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1999 Post-Assembly Edition - FPR

October 1999

Academy begins national research network

The AAFP Congress of Delegates, which met Sept. 14-16 in Orlando, Fla., adopted without question a Texas AFP resolution for the AAFP to develop the internal infrastructure necessary to support a national family practice office-based research network. Delegates also accepted the Board of Directors' report on plans for an AAFP practice-based research network.

According to the Board report, the network's mission will be to conduct, support, promote and advocate primary care research in practice-based settings that (1) addresses questions of importance to the discipline of family medicine and (2) improves health care delivery to and health status of patients, their families and communities.

The new network will maintain a spirit of cooperation and collaboration, providing technical support and advocacy as needed for existing and developing chapter and member networks.

The Ambulatory Sentinel Practice Network recently announced that because of financial difficulties, it would close by the end of the year after wrapping up existing projects. Faced with the void created by ASPN's demise, the Academy's Board of Directors decided Aug. 28 to establish a new network.

The Board action is the latest to demonstrate AAFP's commitment to primary care research, said outgoing Board Chair Neil Brooks, M.D., of Rockville, Conn. "This will accomplish two important things. It will give high priority to office-based research, and it will give family physicians exposure to the importance of research. Supporting and promoting office-based research are key strategies for helping AAFP members provide patients with the best possible care."

The network will be phased in over three to five years, and staff will work in the AAFP Scientific Activities Division at the new headquarters building in Leawood, Kan. More information will be available later this month, when the AAFP will begin recruiting ASPN practices and other researchers to join the network.

Family physician John Beasley, M.D., of Madison, Wis., who chairs the Federation of Practice-Based Research Networks steering committee, said the Academy's network will continue the momentum started by ASPN by generating interest and enthusiasm among participating family physicians, providing support and advocacy for research and researchers, and ensuring the constant flow of researchers and funded projects. "We are extremely pleased to see the AAFP pick up this critically important centerpiece for research in the discipline," he said.

The Academy is encouraging family practice researchers to attend ASPN's 1999 Convocation of Practices Dec. 1-4 at the Cheyenne Mountain Conference Resort in Colorado Springs, Colo. The convocation will focus on the theme "Doctors and Patients in the Changing Health Care Environment."

The convocation will include sessions to discuss ongoing research, results of completed research and ideas for new research.

Beasley said the convocation will feature "a clear hand-off from ASPN to the Academy. This meeting is really going to draft the future for the overall enterprise of research in family practice."

For more information on the ASPN convocation or the AAFP's research initiative, call the AAFP Scientific Activities Division at (800) 274-2237.

colposcopy workshop
Instructor E. J. Mayeaux Jr., M.D., of Shreveport, La., helps Paula Silha, M.D., of Spokane, Wash., during a colposcopy procedures workshop at the 1999 Scientific Assembly in Orlando, Fla. Hurricane Floyd's threat caused Assembly to open a day late but still with many opportunities for CME.

Assembly survives Hurricane Floyd

For the first time in its 51-year history, the AAFP Scientific Assembly got under way a day late when Hurricane Floyd neared central Florida and threatened to wreak havoc on Orlando. Airport closings and storm preparations led to a shortage of program speakers and local laborers, shutting down the Assembly on its first day, Sept. 15.

Despite the setback, almost 4,500 physicians braved the storm to attend the convention. Final figures weren't available, but at press time registration for physicians and guests totaled 9,060. More than 3,100 exhibitors also made it to Orlando for the Assembly.

The degree of AAFP Fellow was awarded to 490 family physicians at the annual Fellowship Convocation. The degree recognizes service to family medicine, advancement of health care to the American people, and professional development through medical education and research.

Because more than a day of CME and other activities was canceled, members and AAFP staff scrambled to rearrange schedules. "We really appreciate members' patience as they weathered the storm with us," said EVP Robert Graham, M.D.

Bylaws amendments streamline process for belonging to AAFP

The Academy just simplified its membership process. New AAFP Bylaws changes, adopted by the Congress of Delegates Sept. 14-16 in Orlando, Fla., support "seamless membership," and a far-ranging plan reviewed by the Congress promotes a "once a member, always a member" culture.

Bylaws amendments. On completion of residency training, resident members will automatically become active members. (That's right -- no application needed.) Residency graduates who relocate will automatically transfer to their new chapters (again, no application needed).

New student members will have a one-time dues payment for the duration of their student membership. Current student members who have already paid dues will not need to pay more dues as students.

To speed up the process for joining the AAFP, designees of chapter boards may approve membership applications. In addition, the AAFP Board may delegate its authority to waive or reduce dues.

Other aspects of plan. The Membership Master Plan for Satisfaction and Retention has a plus for members new to practice. National dues will be reduced by $200 in the first year of practice, $125 in the second year and $75 in the third year.

The plan lists specific strategies to gain and retain members. A sampling: Bring together members with similar interests. Solicit members' input on key issues. Contact members in jeopardy of losing their membership. Educate employers, especially HMOs, about the value of AAFP membership. Ensure an Academy-wide commitment to customer service. Use research data in developing new member services. Monitor the effects of generational issues on the use of AAFP products and services.

New AAFP officers, directors installed at Assembly

Bagley
Bruce Bagley, M.D.,
Albany, N.Y.
President

roberts
Richard Roberts, M.D., J.D.,
Madison, Wis.
President-elect

fleming
Michael Fleming, M.D.,
Shreveport, La.
Speaker

lopez
Carolyn Lopez, M.D.,
Chicago
Vice Speaker

birkholz
Karla Birkholz, M.D.,
Glendale, Ariz.
Director

dibble
Burton Dibble, M.D.,
Kingston, N.H.
Director

vandurme
Daniel Van Durme, M.D.,
Tampa, Fla.
Director

meyers
David Meyers, M.D.,
Washington, D.C.
Resident Director

duane
Marguerite Duane,
Stony Brook, N.Y.
Student Director

White House event on health policy features talk by outgoing AAFP president

Outgoing President Lanny Copeland, M.D., of Albany, Ga., was one of three speakers at a White House event on health policy Sept. 8. He shared the podium with President Bill Clinton and Donna Shalala, Ph.D., secretary of the Department of Health and Human Services.

Copeland won applause from reporters and others at the White House when he said, "Communication between physicians and patients should never be restricted by health plan gag clauses. If I can't talk to my patients about their options, that's bad medicine!"

He added, "I took a solemn oath when I started practicing medicine to put my patients' interests first, and I believe in that oath. Health plans should not second-guess my expertise by capriciously denying appropriate medical care."

Referring to Medicare, Copeland said, "As we make the program financially secure, we can add other benefits in a fiscally responsible way -- benefits like prescription drug coverage. I do not want to keep worrying about patients who never have their prescriptions filled because they cannot afford to."

Copeland's words won praise from President Bill Clinton. Clinton said he has tried to bring people to the White House who have firsthand experience with the problems facing many Americans -- to bring more of America to Washington, D.C. "Dr. Copeland, I don't think anybody's ever done a better job than you have of bringing here the health care challenges of ordinary people from all walks of life on a day-to-day basis," Clinton said.

Herbal therapies: Are they good medicine if used properly?

Assembly speaker discusses specific herbal therapies that are popular with consumers

An estimated 60 million Americans use herbal medicines every year, spending more than $3 billion annually on the botanical products. At least a third of these people never tell their physicians they are taking alternative medicines, despite the fact that herbals can cause side effects, interact with prescription drugs and mimic other illnesses.

Are herbal remedies safe and effective medicines or just the subject of old wives' tales? Raul Zimmerman, M.D., associate director of the Halifax Medical Center Family Practice Residency Program in Daytona Beach, Fla., said many herbals can be good medicines if used properly. He spoke at a Sept. 16 Assembly clinical seminar on herbal therapies in Orlando, Fla.

A 1997 Journal of the American Medical Association article found that ginkgo modestly stabilized mild to moderate dementia by improving memory.

Americans take herbal medicines for various reasons. Many believe that because herbs are natural, they are safe. Or they think that conventional medicine is too technical, impersonal and expensive, and may have certain fears about prescription drugs due to highly publicized recalls, such as the withdrawal of fen-phen from the market.

Herbal medicines have been used for thousands of years by native cultures around the world, Zimmerman said. In many poor countries today, herbals are the only affordable medicines. Native Americans have a long tradition of using herbs for medicinal purposes, and Europeans brought herbal remedies from their homelands to the United States.

However, the widespread abuses engendered by snake-oil salesmen and other quacks in the 19th century patent medicine era led to the establishment of the Food and Drug Administration and strict regulation of drugs in America, he said. But herbals are not regulated by the FDA as long as they are sold as food supplements.

Under the 1994 Dietary Supplement and Health Education Act, herbal products may go to market without testing for efficacy and without proof of safety. To remove an herbal remedy from the market, the FDA must show that it is harmful and ineffective, Zimmerman noted. Manufacturers and marketers of herbal products must not, however, claim that the product can cure or prevent disease. Nonetheless, labels may describe how the supplement may affect a body structure or function.

Zimmerman discussed specific herbal therapies that are popular with consumers, including these:

Take the challenge

Make electronic communications part of your daily office routine

Just as the car and the telephone moved family physicians from house calls to office visits, e-mail and electronic medical records will change the way FPs deliver health care in the 21st century, Joseph Scherger, M.D., said in his Assembly lecture about "Family Practice in 2010" Sept. 18 in Orlando, Fla.

"Health care in America is ripe for a radical change in how we deliver it. FPs must seize this communication opportunity to avoid being marginalized in the future," said Scherger, professor and chair of the family medicine department at the University of California-Irvine College of Medicine. He recently became editor-in-chief of Hippocrates magazine.

"I challenge each and every one of you to give your e-mail address to patients when you get home from Assembly," he said. "Ask patients to send you information and updates. If you don't have electronic medical records, then print out the e-mails and store them in the patient's record. Begin a process your patients will appreciate deeply."

Scherger, who communicates with patients daily via e-mail, outlined three enabling factors to move family practice into the new world of health care communication.

Antibiotic resistance emerging as major public health problem

More must be done to control the growth of antimicrobial resistance among community-acquired pathogens, and family physicians can play an important role in this campaign, according to Benjamin Schwartz, M.D., deputy director of the Epidemiology and Surveillance Division, National Immunization Program, Centers for Disease Control and Prevention.

"The emergence of antibiotic resistance, a consequence of widespread and inappropriate antibiotic use, is a significant and troubling infectious disease threat," Schwartz said on his Assembly lecture Sept. 17 in Orlando, Fla. He announced a national campaign initiated by the CDC to promote more judicious use of antibiotics.

"I have subtitled my lecture 'An Individual Response' because this is a problem that every individual health care provider must face," he said.

He emphasized that FPs should be concerned about this problem because:

Abuse of antibiotics has resulted in resistant nosocomial infections, resistant foodborne infections and resistant community-acquired infections, Schwartz said. Population-based surveillance has indicated that in some areas of the United States, more than 30 percent of pneumococci strains are not susceptible to penicillin, with more than half of these being highly resistant.

"Resistance is a global problem," he said. "With international travel so common today, any of the selection of resistant pathogens plaguing various parts of the world could be presented to you in your office at any time."

Studies indicate that in recent years, some 75 percent of all outpatient antibiotic prescriptions in the United States have been issued for five conditions: otitis media, acute sinusitis, bronchitis, pharyngitis and the common cold.

"With international travel so common today, any of the selection of resistant pathogens plaguing various parts of the world could be presented to you in your office at any time."

--Benjamin Schwartz, M.D.

The CDC's campaign to decrease unnecessary prescribing focuses on educating both the public and health care providers, Schwartz said. Campaign strategies are to improve patient compliance with antimicrobial therapy, to improve antibiotic selection and dosing by physicians, and to decrease the overall use of antibiotics. At several demonstration sites, he said, active promotion of recommendations for diagnosis and management of respiratory infections and use of patient education materials have led to a 20 percent decrease in antibiotic use.

"Physicians often report that they are pressured by patients to prescribe unnecessary antibiotics," Schwartz said. "Therefore, an improved understanding by the general public, as well as a realization by physicians that patient satisfaction does not depend on prescribing an antibiotic, should help physicians in their efforts to restrict the overuse of antibiotics."

Rates of antimicrobial drug use are highest in children, Schwartz noted. Also, high income has been shown to be a significant risk factor for antibiotic-resistant infections, he said, a fact most likely related to access to health care.

"One key to judicious use of antibiotics is to make an appropriate distinction between acute otitis media and otitis media with effusion, and to use shorter courses of antibiotic therapy in uncomplicated cases of otitis media," Schwartz told the FPs.

Also, he said, prophylaxis for otitis media should be limited to recurrence, defined as three or more distinct and well-documented episodes every six months or four or more episodes every 12 months.

"The CDC has estimated that following principles for judicious use of antibiotics would prevent some 50 million unnecessary antimicrobial prescriptions annually in the United States," he said.

Schwartz pointed out that research data from other countries, and research on nasopharyngeal carriage of resistant pneumococci in the United States, suggest that reducing the spread of resistant bacterial pathogens through appropriate use of antibiotics is possible.

"The battle can be won," Schwartz said. "By using antibiotics more judiciously and by selecting treatment regimens that are less likely to select for resistant strains, trends in antimicrobial resistance can be changed or even reversed."

Assembly keynoter David Broder ponders health care policy

David Broder
Budget caps in Congress create obstacles for health care policy, David Broder explains in his keynote address.

The prospects are bleak for any substantial action on health care policy in the U.S. Congress this year, according to Pulitzer Prize-winning columnist David Broder, who presented the Assembly keynote address Sept. 16 in Orlando, Fla.

It was believed that once the impeachment furor subsided, Congress would take a little time to recuperate and then get down to business after the August recess, said Broder, a national political correspondent for The Washington Post. "The reality is that it's not happening." With just two weeks left in this fiscal year, most 2000 appropriations bills have yet to reach the president's desk, he said.

Health care faces the additional obstacle of being lusted after by Democrats interested in framing the 2000 campaign and being dismissed by Republicans who don't want to hand any victories to a lame-duck president. But the gridlock extends beyond the beltway, Broder explained.

"This country -- not just this government -- is as closely balanced between Republican and Democrat as it has ever been," he said. "The public is equally attracted or equally distrustful of both parties. It's not simply partisan sniping but a fundamental disagreement on public policy."

The issues of cost, quality, access and long-term care simply aren't getting the attention they deserve on Capitol Hill, Broder said, quoting Donna Shalala, Ph.D., secretary of the U.S. Department of Health and Human Services, who said, "We have a dysfunctional system in health care in this country."

"She is right," said Broder, "but the chances that we are going to see politicians step up to that systemic challenge are not very good."

Good communication is sign of good medicine for FP of the Year

Family Physician of the Year
Family Physician of the Year Harry Depew, M.D., of San Diego uses American Sign Language during his speech to the AAFP Congress of Delegates on Sept. 14.

The Academy's 2000 Family Physician of the Year opened his speech to the Congress of Delegates Sept. 14 in Orlando, Fla., with a few comments in sign language. "If you were a hearing person in a deaf world, where you could not understand sign language, how would you feel communicating with your doctor?" he asked out loud.

Harry Depew, M.D., of San Diego grew up in Los Angeles with deaf parents and two deaf sisters, so the family communicated using American Sign Language. He's among just a few San Diego physicians who can care for members of the deaf community without using a translator.

"I hardly think of them as deaf patients," he said. "I just talk to them like I would with hearing patients. By signing, we can communicate much better than with written messages. When people talk, we talk with inflection. Well, they put inflection into sign."

Deaf patients often seek out his practice because they know Depew can sign. But occasionally, new patients will show up for an appointment unaware. When the doctor greets them in sign language, "a great big smile breaks out across their faces," Depew said. "Being able to sign improves communication, and any time you improve communication in the exam room, you will help them get better health care."

Depew represents the California AFP on the state's Advisory Group for Newborn Hearing Screening Program. "Recent research shows infants with hearing loss who have appropriate diagnosis, treatment and early intervention services initiated before they are 6 months old are likely to develop normal language and communication skills," he said.

One hearing-impaired patient, Walter Cook, wrote a poignant letter recommending Depew for the Family Physician of the Year award. Although husbands often weren't allowed in the delivery room in the mid-'70s, Depew invited Cook to attend the birth of his son, Brian. Everyone in the room was wearing a surgical mask, which precluded lip reading, but Cook and his deaf wife, Brenda, were able to understand what was happening every step of the way. "The fact that Dr. Depew was very fluent in American Sign Language made my day because I was able to follow Dr. Depew's description of what he was doing to deliver our baby," Cook wrote. "I have never forgotten seeing our son being born and I never will, thanks to Dr. Depew."

Depew, who turns 80 this month, credited his family for supporting his career and volunteer activities over the years. "I couldn't do it without a wonderful wife," he said of Sara, a "south'na" from Alabama.

Sara Depew and their two daughters attended the Assembly to help celebrate with the Family Physician of the Year.

Physician compensation can improve quality of care and bottom line

Dallas 2000

Compensation plans for group-practice physicians have a lot to do with how physicians provide care, their productivity and where they tend to focus their efforts. In an Assembly session on physician compensation Sept. 16 in Orlando, Fla., two expert speakers shared their insights into compensation plans that improve both quality of care and the bottom line.

"Compensation in primary care has increased at the rate of about 9 percent over the past five years," said Steven Berkowitz, M.D., president of the consulting firm SMB and Co. in Austin, Texas. "In the same period, productivity has gone up by 8 percent. So primary care physicians have had to work harder to increase their compensation."

He said that, in general, physicians need to increase their efficiency and productivity by at least 10 percent per year to keep pace with inflation. A key way to increase physician productivity is with a fair and equitable compensation plan.

Berkowitz discussed two models for compensating physicians -- a market model, in which physicians are paid relative to free-market compensation for their particular specialty and demographics, and a net economic contribution model, in which physicians are paid relative to their contributions to the group practice. The contribution model, he said, provides greater incentives to increase productivity.

Leonard Fromer, M.D., associate clinical professor of family medicine at the University of California at Los Angeles and a member of the Prairie Medical Group in Santa Monica, described a sample compensation plan based on his own experience at Prairie Medical.

The first step, he said, in developing a group-practice compensation plan is to establish a long-term plan to achieve desired outcomes, including improving patient satisfaction, encouraging comprehensive care, improving continuity of care, improving quality of care and increasing revenues.

"In the transition from fee-for-service to partly or fully capitated systems, physicians need to change their thinking from focusing on what's good for the individual to focusing on what's good for the group," Fromer said. "If the group prospers, so do you."

In any compensation plan, peer review is a key regulator of the quality of care the group produces, he said. In his group, the plan rewards quality of care, links performance to compensation and bases 30 percent of pay on peer-review scores.

Another key factor is patient satisfaction. Fromer recommended that each group do patient surveys to assess satisfaction. He advised the physicians at the seminar to use Vital Signs, which is patient survey software available from AAFP.

Help children and adults overcome attention disorders

Attention-deficit/hyperactivity disorder can be difficult to diagnose, yet proper intervention and treatment can have a profound impact on the lives of patients with attention disorders.

During an Assembly case study session on children and adults with attention disorders Sept. 16 in Orlando, Fla., two experts in the field presented overwhelming evidence that even patients with severe AD/HD can be helped.

"Diagnosis at an early age is critical, because the earlier you can intervene the better chance the patient has to develop skills to cope and find success in life," said Clare Jones, Ph.D., a nationally known expert on AD/HD and the author of four books on the subject. "It's important for the patient and family to develop a positive attitude. The message is, 'You can help this unique child survive and thrive.'"

Jones and James Nahlik, M.D., associate clinical professor of community and family medicine at St. Louis University Medical School, discussed six case studies of patients ranging in age from 5 years to adult. AD/HD is a lifespan disorder, Dr. Nahlik said.

"The symptoms may change over a patient's life, but children do not outgrow AD/HD," he said. "You can diagnose AD/HD at any time during a patient's life."

Jones noted that mild attention disorders are the most difficult to diagnose, because patients often develop their own coping skills.

"Many patients with mild AD/HD never realize they have the disorder because they have been able to deal with it effectively on their own," she said. "Thus the patients you are most likely to see in your practice will have moderate to severe AD/HD and definitely need your help."

Behavior modification, psychotherapy, family therapy and support groups can be indicated for AD/HD children and their families, Nahlik said. Family therapy is important, he noted, because some 70 percent of children with attention disorders have one or both parents with the same disorder.

He went on to discuss some of the commonly prescribed medications for AD/HD, including psychostimulants such as the commonly prescribed Ritalin® and Cylert®.

"Psychostimulants are beneficial in 70 to 80 percent of patients with AD/HD, but parents often ask us, 'Why stimulate the hyperactive child?'" Nahlik said. "The explanation is that these medications specifically stimulate the part of the brain involved with attention."

Although medications are beneficial, both speakers recommended a "skills, not pills" approach to treatment.

"Medication can be helpful as part of the process of helping a patient learn to focus and stay on task," Jones said. "Just writing a prescription isn't enough -- you have to empower your patients to help themselves."

AAFP storms Orlando

The American Academy of Family Physicians' 51st annual Scientific Assembly featured a whirlwind of education, entertainment and family fun in Orlando

brooks
Outgoing Board Chair Neil Brooks, M.D., of Rockville, Conn., and other Board members slip into Cat in the Hat attire in the AAFP Congress of Delegates to promote the All-Member Event in Seussian rhyme. The All-Member Event was held at Universal Studios Islands of Adventure, which includes Seuss Landing.
new president
Bruce Bagley, M.D., of Albany, N.Y., has several kind words for outgoing President Lanny Copeland, M.D., of Albany, Ga., after Copeland swore him in as new president.
graham
Academy EVP Robert Graham, M.D., receives the first-ever Family Physician Executive Award in the Congress of Delegates.
congress of delegates
Michigan delegates James Shetlar, M.D., left, of Frankenmuth and Timothy Tobolic, M.D., of Byron Center share a relaxed moment at the close of the Congress of Delegates.
lecture
Top-notch scientific lectures draw large crowds at the 1999 Scientific Assembly.
SeaWorld
Martha Rail and other children enjoy a visit to SeaWorld as part of the Assembly's youth program. She is the daughter of Carla Rail, M.D., and Anton Rail of Wheat Ridge, Colo.
techniques
Mickey Seffinger, D.O., left, of Torrance, Calif., demonstrates the proper technique for manipulative medicine to Marc Weinberg, M.D., of Sarasota, Fla.
steps
Despite the best efforts of Hurricane Floyd, Assembly-goers are able to rearrange their schedules to fit the delayed opening of the 1999 Scientific Assembly.
congratulations
Outgoing President Lanny Copeland, M.D., left, of Albany, Ga., congratulates new President-elect Richard Roberts, M.D., J.D., of Madison, Wis.
Fellowship Convocation
One of nearly 500 members prepares to become an Academy Fellow during the Fellowship Convocation.
Universal Studios
Rides at Universal Studios Islands of Adventure expose Academy members to hurricane-like conditions during this year's All-Member Event.

Congress addresses urban health, IMGs, collective bargaining

Among its decisions Sept. 14-16 in Orlando, Fla., the AAFP Congress of Delegates created a task force and forum, and opted to continue studying collective bargaining.

"I have both trained and practiced in an urban environment," said delegate Donya Powers, M.D., of East Providence, R.I. "We are dealing with tertiary care centers; many of our people don't know what a family physician is. The Academy has been very good at dealing with issues about rural practice, and we're asking the same for urban issues."

The task force will address such topics as recruitment of residents to urban practice, retention of urban family practices, funds for such practices, inner-city violence and the relationship a physician may have with a community in which he or she does not live.

The Michigan, Minnesota and Wisconsin academies sought support for a new committee on urban and inner-city issues, but the Congress instead requested a task force.

The 1997 Facts About Family Practice says that 15 percent of active AAFP members are IMGs, and 14 percent of family practice residents are IMGs.

Clinical meets ethical

The Congress of Delegates adopted policies on topics ranging from adolescent sexuality to research sponsored by drug companies during its Sept. 14-16 meeting in Orlando, Fla. A few of the delegates' decisions:

Congress calls for FP-friendly productivity guidelines

The Congress of Delegates voted Sept. 15 to have the AAFP create productivity guidelines friendly to family physicians. The Congress also tackled other health care services issues at its meeting in Orlando, Fla.

Productivity. "We need a better way of measuring what we do than counting the number of people who come through our door," delegate Thomas Norris, M.D., of Seattle told the Congress.

Delegates agreed. They adopted a Washington AFP resolution revised by Norris, as follows: The Academy should recommend physician productivity guidelines that take into account complexity of patient management and practice mix and assure that quality of care can be maintained.

"The Academy needs to develop these guidelines over the next year or so," Norris said after the Congress approved his revision. "What we measure determines what we get paid for."

Drug costs. In an era in which HMO drug expenses approximate HMO costs for primary care services, the AAFP Congress suggested steps to curb spending on pharmaceuticals. Delegates asked the AAFP to:

Drugs for indigent patients. Drug companies have programs to provide medicines to the indigent, but each company has a different application process, and the time lag between a request and the patient's receipt of the medicine may be as much as six weeks, said delegates.

They voted for the Academy to work with the pharmaceutical industry to develop an easily available application process (online or otherwise) for the drugs.

E/M guidelines. Delegates urged the Academy to work to ensure that evaluation and management documentation guidelines will be used as an educational tool, not a punitive instrument, and that fraud and abuse charges will be imposed on physicians only in cases in which the intent to defraud is clear.

Reimbursement for treating tobacco use, obesity. The Academy should actively support reimbursement for treatment of tobacco use and obesity, including pharmaceutical and behavioral modification treatments, said the delegates.

Hospitalist issues. The delegates supported patients' freedom to choose their family physician to provide inpatient care. Delegates also said FPs should be reimbursed for care of their own hospitalized patients.

Board to consider electronic medical records task force

Incoming President Bruce Bagley, M.D., of Albany, N.Y., painted a picture of technology-rich family practices in his address to the Congress of Delegates Sept. 14 in Orlando, Fla.

"Electronic medical records will need to be in most of our offices in the next five years," said Bagley. "Computer solutions are being developed which are low-cost and user-friendly. Yes, voice recognition is a reality at this time."

Bagley asked the Academy to create a task force to intensify AAFP efforts in evaluating and promoting electronic medical records that will support the core business of family physicians.

The Congress of Delegates referred Bagley's recommendation to the Board, asking it to assess the fiscal implications of the EMR initiative.

In his speech, Bagley said current family practice office systems are not well designed to:

"We need to transform our old office routines," he said. "I challenge you to continue to lead change, not just watch it happen; to embrace technology, not just tinker with it; and the most important challenge of all, to keep the patient and family at the heart of what we do."

Proprietary practices paper available

The Academy has compiled statements it supports related to proprietary practices, and a summary is available on request. The Congress of Delegates received the document during its Sept. 14-16 meeting in Orlando, Fla.

The document begins with the 20-page summary and proceeds with 143 pages of attachments, including statements from the AAFP, AMA, FDA, Accreditation Council for Continuing Medical Education, and federal laws and regulations.

The summary tells where the AAFP stands on issues such as direct-to-consumer ads, referrals to entities in which physicians have an ownership interest and selling products not related to health in physician offices.

One of the attachments -- "Gifts to Physicians from Industry" from the AMA Council on Ethical and Judicial Affairs -- was developed to prevent abuses by pharmaceutical organizations in their relationship with physicians. The AAFP adopted the same guidelines, said Norman Kahn, M.D., AAFP vice president for education and science.

"These guidelines help prevent companies from currying favor with physicians," said Kahn. "And they help a physician avoid promoting a particular product over another because of pressure from a company."

Kahn said he talked with several representatives from pharmaceutical companies over the summer, and they asked AAFP and other medical specialty societies to remind their members about the guidelines. "This issue is heating up again, and we want to be sure everyone involved understands the ethical implications," Kahn said. "We agreed to share in the responsibility of educating both companies and physicians about what these guidelines are and why they exist."

You can order a copy of the document, "AAFP Policies and Positions Related to Proprietary Practices," the 20-page summary, or attachments including "Gifts to Physicians from Industry" by calling Carolyn Rackers in the AAFP Division of CME at (800) 274-2237.

Violence stirs debate among delegates

Violence and means to prevent it sparked discussion during the Congress of Delegates Sept. 15 in Orlando, Fla. Delegates wrestled with issues under two headings: gun control and violence against physicians.

congress discussion
California delegates Mary Frank, M.D., of Rohnert Park and Leonard Fromer, M.D., of Santa Monica discuss Congress activities Sept. 15 in Orlando, Fla.

Gun control. "I respect that for many Americans, and indeed for many of my colleagues here today, guns are part of their culture, part of their way of life," said delegate Mitchell Finnie, M.D., of San Antonio, representing new physicians. "Unfortunately, guns are also part of the culture of children in East Los Angeles, the South Bronx, Chicago, Miami and even in places such as Columbine High School in Colorado."

The Wisconsin AFP and the Joint Constituency (including women, minority and new physicians) proposed several gun control resolutions, most of which won approval. Delegates nixed a proposal to support raising the minimum age from 18 to 21 for licensing guns.

The new policy says the AAFP will:

A question arose about defining assault weapon. "The common definition of assault weapon is not a penknife or handgun, it's an Uzi," said delegate Mary Frank, M.D., of Rohnert Park, Calif. "In California, we don't know why any citizen would have to have an assault weapon."

The voice vote on the final policy was so close a standing vote was needed.

Violence against physicians. The Congress condemned violence and illegal acts against physicians and other health professionals providing lawful services. Delegates deplored activities interfering with the welfare of patients seeking lawful care. The Congress also condemned the 1998 murder of gynecologist Barnett Slepian, M.D., of Amherst, N.Y., and extended sympathy to his family.

The Congress asked the AAFP Board to try to identify the extent of the problem of violence against family physicians and to develop an educational forum on ways FPs can deal with threats of violence in the workplace.


Resident/Student News

Education items crowd Congress' agenda

The Congress of Delegates took action on a variety of education issues Sept. 14-16 in Orlando, Fla.

The student constituency succeeded in having the AAFP broaden its nondiscrimination clause to include students. The revised statement reads, "The Academy supports the application of this principle (nondiscrimination) for practicing physicians and for physicians and medical students applying to a residency program."

The resident constituency obtained AAFP's opposition to a recent recommendation of the Federation of State Medical Boards. The FSMB suggested states should require three years of postgraduate training for full licensure.

"Thirty-four states now require one year of training, 14 require two years and only two states require three years," David Meyers, M.D., of Washington, D.C., told the education reference committee. "The FSMB recommendation would stop the practice of moonlighting, something dear to the hearts of residents." He spoke as chair of the 1999 National Congress of Family Practice Residents. The residents' resolution also said the three-year requirement could keep residents from helping staff clinics, urgent care centers and emergency rooms.

Delegate Tess Garcia, M.D., of Grain Valley, Mo., representing students, said waiting until residency graduation to become licensed could postpone board certification, which would postpone participation in such programs as the National Health Service Corps.

"Any requirement that would not allow us to become board-certified immediately upon graduation from a residency would mess up our NHSC program," Garcia told the committee. "To have to wait to sit for the boards limits the NHSC sites we could choose."

On other topics, the Congress called for the addition of cross-cultural and end-of-life training to family practice residency requirements, as well as the incorporation of cross-cultural issues in CME courses.

FMIG leaders attend Congress

This year, for the first time, the AAFP Board gave 11 student leaders a free ride to the Congress of Delegates. The leaders were the national coordinator and 10 regional coordinators of family medicine interest groups at medical schools.

Their enthusiasm for family practice spreads to local FMIG leaders, who introduce students to the specialty. "The Board appreciates the work you do all year," AAFP Past President Patrick Harr, M.D., of Maryville, Mo., told the FMIG leaders at Assembly. "Bringing you to the Congress is sort of a payback."

Regional coordinator Kerri Harting of Springfield, Ill., had two words for the Congress: passion and family. "The speakers are passionate about what they believe," said Harting. "And we're all one family here." Harting will chair the 2000 National Congress of Student Members.

Leslie Brott of San Antonio, the 1998-99 national coordinator, said she was glad the Congress of Delegates suggested cultural awareness training should be part of the residency curriculum. "I've worked with Hispanic and minority populations for 12-13 years, since way before medical school," she said. "People need to learn about other populations than the one they came from."

"Most students think medical societies focus mainly on regulations and legislation," said Saria Carter of Gainesville, Fla. "But the AAFP Congress was concerned about issues like violence and cultural awareness."

Carter said she headed an FMIG last year because no one else was interested. "I began to realize the voice that students have in the Academy and decided to become more involved," said Carter, the new national FMIG coordinator.


New drugs make HIV management more complex

Managing patients infected with the human immunodeficiency virus and AIDS is a challenge to any physician, especially in light of new combination therapies that are offering renewed hope to these patients.

In an Assembly clinical seminar held Sept. 17, Scott Warner, D.O., J.D., assistant director of the family practice residency at Florida Hospital in Orlando, reviewed the latest testing and treatment techniques for opportunistic infections and other complications of HIV infection and AIDS.

"There are now 17 antiretroviral medications available to treat these patients," Warner said, "and sorting out the right ones to use can be a formidable task." To help family physicians make informed decisions about management, he offered these suggestions:

Some common methods used to evaluate HIV-infected patients include: hemoglobin testing, because about 85 percent of patients have some form of anemia; white blood cell counts; platelet counts, because thrombocytopenia occurs in 11 percent; creatinine levels; testing for toxoplasmosis; TB testing; a baseline chest x-ray; Pap smears; genotype testing; phenotype testing; absolute CD-4 counts; and HIV-RNA measurements of viral load.

Warner pointed to the latest (eighth) edition of the Sanford Guide to HIV/AIDS Therapy as a seminal source of treatment information. The guide recommends that physicians initiate antiretroviral therapy "early in the course of the disease when viral load is still low (and near-complete suppression can still be achieved) and before clonal depletion of CD-4 has occurred," but only if the patient is committed to following the regimen.

"Begin HAART therapy if CD-4 counts are greater than 500 and HIV-RNA measures are less than 10,000 within six months of seroconversion when the patient has such symptoms as thrush and unexplained fever," Warner said. "Response to therapy should be monitored by RNA copies until they are undetectable."

The recommended initial HAART treatment consists of a combination of two nucleoside reverse-transcriptase inhibitors plus one protease inhibitor or one non-nucleoside reverse-transcriptase inhibitor. If a patient shows resistance to HAART, genotype testing may be indicated to determine which drugs he or she may tolerate, Warner said. Unfortunately, if a patient is resistant to one PI, he or she is usually resistant to all PIs.

In HIV-infected patients, opportunistic infections first begin to occur when CD-4 counts slip below 71. Among the opportunistic infections common to HIV-infected patients are Pneumocystis carinii pneumonia, depression and dementia from wasting, chronic non-healing ulcers, disseminated Mycobacterium avium-intracellular complex, candidal esophagitis, Kaposi's sarcoma (but rarely in women), cytomegalovirus-related retinitis, cerebral toxoplasmosis, TB, lymphoma, chronic herpes and cryptococcal meningitis.

PCP can be treated with trimethoprim and sulfamethoxazole, Warner said. Dapsone is useful as prophylaxis against PCP when the patient's CD-4 count is less than 200. Patients who have DMAC and a CD-4 count below 50 may be treated with clarithromycin.

For patients who suffer wasting, Warner recommended treating the depression and dementia first. If the patient is not depressed or demented, try treating with megestrol (Megace) or dronabinol (Marinol). If the wasting continues and the patient is male, check the patient's testosterone levels and consider anabolic steroids. If the patient is resistant to steroids, consider human chorionic gonadotropin therapy.

Deadly diabetes deserves attention

Diabetes is one of the deadliest and most costly diseases known to humankind, noted William Miser, M.D., associate professor of family medicine at the Ohio State University in Columbus and speaker for a clinical seminar Sept. 17, "Office Management of Type 2 Diabetes," at the Assembly in Orlando, Fla.

It's estimated that more than 16 million Americans have diabetes mellitus, but the condition goes undetected at least half the time, Miser said.

Screening for diabetes may be done as part of a routine medical exam if the patient has one or more risk factors: is obese, has a first-degree relative with diabetes mellitus, has hypertension, has a high-density lipoprotein cholesterol level below 35 mg/dl or a triglyceride level above 250 mg/dl, is a member of a high-risk ethnic group, had a previous test indicating impaired glucose tolerance or impaired fasting glucose, or has borne a baby weighing more than nine pounds or has been diagnosed with gestational diabetes.

The diagnosis of diabetes may be made in one of three ways, Miser said. If the patient has symptoms of diabetes, such as polyuria, polydipsia or weight loss, along with random serum glucose levels above 200 mg/dl; if the patient has fasting plasma glucose levels above 126 mg/dl; or if the patient has an oral glucose tolerance test two-hour value above 200 mg/dl, he or she may have diabetes. However, each of these tests must be confirmed on a subsequent day. Miser said the fasting glucose test is preferred; it is the easiest to perform and the least costly.

"Diet and exercise are the cornerstones of therapy for diabetic patients," he said. "Eighty percent of type 2 diabetes could be controlled with diet alone." However, up to 60 percent of patients don't follow the diets they are prescribed, and exercise carries some risks, including hypoglycemia, cardiovascular events and foot or soft-tissue injury. Patients may need a stress test before starting to exercise.

When diet and exercise fail to control diabetes, physicians need to consider prescribing drugs, Miser said.

Sulfonylureas are indicated for type 2 diabetic patients who have some pancreatic function left and whose plasma glucose can no longer be controlled by diet and exercise. More than 60 percent of type 2 diabetics respond initially to sulfonylureas, but after five years of use, half of all patients taking these drugs require other medications to control their glucose levels, he said.

One of the newer drugs, metformin, is effective in lowering fasting glucose levels, does not cause weight gain and works by decreasing hepatic glucose output and increasing glucose uptake. Metformin used in combination with sulfonylureas is capable of improving glycemic control in adults refractory to sulfonylureas alone.

Another new class of drugs, alpha-glucosidase inhibitors, delays glucose absorption, reduces postprandial serum glucose and fasting insulin responses, and decreases postprandial hyperglycemia, he said. They may cause flatulence, cramps, abdominal distention and diarrhea. They are contraindicated in patients with renal dysfunction or diseases of the large intestine.

The glitazone drugs -- troglitazone, rosiglitazone and pioglitazone -- decrease insulin resistance and increase insulin sensitivity. In rare cases, however, they have been associated with liver toxicity, he said.

The final class of diabetes drugs, repaglinide, is similar to sulfonylureas but much more short-acting, Miser said. This class of drugs is effective for patients who skip meals or do not eat regularly.

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AAFP grant helps researchers develop proposals

Eleven family practice researchers will develop research proposals, thanks to an AAFP grant. The grant recipients were announced at the Scientific Assembly Sept. 16.

Earlier this year, the AAFP Task Force to Enhance Family Practice Research awarded a supplemental grant of $25,000 for one year to the Center for Family Medicine Science at the University of Missouri, Columbia. The center is one of three family practice centers nationwide that initially received funding through the Academy's $7.72 million research initiative, which began in 1997.

Through the Grant Generating Project, a joint program underwritten by the AAFP and the North American Primary Research Group in cooperation with the Association of Family Medicine Organizations, those funds have been awarded to 11 researchers: John DiFiori, M.D., of Los Angeles; Christine Wilson Duclos, Ph.D., of Denver; John Ely, M.D., M.S.P.H., of Iowa City, Iowa; James Gill, M.D., M.P.H., of Wilmington, Del.; Kim Griswold, M.D., M.P.H., of Buffalo, N.Y.; C. Dale Guenter, M.D., of Ontario, Canada; Michael Parchman, M.D., of San Antonio; Robert Philips Jr., M.D., of Columbia, Mo.; Burke Richmond, M.D., of Madison, Wis.; Tamara Stone, Ph.D., of Columbia, Mo.; and Therese Zink, M.D., M.P.H., of Cincinnati, Ohio.

The year-long Grant Generating Project involves training in the highly competitive process of grant preparation.

Eight FPs win advance research training grants

At the Assembly's Sept. 15 research reception in Orlando, Fla., grants in the second cycle of the Academy's Advanced Research Training Grants were awarded. Each researcher will receive up to $50,000 a year, for two years. Another cycle of awards will be made next year. The 1999 recipients are:

Awards recognize contributions

Family Physician of the Year -- Harry Depew, M.D., of San Diego (see story in this issue).

Public Health Award --David Carlyle, M.D., Ames, Iowa.

Exemplary Teaching Awards -- Kevin Ferentz, M.D., Baltimore (full-time); Ellsworth Seeley, M.D., Lexington, Ky. (part-time); and Diane Nightengale, M.D., El Dorado, Kan. (volunteer).

Thomas W. Johnson Award -- Melessa Phillips, M.D., Jackson, Miss.

John G. Walsh Award -- Fitzhugh Mayo., M.D., Virginia Beach, Va.

Parke-Davis Teacher Development Awards -- Daisy Braaten, M.D., Chicago; Stephen Cobb, M.D., Norman, Okla.; Ross Colt, M.D., Tacoma, Wash.; Neva Edens, M.D., Chapel Hill, N.C.; Margaret Gill, M.D., Rochester, Minn.; Michael Lebens, M.D., Denver; Mary Mason, M.D., Lake Forest, Ill.; Hogai Nassery, M.D., Decatur, Ga.; Amaryllis Sanchez Wohlever, M.D., Ft. Walton Beach, Fla.; Steven Schwartz, M.D., Chevy Chase, Md.; Eric Stamberg, M.D., Highland, N.Y.; Mark Stephens, M.D., Bethesda, Md.; David Switzer, M.D., Luray, Va.; Sharon Elizabeth Tucker, M.D., Mesquite, Texas; and Paul Ullom-Minnich, M.D., Moundridge, Kan.

American Family Physician - Walter H. Kemp Award -- Ross Lawler, M.D., San Antonio, Texas, for his article "An Office Approach to the Diagnosis of Chronic Cough" published in the December 1998 AFP.

Family Physician Executive Award -- Robert Graham, M.D., AAFP's executive vice president.

You can help North Carolina FPs flooded by Floyd

The North Carolina AFP is seeking support for FPs in towns flooded by Hurricane Floyd. The chapter’s foundation has established a Floyd Relief Fund. All financial donations will be distributed to FPs whose practices were flooded. The money will be used to rebuild and replenish supplies. The chapter also is looking for volunteers to cover practices for FPs consumed with cleaning up their flooded homes. Because many practices will be closed, those that are open should be very busy.

Call NCAFP at (919) 833-2110. Or send your contribution to the North Carolina AFP Foundation Floyd Relief Fund, P.O. Box 10278, Raleigh, NC 27605.


Humanitarian Projects

Feed the Need aids needy people in host city

For the eighth straight year, needy people in the Assembly's host city were helped by Feed the Need, which collected in-kind gifts, food and cash for the Health Care Center for the Homeless.

The Health Care Center for the Homeless was founded by Orlando family physician Richard Baxley, M.D., in 1993.

The program received more than $11,600 in contributions from exhibitors.

Assembly attendees participated by purchasing Assembly lapel pins. Pin proceeds will be split between Feed the Need and the AAFP Foundation's Resident Repayment Program.

Corporate contributors
3M Pharmaceuticals
Abbott Laboratories
American Optometric Association
Bayer Corporation
Biostar Inc.
Clement Clarke
Eggland's Best
Endo Pharmaceuticals Inc.
Expeditor Systems Inc.
Facts and Comparisons
Florida Hospital Waterman
Gerber Products Company
GE Marquette Medical Systems
Highlights For Children
Intelligent Medical Systems Inc.
Johnson & Johnson Consumer
Kellogg Company
Eli Lilly and Company
McNeil Consumer Healthcare
Medical Economics Company
Nestle/Carnation Nutrition Division
Novartis Pharmaceuticals Corporation
Olsten Health Services
Ortho-McNeil Pharmaceutical Corporation
Pasteur Merieux Connaught
PCS Health Systems Inc.
Rhone-Poulenc Rorer Pharmaceuticals Inc.
Ross Products Division - Abbott Laboratories
Ross Products Division - Health Source
Schering Oncology/Biotech
SCP/Cliggott Communications
Shimadzu Ultrasound
Siemens Hearing Instruments
Sisters of St. Joseph Health System
Slim-Fast Foods Company
Smith & Nephew Inc.
SmithKline Beecham Pharmaceuticals
Spacelabs Burdick Inc.
Star Pharmaceuticals Inc.
STC Technologies Inc.
UCB Pharma Inc.
Vantage Health Solutions
Whitehall-Robins Healthcare
Women's Health in Primary Care
Wyeth-Ayerst Pharmaceuticals

Physicians With Heart takes medical supplies to Uzbekistan

The annual Physicians With Heart airlift headed for Uzbekistan this year.

The Sept. 25-Oct. 5 mission was scheduled to deliver medical supplies and health education materials donated by pharmaceutical and other health care companies. Funds from individual FPs provided products for hospitals and clinics and helped pay for food and clothing for Uzbek orphans.

The Academy, the AAFP Foundation and the humanitarian organization Heart to Heart International have delivered medical supplies to the former Soviet Union since 1993.

Within Uzbekistan, the airlift delegation planned to monitor the delivery of the products and confer with Uzbek health professionals about the materials and the specialty of family practice, a new concept to most Uzbek health professionals.

Corporate contributors
3M Health Care
Beiersdorf-Jobst Inc.
Bionix Engineered Medical Technologies
Bristol-Myers Squibb
Burrows
Carrington Laboratories
Chlorine Chemistry Council
Derma Sciences Inc.
Glaxo Wellcome Inc.
Hoechst Marion Roussel Inc.
Johnson & Johnson Companies
Lever Brothers
Eli Lilly and Company
Maxxim Medical
McNeil Consumer Healthcare
Mead Johnson Nutritionals
Mera, King and Company
Merck & Company
Owens & Minor
Parke-Davis
Pharmacia & Upjohn Inc.
The Purdue Frederick Co.
Schering Laboratories/Key Pharmaceuticals
Searle and Co.
Sunshine Productions
UCB Pharma
Welch Allyn
Welch Allyn Tycos
Wyeth-Ayerst Pharmaceuticals


FP Report is published by the AAFP News Department. Copyright © 1999 by American Academy of Family Physicians.


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