Ohio General Assembly to pass a bill not only funding training for undergraduates and graduates but also noting, "The [family practice] department shall be a full department coequal with all other departments."

The specialty's line-item funding in Ohio continues to this day.

University of Chicago opens family medicine department

The University of Chicago will soon have a family and community medicine department.

The university senate voted for the new department in mid-December. "The changing face of health care makes it incumbent on academic institutions to have outreach to the community for primary care delivery," said internist Larry Wood, M.D., dean for medical education at the university's Pritzker School of Medicine. "A department of family medicine becomes the laboratory for investigating population-based sciences in the community and becomes the classroom for teaching the principles of primary care."

The Academy's "target schools" list of medical schools without family medicine departments or divisions now has 10 schools, down from 21 schools in 1989, the year the list was created.

On tap: the 25th NCFPR/NCSM

A few years might have passed since you've attended the National Congress of Family Practice Residents and the National Congress of Student Members in Kansas City, Mo. Quite a few, in fact. This year marks the 25th celebration of these annual events.

Scheduled for July 29 - Aug. 2, the 1998 NCFPR/NCSM will include several special events for alumni who might have been in Kansas City as far back as the mid-1970s.

Watch your mail and the FP Report for more details.

Thirteen constituent chapters receive grants totaling $17,000

Thirteen constituent chapters recently received more than $17,000 in grants to support research activities, Charles E. Driscoll, M.D., of Iowa City, Iowa, chair of the AAFP Commission on Clinical Policies and Research, recently announced.

Funding requests from the chapters exceeded the available funds, and the commission had to apportion funding among those that received favorable review.

California, Connecticut, Indiana, Maine, Michigan, Minnesota, Missouri, New Jersey, Ohio, Oklahoma, Pennsylvania, Rhode Island and Wisconsin received funding through the Matching Grants for Constituent Chapter Research Activities program. Applications are considered at the January and May commission meetings. This is the 10th year that the program has offered $25,000 annually in matching grants to stimulate research activities at the chapter level.

The next deadline for submissions is April 28, 1998. For more information, contact your constituent chapter or the AAFP Scientific Activities Division, (800) 274-2237, Ext. 5562.

The application is also available at http://www.aafp.org/members/research/matchapp.html at AAFP's site on the World Wide Web.

Products and services

Electronic CME tops list of new resources

Electronic CME options, a CME monograph on HIV and a book on rural practice -- these are some of AAFP's new resources that can help you and your practice.

Assembly CD-ROM. For the first time, you can obtain CME via a CD-ROM presenting main-stage lectures from an AAFP Assembly.

The new CD-ROM features nine of the top lectures at the 1997 Assembly, with topics ranging from fibromyalgia to congestive heart failure to physician-assisted death. For each lecture, you can view slides while listening to the presenter. The post-test is interactive -- when you select a wrong answer, the test sends you back to the correct answer in the lecture.

The CD-ROM, "Lecture Highlights of the 1997 AAFP Scientific Assembly," is approved for up to 10 hours of Prescribed credit. Item #R045, it costs AAFP members $99.

HIV Monograph. The AAFP Home Study Self-Assessment program, which develops CME materials for subscribers, is making the new monograph HIV Infection available to all who request it. The monograph provides current treatment information and may be used to obtain five hours of Prescribed credit. The monograph, item #R291, costs members $25.

Online CME quizzes. Clinical quizzes from American Family Physician now appear on the AAFP's World Wide Web site. Visit http://www.aafp.org/afp/afpquiz.html to take the online clinical quiz, check your answers electronically, review the article and then report the quiz for CME credit.

In addition, CME quizzes from Family Practice Management are accessible online at http://www.aafp.org/fpm/fpmquiz.html on the Web.

E/M documentation pocket guide. A handy pocket guide will help you and your colleagues follow Medicare's revised documentation guidelines for evaluation and management services. The guidelines take effect July 1. The pocket guide (item #R557), developed by FPM, costs members $5 apiece for fewer than 10 copies, $2 apiece for 10-24 copies, and $1.50 apiece for 25 or more copies. FPM's monograph Mastering Medicare's Docu-mentation Guidelines (item #R574) may be available by early April.

Rural family practice book. Is country life calling you? If so, a 44-page book, recently revised, might help you find your niche. Rural Family Practice: You Can Make a Difference shares the insights of rural family physicians. For example, Teresa Heavner, M.D., of Hayesville, N.C., says, "My front office staff grew up in this community and know, or know of, most of my patients. I often see several generations ... the extended family."

The book lists questions to ask about the prospective practice, the medical community, the hospital and your own preferences. Item #R717, the book costs members $7.50.

Tar Wars Talk. This quarterly newsletter features information about the Academy's tobacco education program for grade school children, including spotlights on Tar Wars activities in various states. Tar Wars Talk presents success stories, tips, research and other news. To request the newsletter, call Tom Stewart in the AAFP Scientific Activities Division at (800) 274-2237, Ext. 5538.

You can order most of these items from the AAFP order department at (800) 944-0000.

Power surge: AAFP at AMA

The Academy has eight delegates to the AMA House of Delegates, thanks to about 15,000 AAFP members who have told the AMA, "AAFP is my voice, my choice!"

For the last two years, the AMA has asked its members to name the specialty society that speaks for them -- a way to expand the societies' AMA delegations. Each society within the AMA automatically has one delegate and currently earns another delegate for every 2,000 votes it receives.

Last fall, the AMA decided its members needed to vote only once, unless they wished to change their votes. So votes cast in 1996 didn't need to be repeated. AAFP's total of 14,874 reflects 5,356 votes in 1996 plus 9,518 new votes in 1997, according to the latest information from the AMA. So the AAFP has earned seven delegates via the vote and has a total of eight delegates.

Other societies earned fewer delegates by the vote. Out of 94 specialty societies within AMA, only 18 had more than 2,000 votes; they have earned a total of 34 delegates by the vote.

The graph above shows the medical societies with the most AMA delegates -- AAFP, American College of Radiology and American Society of Anesthesiologists -- and a few other societies -- American Academy of Pediatrics, American College of Obstetricians and Gynecologists, American College of Physicians, American College of Emergency Physicians and American Society of Internal Medicine.

"The response of AAFP members was far higher than the response of members of other specialty societies," said Robert Graham, M.D., AAFP executive vice president. "We're delighted with these results."

By the turn of the century, the AMA will allow a new delegate per 1,000 votes instead of the current 2,000 votes.

Wanted: community preceptors!

The future of the specialty depends on medical students who decide to follow today's family physicians into family practice. And currently, there's an urgent need for more community family physicians to serve as preceptors, to teach students "real-world" knowledge that can't be learned at medical school.

As a preceptor, you can help students ranging from newcomers learning basic history-taking and exam skills, to senior students planning to enter family practice residencies and needing more hands-on clinical experience.

What's in it for you?

"You can share the incredible rewards that come from being a mentor and role model, and give back to the medical profession by shaping the attitudes and the knowledge base of those who will care for your patients in the future."

-- AAFP President Neil Brooks, M.D.

MYTH:
My patients won't like having a student around.

FACT:
Most patients truly enjoy having a student spend time with them. The student may have a chance to practice "therapeutic listening," and the patient can learn from the preceptor's explanations to the student.

Call your local family medicine department, family practice residency or constituent chapter office for more information about preceptor opportunities in your area.

Waging War on Tobacco

AAFP: 'Tobacco companies should be held responsible'

Congress and the president should support comprehensive tobacco control legislation with no immunity for tobacco companies.

That's AAFP's message in the tobacco control debate -- don't shelter the industry from health-related lawsuits.

"Tobacco companies must be held accountable for their wrongdoing," said AAFP Board Chair Patrick Harr, M.D., of Maryville, Mo., in a Jan. 26 news release. "Lawmakers should not be swayed by threats from the tobacco industry to walk away from any tobacco settlement that does not protect them from their victims and from America's courts."

A settlement proposed by 40 state attorneys general and the industry would require tobacco companies to pay $368.5 billion over 25 years for public health programs but would protect the industry from class-action lawsuits, including state suits. Individuals' lawsuits would still be fair game. Congress is considering the settlement and other tobacco control bills.

The Academy contends the proposed settlement doesn't go far enough to reduce smoking. Although the proposal would financially penalize the industry for failing to meet smoking cessation goals for youngsters, the proposal has no penalties related to adult smoking patterns.

"Allowing tobacco companies to simply shift their marketing efforts from teenagers to young adults is dead wrong," said AAFP President Neil Brooks, M.D., of Rockville, Conn., in the news release. "America can't afford to leave this loophole open and let the tobacco industry create another generation of slightly older addicts."

Spreading the message

The Academy is spreading its "no immunity" message in various arenas. For example, on Feb. 17, Executive Vice President Robert Graham, M.D., met with CEOs of other organizations in the 33-member coalition, Effective National Action to Control Tobacco. Graham urged the leaders to move ENACT's policy closer to that of AAFP's no-immunity stance, and they did.

Also on Feb. 17, Former Surgeon General C. Everett Koop, M.D., and Former FDA Commissioner David A. Kessler, M.D., held a press conference to publicize their letter to Congress co-signed by the Academy, the AMA, the American Lung Association, and other health advocacy groups. The letter asserts, "Congress should focus its efforts on public health, not on the concessions the tobacco industry seeks. Comprehensive legislation should not shield the tobacco industry from future liability or cover it with a blanket of financial security for decades to come."

On Feb. 18, Graham and several other ENACT representatives explained the coalition's consensus statement at a congressional briefing. The statement includes:

no marketing to children,

tough penalties for the industry if tobacco use by youngsters does not drop substantially,

funds for international groups to implement tobacco controls,

protection for tobacco farmers and their communities,

full FDA authority over tobacco products and

insistence that any tobacco control legislation must not weaken the rights of victims to seek compensation for their injuries.

Because a bill proposed by Sen. Kent Conrad, D-N.D., the Healthy Kids Act, reflects the above points, the ENACT coalition welcomed its introduction. The administration supports the bill, which would raise cigarette taxes by $1.50 a pack over three years.

Marking progress

Three states have won settlements from the industry -- Mississippi, $62 million; Florida, $11.3 billion; and Texas, $15 billion. Early this year, as Minnesota and Blue Cross and Blue Shield of Minnesota pleaded their case, they introduced documents disclosing the tobacco industry's interest in young buyers and its awareness of nicotine's addictive effects.

On Jan. 30, executives from four of the nation's largest tobacco companies told the House Commerce Committee that nicotine is addictive. Four years ago, the companies' leaders all denied that statement in testimony to the committee.

Reader's Forum

Hospitalist experience interesting

To the Editor:

I have watched with some interest the growing debate over hospitalists versus generalists who do their own inpatient care.

I participated in a group of hospitalists in United and Children's Hospital in St. Paul in 1995-96 while a staff physician at the Westview Clinic (with 11 doctors -- all FPs -- and four physician's assistants at the time). Our group was approximately 20 physicians who did a week on service about every seven to eight weeks. We had several physicians who worked part-time on the service, generally for weekend and night call. Our director generally paired an internist with an FP to facilitate coverage of our Children's Hospital needs.

I personally found the week on the service to be extremely demanding of time and energy, but it focused my hospital skills to a degree not seen since residency. In general, I agree with both the benefits and questions described in President Brooks' Q and A in the January FP Report. However, the hybrid service (both office and hospitalist) made both more interesting.

In addition, I worked part-time in the very busy emergency department of this large teaching hospital. As an ED physician, the hospitalist was a godsend, as the service took all out-of-town and non-staff attendings' admissions. Our director, Dr. Scott Tongen of Woodbury, Minn., and the physicians on the service were careful to notify the personal M.D. at least twice a week routinely and for significant changes in any patient. Some patients did complain about not seeing "their doctor," although I did care for several of my own patients during my several weeks spent in the hospital over the period of 15 months on the service. In general, this version of hospitalism seemed to be a very viable system, largely due to the efforts of the director and the team of hospitalists.

ROLF NALEY, M.D., M.S., Sherman, Texas

More News

Ask health plans to use standard application form

If you're tired of having your staff complete different application forms for you to join managed care organizations, try a new tack: Ask the health plans to use the standardized form of the American Association of Health Plans.

AAHP's standardized form has been requested by about 450 health plans across the country but may not be implemented yet by them. The form, developed last spring with input from groups including the Academy, should help you streamline your paperwork. You can obtain the form at http://www.aahp.org on AAHP's Web site (click on "initiatives") or by calling Susan Probyn at AAHP, (202) 778-3272.

Candidate is announced

The Minnesota AFP announces the candidacy of Jerry P. Rogers, M.D., of Moorhead for the AAFP Board of Directors.

FP REPORT SPECIAL SECTION:
Family-Centered Maternity Care

OB privileges: The battle continues for family physicians

When Robert Gobbo, M.D., decided to move from rural Oregon to Merced, Calif., he hoped to retain his obstetrics and Caesarean section privileges in his new practice.

Keeping current on techniques helps FPs deliver the best possible maternity care and can help them earn their privileges. Mark Deutchman, M.D., of Denver, demonstrates proper suture technique for a perineal laceration repair during the AAFP's Family-Centered Maternity Care conference last summer.
(Photo by Leigh Ann Bathke/AAFP)

That was five years ago. And even though Gobbo's privileges include obstetrics and C-sections, he still feels the tension. He became the first family physician at Sutter-Merced Medical Center to have the privileges.

"I'll admit it was a long process," said Gobbo. "My privileges were negotiated before I got here. And my taking the position was contingent on my having these privileges."

FPs wanting obstetrics and C-section privileges usually face a battle. But studies show that family physicians deliver 20 percent of America's babies, and research shows that mothers and infants who have C-sections performed by family physicians can experience excellent clinical outcomes compared to standard measures of surgical care.

"It is the position of the Academy that clinical privileges should be based on each individual physician's documented training or experience," said Mark Deutchman, M.D., of Denver, who wrote the paper "Caesarean Section in Family Medicine" for the AAFP.

"What a lot of family physicians are facing is a numbers game," said Deutchman. "They are told they can have privileges if they've done some impossibly high number of C-sections. But these numbers don't prove skill. Some physicians are better at acquiring skills than others. The OB-Gyns are trying to set the stick at a different height for FPs to jump over."

Eric Runte, M.D., a California family physician, has taken his fight for obstetrics privileges to the federal courts.

In 1996, Runte filed an antitrust lawsuit against Sonora Community Hospital and three OB-Gyns. Runte directs the Primary Care Clinic at Tuolumne General Hospital in Sonora. Because this hospital doesn't have a birth center, he delivers babies at Sonora Community Hospital.

Robert Gobbo, M.D., negotiated OB and C-section privileges when he moved to a new practice in Merced, Calif. Above: He explains proper ultrasound scanning techniques.
(Photo by Leigh Ann Bathke/AAFP)

Although Runte had completed a family practice residency with training in obstetrics, had performed 110 C-sections and was the primary surgeon for 70 of them, he was denied C-section privileges at the community hospital.

While his application for C-section privileges was pending, the hospital adopted a policy precluding FPs with training in maternity care, including C-sections, from obtaining C-section privileges. The hospital had sought advice from a joint task force of FPs and OB-Gyns, but then refused to follow the task force's recommendation that C-section privileges not be specialty-based.

This February, the attorneys for both sides presented motions to the judge for a summary judgment.

"This means that each party says there are no facts in dispute, nothing for the jury to decide," said Barbara Hensleigh, Runte's attorney. "We're both asking for the judge to apply the law. But the judge can decide for either party or say there needs to be a jury trial."

Hensleigh said she would like to see the case go before a jury. "We want a jury to hear the facts in this case," she said.

A May 12 trial date has been set in the Runte case, contingent on the judge's decision.

"We believe that any policy for privileges should be based on demonstrated competency, training and experience and shouldn't have criteria discriminatory against family physicians," Hensleigh said.

Family physicians wanting to earn obstetrics and C-section privileges need to do careful paperwork. They should keep track of the number of procedures during training and practice, summarize data for each patient, and obtain letters from instructors, preceptors and proctors documenting training, experience, demonstrated abilities and current competence. Deutchman's paper for the Academy is available by calling the AAFP order department at (800) 944-0000 and asking for item #R715.

Family physicians moving to new practice sites should research the policies and procedures for privileging in their new locations.

Although Gobbo made obstetrics privileges part of his negotiations for the job in California, his new family practice department had to work to get those privileges for him.

First they went to the OB-Gyn department for help, but received none. So the family practice department drafted its own criteria, which were approved by the hospital's credentials committee. Then the hospital's governing board approved the plan.

"The OB-Gyns were asked to contribute throughout the process, but most refused," Gobbo said. "As part of the credentialing procedure, I needed to be proctored for three C-sections by an OB-Gyn. One agreed to do it, and my privileges were granted."

Although the governing board of the hospital approved privileges for family physicians, the OB-Gyn department was still uncomfortable with the governing board's decision.

To ease tension between the departments, Gobbo and the head of obstetrics at the hospital tried to hammer out a compromise on paper. The agreement outlines guidelines for family physicians wanting to have C-section privileges.

"The family practice department approved the guidelines, yet the OB-Gyn department was unable to come to a consensus on it," said Gobbo. "I have been in this community now almost five years and have a good relationship with many of the OB-Gyns. However, many still have a serious objection to any family physician having C-section privileges. It is true that this process was not the easy road to take. Without the support of my wife, family and my partners, I don't think I would have been able to do it. I'll admit it was difficult, and processes like this are not something you can do in a vacuum. But it has been worth it to me and our residency program."

Deutchman said there's no excuse for family physicians being treated as second-class citizens at their hospitals.

"I'm saying that FPs with proper training, experience and demonstrable abilities should be able to have C-section privileges," Deutchman said. "And when residents see FPs doing obstetrics, they realize these skills are part of the job."

Gobbo agrees he serves as a role model for residents.

"Residents who come through the programs where the family practice faculty are practicing obstetrics are much more likely to feel confidence in their obstetric skills. They see obstetric skills as part of what they're expected to learn, and are more likely to provide obstetric care when they leave residency," Gobbo said.

Doulas ease patient labor

For family physician Chip Taylor, M.D., doulas during labor and delivery are a necessity. "I've done labor and delivery with doulas and without," he said, "and labor really seems to work better for the patient if there is a doula there."

Doulas are women who support the laboring patient. They don't work as midwives; they aren't nurse practitioners. Doulas serve as labor coaches and advocates for the woman giving birth.

Research shows that the presence of a doula can shorten the duration of labor, says Chip Taylor, M.D., who works with volunteer doulas at the Naval Hospital in Jacksonville, Fla.
(Photo by Leigh Ann Bathke/AAFP)

"Their concern is for the woman -- meeting her needs that aren't clinical," said Taylor, a family physician at the Naval Hospital in Jacksonville, Fla. "Sometimes a husband can get caught up in the moment and not be able to help the patient. Doulas know their job is to help the woman get through labor and delivery."

In fact, 1996 research at Mount Sinai School of Medicine in New York showed that labor can be shortened by 2.8 hours if a doula is present. A 1997 study from the University of California-San Francisco showed not only a reduction in the duration of labor, but also less use of medications for pain relief and fewer operative vaginal deliveries and Caesarean sections. A 1991 study published in the Journal of the American Medical Association said of 412 women studied, the rate of Caesarean sections, epidurals and forceps deliveries among the 212 women with doulas was less than half that of the 200 women in the control group.

Taylor, who first started using doulas about two years ago, asks all his pregnant patients if they want one present during delivery.

"There's a volunteer doula service here," he said. "I explain to my patients what a doula does and how research shows their presence can help cut short labor. Most of my patients request one, even if their husbands are going to be there."

But since Taylor works at a military hospital, having husbands present isn't always possible.

"I had one patient whose husband had been shipped out to Italy," Taylor said. "The doula walked the patient up and down the hall until about 15 minutes before delivery. We were in the room in the final stages of delivery when the patient decided she wanted her husband on the phone. The doula quickly called the base in Italy, and the husband got on the phone line just in time to hear his baby crying half a world away."

Doulas should be one of the main supports for a program of family-centered maternity care, Taylor said. Their purpose is to make the mother feel safe, comforted and supported during labor.

"Family-centered care means there's a difference between delivering babies and birthing babies," Taylor said. "It means a change in philosophy beyond guiding babies down the birth canal."

Doulas offer a continuous presence in active labor. Although nurses may come and go, a patient knows her doula will be there throughout the labor. Doulas offer a comforting touch with encouraging words throughout the birth process.

Sometimes the patient's viewpoint means asking for more medication, not less, and it's the doula's job to see that the patient's wishes are followed.

"I had one patient who came to me because she didn't want an epidural or an episiotomy," said Taylor. "I talked to her about doulas, and she was enthusiastic about having one present."

But once this patient had been in labor awhile, she decided she wanted an intrathecal narcotic at the last minute. It was the doula who went out to find Taylor and tell him about the patient's wishes.

"The doula served as the patient's advocate in this case," Taylor said. "And the patient was grateful. But this kind of collaboration can be threatening if not done appropriately."

Some critics of doulas are concerned that doulas may force their wishes on the patient. Taylor said he's never had that problem with the doulas he's worked with. But the doula-patient relationship works best if the doula gets to know the woman before delivery and supports the patient afterwards.

"A professional doula understands her role," Taylor said. "I've worked with several of them, and they do make the labor and delivery go a lot smoother. Doulas can reduce the need for intervention. A majority of my patients who gave birth with a doula would do it again."

Breast-feeding traditions can't be ignored by anyone in the family ...

Cultured milk

Valerie King, M.D., M.P.H., talks to all her patients about breast-feeding, no matter their gender or their age.

King talks to her younger female patients about the importance of breast-feeding during their well-woman visits. "I want them to be thinking about breast-feeding before they get pregnant," King said.

She tells them research shows women who breast-feed or who were breast-fed have a smaller chance of developing breast cancer.

"I want to avoid the fast-food menu approach to infant feeding," said King. "The choice between breast and bottle is not equal. I want to teach everyone that babies should go to the breast early and often."

For her older female patients, King asks them whether they were breast-fed or whether they breast-fed their children. And she asks whether they encourage their children to breast-feed.

"Grandmothers have a lot of pull in some communities," said King. "I talk to them about the benefits of breast-feeding with hope that they will pass it on to the mothers of their grandchildren."

King will mention breast-feeding when she sees male patients too, especially if their child is in the office for an ear infection or gastroenteritis.

"I mention that they might consider breast-feeding for their next baby to help avoid this type of problem," King said.

The Academy urges its members to acquire and maintain the scientific and practical knowledge related to breast-feeding so they can provide sound guidance to mothers and families regarding its value. The AAFP acknowledges that human milk is the optimal form of nutrition for infants except in instances of specific contraindications to its use.

The American Academy of Pediatrics recently issued guidelines asking women to breast-feed their babies for at least a year.

"Unfortunately, in our culture, breast-feeding isn't something people talk about. They don't see it from a young age. It's not generally done in public, and it's not promoted enough," King said.

What mothers-to-be do hear is misinformation from aunts, sisters, mothers, friends and relatives. Mothers-to-be are told about how much breast-feeding hurts and how they were bottle-fed and came out fine.

Another mixed message new moms receive is from their partners. King said in the United States, breasts are viewed in a highly sexualized way.

"We use breasts to sell cars and chicken wings," said King. "Breasts aren't portrayed as something to feed babies."

When some women want to breast-feed, their partners -- who see the breasts as their property -- get jealous of the infant taking over.

"In the community I live in, the norm for many Latinas is to both breast- and bottle-feed. It starts in the hospital and goes on for a year or more. These women will breast-feed all day long and are happy to do so, so why are they using bottles too?" said King. "It took me a long time to find out why, but for many of them the deal was when the partner comes home, the breasts are his. The bottle comes out when the partner gets home."

Women who work outside the home are often concerned that they won't be able to breast-feed. King helps them strategize the best way to go about it.

"I ask them what their workplace is like. Of course, it's more difficult for women who do not have a private office or who are in a factory-type, blue-collar job to find a place to pump at work," King said.

And if the patient can't pump at work, King recommends that they breast-feed the baby before and after work, with formula feedings in between.

"It's still better for the baby than formula-only feeding," she said. "And for many women, breast-feeding when they get home is a wonderful way to slow down and reconnect with the infant."

FPs can encourage breast-feeding in several ways. Besides talking to their patients about it, they should ensure that their reception area and exam rooms are "breast-feeding-friendly" with posters and pamphlets available to all. And there should be a comfortable place for women to breast-feed.

"The message from us and from our offices should be that breast-feeding is best for mothers and babies," said King.

Family physicians should also serve as a resource, having available a list of phone numbers for the local La Leche League chapter, lactation consultants and the local Women, Infants and Children program.

Teamwork key to FP-midwife mix

To Valerie King, M.D., M.P.H., family-centered maternity care means family physicians and midwives working together.

King, a clinical instructor in the family medicine department at the University of North Carolina-Chapel Hill, first started working with midwives in Siler City, N.C., during medical school. Then she participated in an obstetrics clerkship in Scotland and learned about a midwife-based system.

Valerie King, M.D., of Chapel Hill, N.C., believes the family physician and midwife partnership is invaluable.In medical school, a clerkship in Scotland showed her the pluses of a system that uses midwives.
(Photo by Leigh Ann Bathke/AAFP)

After she returned to America, King said she found the American way of birth rather shocking.

"The system I saw in Scotland trusted women to give birth and didn't interfere unless it was necessary. I have learned about things like alternative positions, massage and whirlpool tubs for pain relief from midwives," said King, who is also a postdoctoral research fellow at the Cecil G. Sheps Center for Health Services Research in Chapel Hill. "The American system is more like the Ford production line, with lots of intervention, much of it not necessary or desirable."

During King's first year on the university faculty, she worked with some of the same Siler City midwives she had encountered during her medical school preceptorship.

The midwives had started a birth center in town called Piedmont Women's Health Center under the auspices of Piedmont Health Services, one of the longest-running community health centers in the United States.

King, along with other family physicians at UNC-Chapel Hill and Piedmont Health Services, helped them develop the center and serves as its primary consultant, on contract from the UNC family medicine department.

The UNC-Chapel Hill residency benefits from the center in several ways:

There's a referral base of patients unable to deliver at the birth center because of risk and insurance status.

The center provides an educational opportunity for family medicine residents to act as consultants for community health providers.

Residents are exposed to a selected population of women and families, many of whom have specific expectations for their birth experience and a high commitment to breast-feeding.

King said midwives are good at understanding where a woman is in her labor, "so women get the level of care they really need. An important part of the midwife's role is to show residents how a midwife can help a patient--and show them how to do the same."

The residency program is also one of the first to have a midwife, Trish Payne, C.N.M., M.P.H., as part of the department. She also has full privileges at UNC hospitals.

"Residents are exposed to a whole new way of pregnancy care and birth," said King. "They learn a lot of low-intervention techniques and alternatives. If you can get a baby out by changing the mother's position, then it's good for the mother and better for the baby. Their box of tricks is more full when they graduate."

Residents participate in an integrated rotation. They take care of women who are due to deliver during the month when the resident will be doing deliveries.

"That way they work with the mother all through the pregnancy. They really get to know their patients," King said. "And the residents see it as part of what family physicians do regularly, not just in the middle of the night."

King said she's had several residents start the program saying they didn't want to do obstetrics, then change their minds.

And the patients love having midwives and family physicians to help them through their pregnancy. King said the volume of pregnant women coming to the family practice center has increased because of the presence of midwives.

In 1996, the Academy adopted a position stating that certified nurse midwives should function only in a collaborative practice arrangement under the direction and responsible supervision of a practicing, licensed physician qualified in maternity care.

Some family physicians worry about whether midwives are competition. King said she hasn't seen that in her community; in fact, just the opposite has occurred.

"I think family physicians and midwives are a natural fit," King said. "They each have skills the other can use. It's a partnership that really needs to be explored."

OUCH!

Help your patients prevent or heal sore nipples

Make sure your baby is sucking the right way; if the sucking hurts, your baby's mouth may not be positioned correctly.

Let your nipples air dry between feedings. Let the milk dry on your nipples.

Use a hair dryer on a low setting to warm and dry your nipples between feedings.

Offer your baby the less sore of your two nipples first; your baby's sucking may be less vigorous after the first few minutes.

Change nursing positions.

If possible, position any cracked or tender part of your breast at the corner of your baby's mouth, so that it gets less pressure during feeding.

Wash your nipples daily with warm water.

Avoid bra pads lined with plastic.

Express milk until your let-down reflex occurs. This will help make your milk more available so your baby sucks less hard.

Breast-feed often to prevent engorgement (overfullness of your breast). Engorgement can make it hard for your baby to latch on.

-- excerpted from Health Notes From Your Family Doctor

FP Report * March 1998* Volume 4/Number 3

The official news publication of the American Academy of Family Physicians. Published monthly by the News Department, Communications Division, for distribution to all AAFP members. Opinions expressed in the FP Report do not necessarily reflect the policies of the AAFP.

Paula Haas Binder, Editor, News Department
Jane Stoever, Managing Editor
Leigh Anne Bathke, Associate Editor
Sharon Dickinson Dent, Associate Editor
Todd Simchuk, Associate Editor
Renee Campbell, Production/Circulation

Address comments and inquiries to the FP Report, 8880 Ward Parkway, Kansas City, MO 64114-2797; fax them to (816) 822-8857; call (800) 274-2237, ext. 4230; or send them to pbinder@aafp.org via electronic mail.

Copyright © 1998 American Academy of Family Physicians. All rights reserved.