Entire Issue - May 1998

May 1998

News for members of the American Academy of Family Physicians

AAFP, ACOG reach consensus

Agreement boosts FP/OB interaction

A new agreement between the Academy and the American College of Obstetricians and Gynecologists reinforces long-standing OB-Gyn training recom-mendations for family practice residents and should help FPs gain OB privileges.

The agreement is twofold: a statement on cooperative practice and hospital privileges, and a revision of educational guidelines for family practice residents.

Photo courtesy of Brian Halpern, M.D.
Disabled veterans and others on the Vietnam Challenge -- a cycling trip across Vietnam-- trek through a fire zone at a former U.S. artillery base. Active land mines were located within 10 yards of the trail, said family physician Brian Halpern, M.D., who led the medical team.

Statement. Health care organizations should create joint practice committees of OB-Gyns and FPs to determine and monitor standards of care and set proctoring guidelines, says the statement.

"Provisional privileges in primary care, obstetric care and Caesarean delivery should be granted regardless of specialty" as long as the physician has the training and experience, the statement notes.

The document calls for common guidelines supported by family physicians and obstetricians on the medical staff of the obstetric unit. "This includes a willingness on the part of obstetricians to provide consultation and back-up for family physicians who provide maternity care. The family physician should have knowledge, skills and judgment to determine when timely consultation and/or referral may be appropriate," the statement explains.

Core educational guidelines. The "Recommended Core Educational Guidelines for Family Practice Residents: Maternity and Gynecologic Care" is similar to the 1980 AAFP-ACOG recommendations, with some updates.

The 1998 and 1980 documents both call for local training committees of FPs and OB-Gyns to develop objectives, monitor residents' experiences and evaluate faculty skills.

"The statement and guidelines should greatly improve cooperation among members of the two specialties," said Daniel J. Ostergaard, M.D., AAFP vice president for education and scientific affairs. "A joint task force of AAFP and ACOG leaders hammered out these understandings over a two-year period."

To order the guidelines and statement, call the AAFP order department at (800) 944-0000 and request item #R202.

AAFP: Stop spread of diseases by IV-drug users

The Academy has joined the chorus of major medical organizations calling for a national strategy to prevent the spread of infectious diseases associated with illicit drug use.

The AAFP Board of Directors was prompted by the Academy's Commission on Public Health to discuss the issue of a federal syringe exchange program.

Marshall Kubota, M.D., a commission member who cares for many HIV-infected patients in Santa Rosa, Calif., said a federal program would exchange --not supply --syringes and needles. Reducing the circulation and sharing of needles can curb the spread of infectious diseases such as AIDS, he said.

"The number one cause of HIV in women is transmission from heterosexuals, most of whom are drug-using men," Kubota said. "If we can reduce the transmission among IV-using men and women, we can also reduce the transmission to newborns."

Kubota said exchanging syringes and needles also provides a point of contact with drug users and an opportunity for education and rehabilitation.

Board Chair Patrick Harr, M.D., of Maryville, Mo., outlined the Academy's position in a letter to Donna Shalala, Ph.D., secretary of the Department of Health and Human Services. The April 1 letter stated, "Six federally funded reports and numerous other scientific studies have concluded that syringe exchange programs reduce HIV transmission and do not encourage drug use. In fact, it was these many authoritative, scientific studies that persuaded the Academy of the appropriateness of supporting syringe exchange programs."

Harr noted that half of all new HIV infections are the result of injection drug use. He also spelled out the Academy's recommendations for components of a federal syringe exchange program. They include:

drug abuse and addiction referral;

HIV testing and counseling;

hepatitis B testing and immunization;

referral for social, health care, mental health and reproductive health services;

processes to assure the safe disposal of exchanged syringes and needles; and

adequate funding for continuity and consistency of syringe exchange programs.

Hospitalist trend gets Academy attention

Buoyed by members' interest and divergent opinions, the Academy continues to look at the trend toward hospitalists and how it might affect the future of family practice.

Director Bruce Bagley, M.D., who chairs the Academy's Task Force on Hospitalists, said he's found the controversy over designated inpatient physicians to be less than cut and dried.

"The trouble is, the hospitalist trend is a mixed bag," said Bagley, of Latham, N.Y. "Some members who use hospitalists are thrilled by the idea of being free from hospital rounds. Others are afraid family physicians will be excluded from hospital care."

The task force, which was created at the urging of AAFP President Neil Brooks, M.D., of Rockville, Conn., met in January and presented its list of recommendations to the Board in March.

Among the recommendations approved by the Board was the distribution of a free informational report -- including a monograph from the California AFP -- to interested members. Academy members can get a copy of the report by calling the order department at (800) 944-0000 and requesting item #R718.

"I want to caution concerned members that the hospitalist idea is not a monolithic trend," said Bagley. "There are many hospitalist models being tested, including one in Boston where a family practice department has a hospitalist rotation made up of internists and family physicians."

Bagley also cited the example of four family physician partners who choose to rotate hospital coverage of the practice's patients by spending one week out of four in the hospital.

"This is something that's been going on for decades; it's just been given a new definition," said Bagley.

In the report, the task force outlined major issues of concern to the AAFP, including the impact of hospitalists on:

quality of patient care,

professional/lifestyle issues,

the mandatory vs. voluntary nature of such a system,

reimbursement and health care resources,

patient satisfaction, and

professional interaction and continuing medical education.

The Board also approved funding a sample survey of AAFP members to determine how the hospitalist idea is affecting FPs and their patients nationwide. The survey will include questions concerning the degree of participation in a hospitalist system, whether FPs are being excluded from the experimental models, and the degree to which physician choice is resulting in relinquishing inpatient privileges.

The hospitalist task force will continue to collect information for the 1998 Congress of Delegates, Sept. 15-17 in San Francisco.

News from Headquarters

ALSO expands international exposure

In its quest to better prepare physicians around the world to handle obstetrical emergencies, the Advanced Life Support in Obstetrics (ALSO^®) program held its first international advisory board meeting Feb. 2-3 in Charleston, S.C.

One key action of the board was creation of the ALSO International Subcommitee, which includes representatives from the Uniformed Services AFP and the ALSO advisory boards in the United States, Canada and the United Kingdom. The subcommittee will share ideas, assist other international health organizations to set goals, and possibly develop a model curriculum for ALSO courses in Third World countries. It will meet about every 18 months.

The advisory board also agreed to:

set up a database with information about ALSO advisory faculty who are bilingual or who are interested in traveling outside the United States to teach international courses,

submit articles about ALSO for publication in U.S. and international journals, and

draft a detailed report on ALSO's international exposure and activities for presentation at the AAFP's Commission on Continuing Medical Education meeting later this month.

ALSO courses already have taken place in Canada, England, Turkey, Spain and Paraguay, and the advisory board discussed proposals for courses in even more countries, including Haiti and Nepal.

Diana Winslow, the Academy's ALSO manager, said the first international board meeting forged a professional bond among the United States, United Kingdom and Canadian leaders. "The ALSO program will be a major part of the international expansion and dissemination of AAFP programs, and family practice in general," she said.

The two-day ALSO course teaches methods of handling obstetrical emergencies, such as malpositions/malpresentations and shoulder dystocia. In addition, ALSO instructor courses train health care professionals in faculty development and specific teaching skills required for didactic lectures and workshops.

For more information on ALSO, contact Winslow by e-mail at dwinslow@aafp.org or by phone at (800) 274-2237, Ext. 5350.

Available on AAFP Express

Call the AAFP Express toll-free number -- (800) AAFP EXP [223-7397] -- and supply your AAFP ID number to have selected materials sent almost immediately to your fax machine for free. Some documents available:

Description of Document
Document #

Weekly "Washington Update" 8009

Order form for Buckle Up America! action kit 9000

Fundamentals of Management application 8000

NCFPR/NCSM information sheet 2011

Applications and grants for scholarships and grants to the Conference on Patient Education 7003

Information and registration forms for:

Family Practice Board Reviews

June 7-13, Seattle

2005

WONCA (World Organization of Family Doctors) 15th World Conference

June 14-18, Dublin, Ireland

3007

Family-Centered Maternity Care

July 22-26, Minneapolis

2010

ALSO (Advanced Life Support in Obstetrics) Instructor's Course

July 21, Minneapolis

2014

Geriatric Medicine

Oct. 15-18

2002

Infant, Child and Adolescent Medicine

Oct. 28-Nov. 1, Portland, Ore.

2012

Feedback shows members disagree on hospitalist issues

Two unscientific gauges of AAFP members' concerns point to one conclusion: Members are divided on hospitalist issues.

A mini-survey in the February FP Report, which drew responses from 110 members, asked, "What impact do you think the trend toward hospitalists will have on your practice?"

"Positive," said 54 responding members; "negative," said 39; "undecided," said 17.

Here's a sampling of comments members wrote on the mini-survey:

"I just don't feel it's good medicine to turn over the care of our patients to someone else at the most stressful and scariest episodes of their illnesses."

"I chose to quit hospital work and am more productive in the office."

"If we give up our hospital-based practices, what is to separate us from nurse practitioners in the eyes of third-party payers and the public, other than their lower costs?"

"I practice at a tertiary-care hospital. The standard of care and newest interventions are constantly changing, requiring almost daily revisions. I take inpatient call for my group of six 50 percent of the time, so call me a pseudo-hospitalist."

"I'm tired of hospital care."

"It's hard to teach and provide continuity of care in an atmosphere that promotes drop-offs."

Out of 110 mini-survey respondents, six are hospitalists and another two are part-time hospitalists. Forty-eight respondents said their practices are already affected by the hospitalist trend.

The Feb. 27 "President's Letter" from AAFP President Neil Brooks, M.D., of Rockville, Conn., also asked members for feedback on hospitalists and other issues. Out of 792 members who returned business reply cards with their comments, 328 focused on hospitalist issues. No other topic received nearly as much attention.

Those opposed to the use of hospitalists numbered 108, while 86 were neutral, often mixing pros and cons, and 134 generally expressed support, though sometimes with reservations.

Tobacco Policy Yardstick

Information is from AAFP tobacco media kit.

To help American families, final legislation must measure up to the following criteria:

End tobacco use by children, with a specific timetable and stiff financial penalties for tobacco companies if they fail to meet targeted reductions.

Reduce tobacco use by adults. The tobacco industry must not be allowed to shift its advertising and marketing practices from teens to young adults.

Allow victims to seek reparations with no legal immunity for the tobacco industry.

Require full disclosure of all documents related to the harmful effects of nicotine.

Ensure that the Food and Drug Administration has unrestricted authority to regulate all tobacco products.

You can help!

Academy urges action on tobacco legislation

Despite the tobacco industry's withdrawal from legislative negotiations, the Academy is encouraging Congress to continue working for a comprehensive tobacco control bill. A strong grassroots campaign and a new AAFP media kit could help convince lawmakers to move forward with real reform.

Help clear the smoke. Contact your representatives in Congress and let them know how tobacco has hurt your patients. Remind them that tobacco kills more than 400,000 Americans every year, and more people die from tobacco use than from AIDS, alcohol, car accidents, murders, suicides, drugs and fires combined. Tell lawmakers that you oppose their use of tobacco industry money to fund campaigns and you support strong legislation that targets youth and adult tobacco use. For information on contacting your representatives, call the AAFP Washington Office toll-free at (888) 794-7481.

Media education. The Academy's new tobacco media kit will be distributed to local and regional media in the Washington area to provide them with details on the tobacco debate.

The kit includes provisions the AAFP believes are essential for tobacco legislation (see Tobacco Policy Yardstick at right), and it encourages reporters and editors to use the Academy as a source of reliable information. The kit also features a useful historical perspective with quotes from tobacco industry leaders.

Free campaign kit, newsletter address public health issues

Seat belts save lives. Youth drinking can destroy lives. Educate yourself and your patients about the importance of buckling up and the dangers of alcohol consumption by young people. Here are two free resources to help:

Buckle Up for Love!

Buckle Up America! The AAFP is participating in the President's Initiative for Increasing Seat Belt Use Nationwide. Goals set by the initiative include increasing seat belt use to 85 percent and reducing child fatalities by 15 percent by the year 2000.

To assist in this effort, the National Highway Traffic Safety Administration is offering Buckle Up America! action kits. Each kit contains resource materials to help organizations and individuals interested in starting Buckle Up America! campaigns in their area.

You can request a kit by writing to the National Highway Traffic Safety Administration, NTS-21, 400 Seventh Street SW, Washington, D.C. 20590. Or get an order form by using AAFP Express (see box on page 2).

Alcohol Alert. Despite a minimum legal drinking age of 21, many young people in the United States consume alcohol. The latest issue of a free newsletter, published by the National Institute on Alcohol Abuse and Alcoholism, can help you stay informed about the risk factors and consequences of youth drinking.

You can subscribe to Alcohol Alert, which is published quarterly, by sending your request to the NIAAA Publications Distribution Center, Attn: Alcohol Alert, P.O. Box 10686, Rockville, Md. 20849-0686.

Alcohol Alert also can be accessed at http://www.niaaa.nih.gov on the World Wide Web. This site provides the full text of Alcohol Alert bulletins and other selected documents, access to the online alcohol research database, and content and order information for the journal Alcohol Health & Research World.

AAFP issues official call to Congress of Delegates

Pursuant to Chapter IX of the AAFP Bylaws, notice is hereby given of the 51st annual meeting of the Congress of Delegates. It will be held Sept. 15-17 in the San Francisco Marriott.

The Congress will open at 7:30 a.m. Sept. 15. Delegates, alternates and other attendees may register in the ballroom foyer from 4 to 7 p.m. Sept. 14 and from 6:45 a.m. to 5 p.m. Sept. 15. AAFP members are encouraged to participate in the Sept. 15 and 16 reference committee hearings, where issues are debated before being considered by the full Congress.

The 50th Annual Scientific Assembly will be held Sept. 16-20 at the Moscone Center in San Francisco. Participants may register at the following times at the center for all Scientific Assembly events: from 2 to 6 p.m. Sept. 15, from 7 a.m. to 6 p.m. Sept. 16-18, from 7:30 a.m. to 5 p.m. Sept. 19, and from 7:30 a.m. to noon Sept. 20.

Robert Graham, M.D.,
AAFP Executive Vice
President and Secretary
to the Congress of Delegates

New document provides guidance on PSNs

Are you thinking about developing or entering a physician-sponsored network? If so, check out the Academy's new set of guiding principles on PSNs -- businesses that are organized and owned by networks of independent physician practices to pursue managed care contracts and other ventures.

The "Preamble and Guiding Principles for Physician-Sponsored Networks" was developed by the AAFP Commission on Health Care Services, which has studied PSNs for about two years, and approved by the AAFP Board of Directors. The commission found that the risks and opportunities for family physicians entering PSNs vary greatly across geographic markets, as do organizational models.

The principles cover topics such as optimal health outcomes for patients, efficient delivery of care, family physicians' expertise in managing care and their focus on preventive health, clinical autonomy for network physicians, physicians' equity and the need for PSNs to demonstrate their value in order to obtain contracts with health plans.

If you would like a copy of the principles, call the order department at (800) 944-0000 and request item #R737.

Manual gives men health tips

National Men's Health Week, June 7-13, is an opportunity to get the attention of your male patients and educate them about common male health issues.

AAFP members can receive 50 free copies of the new "Men's Health Maintenance Manual," produced by Men's Health magazine in cooperation with the AAFP. The manual includes information on topics such as nutrition, stress, physical fitness, disease-prevention strategies, hair loss and sex.

To order your copies, contact Helen Worthley at (800) 274-2237, Ext. 4205.

FP leads medical team across Vietnam

Bicycling trip helps veterans heal emotional wounds

As a family physician emphasizing sports medicine, Brian Halpern, M.D., has witnessed the power of sports to infuse disabled athletes with confidence and strength.

FPs Bob Duncan, M.D., left, and Brian Halpern, M.D., in Vietnam
Photo courtesy of Brian Halpern, M.D.

On his latest endeavor, he saw the events of the Vietnam War through the eyes of disabled veterans and watched a cycling trip reveal the depth of the human spirit.

In January, Halpern, of Colts Neck, N.J., was medical director for the Vietnam Challenge, a 1,200-mile, 16-day bicycle ride from Hanoi to Ho Chi Minh City. Participants included about 35 Vietnam War veterans from the United States -- most of whom were disabled -- as well as about 15 able-bodied and disabled Vietnamese veterans and 30 staff members.

World T.E.A.M. Sports coordinated the event as part of its ongoing effort to encourage and develop opportunities in sports for all people, particularly those with disabilities. (T.E.A.M. stands for The Exceptional Athlete Matters.)

The U.S. veterans hadn't returned to Vietnam since the war, and their reactions upon seeing the country again affected the whole team, Halpern said.

"The first week, all 80 members of our team were crying frequently because of the emotional trauma and humanity we were experiencing with the veterans," he said. "They would visit places where they lost their limbs, and they would recount the stories of how it happened. It was so real, it was as if we were still fighting 30 years ago, living their experiences with them. For one reason or another, being back in the country with people they didn't know very well allowed them a cleansing opportunity."

Most medical care sought by team members was relatively minor: concussions, bumps and bruises, infectious diarrhea. But Halpern and his medical staff sprang into action when a team member suffered acute chest pain.

A two-part documentary about the Vietnam Challenge will air on NBC May 23 and 24.

"We'd prearranged evacuation points and evacuation teams in the off-chance that we had an emergency like this," he said. "The Vietnamese doctors helped us out tremendously in a town called Hue. We managed him with IV morphine and nitroglycerine in the intensive care unit. We also brought our own defibrillator, so that was charged and ready to go. We stabilized him and shipped him out to Singapore. It was an eight-hour ordeal, but he made it."

The team cycled 50 to 120 miles each day. At several stops along the route, they offered medical and educational outreach. Halpern and family physician Bob Duncan, M.D., of Bel Air, Md., joined other medical personnel to tour hospitals, examine patients, make treatment recommendations and lecture to Vietnamese physicians on evaluation and treatment of musculoskeletal injuries. Halpern and World T.E.A.M. Sports also helped establish a thermoplastic-orthotic rehabilitation clinic in Hanoi, which serves disabled Vietnamese.

Halpern recalled one particularly moving experience that occurred during an educational outreach program at a Vietnamese school. An 18-year-old girl approached Jerry Stadtmiller of San Diego, a veteran "who had his face rearranged by an AK-47 and was totally blind," Halpern said. The girl asked Stadtmiller what was the one thing he remembered about the war.

"Jerry is a very sincere guy," Halpern said, "so with tears in his eyes, he said, 'I hate to admit this, but the one thing I remember is running through the rice paddies with gun in hand and shooting anything that moved -- man, woman or child -- because otherwise I would be killed.' So she went over to him, gave him a hug and said, 'The war is over.' The whole place just fell apart. It was incredible."

Among Halpern's other highlights from the trip:

Cycling with Greg LeMond, a professional cyclist who serves on the World T.E.A.M. Sports board of directors.

Going with Sen. John Kerry, D-Mass., to a restaurant that the senator frequented as a soldier during the war. Kerry joined the Vietnam Challenge team for the last two days of the trip.

Climbing the Hai Van Pass, which is a 10-11 percent grade for six miles going from zero to 3,300 feet above sea level, in about 95-degree temperatures.

Physicians With Heart seeks travelers to Siberia

Each year since 1993, AAFP members have served as ambassadors of family practice to former Soviet republics.

As part of the Physicians With Heart delegations, more than 40 family physicians, have traveled to sites as eclectic as St. Petersburg, Russia and Tbilisi, Georgia. Through the airlift program, delegation members have distributed more than 160 tons of medical aid worth more than $40 million.

Join the 1998 airlift!

This year's project will deliver pharmaceuticals and medical supplies to Siberia in early October and organize a second shipment of supplies to Uzbekistan in the spring of 1999. If you want more information about joining AAFP President Neil Brooks, M.D., and the rest of the delegation to Siberia, contact Kirsten Harrison at (619) 687-0343. If you have medical supplies to donate, contact Barb Nielson at (913) 764-5200.

This year, Physicians With Heart -- a joint venture of the Academy, AAFP Foundation and the humanitarian organization Heart to Heart International -- has turned its sights toward Siberia.

"After our successful trip to Georgia, the State Department asked us to consider Novosibirsk and Akademgorodok in Siberia for this year," said Barbi Moore, senior vice president of Heart to Heart International. "We visited and found they need food, fuel and medicines."

Currently, Physicians With Heart is looking for AAFP members and other health care workers willing to work for a chance to see a part of the world they might otherwise never experience.

Daniel J. Ostergaard, M.D., AAFP vice president for education and scientific affairs, has traveled with every airlift. "Family practice residents, medical students, dentists, nurses and others involved with health care are invited as well as FPs and their spouses. Everyone ends up with a task that is meaningful and helpful to the project," he said.

Ostergaard said members of the delegation will travel to several hospitals and clinics in Siberia, assuring that the medical supplies reach their destinations.

"It's also part of our task to provide practical clinical information regarding the use of the pharmaceutical products and medical supplies being distributed," he said.

Delegation members also discuss family practice as a specialty and provide an overview of family practice throughout the world to doctors in the host country.

"In many countries of the former Soviet Union, the concept of family practice is extremely new, and we are often greeted by a mixture of great interest and skepticism about the breadth of our specialty," said Ostergaard. "This is our chance to show what family physicians can do. We prove that they need doctors like us."

Reader's Forum

Preserve OB privileges

To the editor:

In my opinion, the American Academy of Family Physicians, as well as all state and local Academy chapters, must contrive to ensure family physicians retain obstetrical and nursery privileges in all hospitals.

I have had the honor of delivering nearly 4,000 babies and following up with well-baby and sick-baby care. Many of these deliveries were second-generation births. It was most gratifying to give continuity of care from pregnancy to adulthood. In my opinion, this is what family practice is all about. I urge all family physicians to fight for full obstetrical and pediatric privileges in their local hospitals.

MARVIN E. PRIDDY, M.D.
Ft. Wayne, Ind.

Satcher detractor

To the editor:

I recently read the FP Report in which David Satcher's confirmation for surgeon general was hailed as a great victory for the AAFP. Have we become so desperate to be represented in Washington that we would laud the appointment of a man guilty of unnecessary deaths in a supposedly double-blind medical study and who supports partial-birth abortions? What message does this send to family practice residents and to the American people who have high regard for the family doctor? If you have attempted to raise the stature of family practice, you have failed miserably.

SIGURD S. DAEHNKE, M.D.
Winfield, Kan.

Editor's note: Dr. Satcher concurred with President Bill Clinton's refusal to sign a bill banning late-term abortions because exceptions were not made for the health of the mother. He approved a Third World azathioprine study that was criticized in a New England Journal of Medicine editorial; two NEJM editorial board members resigned in protest of the editorial.

Candidates

The Wisconsin AFP announces the candidacy of Richard G. Roberts, M.D., J.D., of Madison for re-election as AAFP speaker.

The Louisiana AFP announces the candidacy of Michael O. Fleming, M.D., of Shreveport for re-election as AAFP vice speaker.

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