December 1999
News for members of the American Academy of Family Physicians
Front Page
Melanoma: Are you missing it in your practice?
LA JOLLA, Calif. -- For Tom Zuber, M.D., of Saginaw, Mich., melanoma is a mission.
"I firmly believe that melanoma is present in patients in all family physician practices," Zuber told an audience of more than 200 physicians. "If you aren't seeing it, you're missing it."
Thomas Triehy, D.O., left, of Great Falls, Mont., and Rimas Janusonis, M.D., of Clinton, Utah, practice electrotherapy techniques during the AAFP's CME course "Common Problems and Diseases of the Skin" Nov. 4-7 in La Jolla, Calif. The new course, scheduled in response to numerous member requests, offered seven procedural workshops, 27 lectures and four case discussion workshops.Zuber, director of the family medicine residency at Saginaw Cooperative Hospitals, was program chair of the AAFP's CME course "Common Problems and Diseases of the Skin," held for the first time Nov. 4-7 in La Jolla. The AAFP created the program because members requested a chance to learn more about the skin problems and conditions they were seeing in their practices. According to a study published in 1996, the estimated lifetime risk for melanoma in 1981 was 1 in 250. In 1996, the risk increased to 1 in 87. Currently, Zuber said, it is estimated that melanoma cases are increasing 6 percent each year.
"Melanoma is the fastest- growing cancer in the United States and worldwide," he said, "and the incidence rate is going through the ceiling in the U.S. Family physicians once again are on the front lines of this disease, and we have to be aware of it."
Zuber urged FPs to do the melanoma ABCD exam, with some modifications, during every comprehensive physical examination.
"Choose a mole that the patient can easily see, like on their arm," he said. "Then demonstrate what you're looking for to the patient."
But Zuber said FPs need to go beyond the ABCD exam by including an E for elevation or enlargement -- and an F for family history.
"Family history is vital to this exam," he said. "Ask the patient whether melanoma or any form of skin cancer has ever been present in their family. Ask what their jobs were as teenagers, whether they spent a lot of time in the sun as kids. 80 percent of lifetime sun exposure occurs before age 18. All of this information is helpful."
ABCDs -- plus E and F -- of Melanoma Recognition
The goal is to recognize melanoma at the earliest stage. Melanomas tend to have the following characteristics:
Asymmetry
Border irregularity
Color variegation
Diameter greater than six millimetersZuber suggests adding:
Enlargement or elevation
Family historyZuber also recommended taking photographs of some moles for the patient's file. Then the FP can keep an eye on changes and show them to the patient.
The most important step FPs can take is to convince patients they need to be protected, either by avoiding the sun or using a strong sunscreen.
"How do you convince someone to stay out of the tanning booth, that having a tan isn't healthy?" asked Barry Hainer, M.D., of Charleston, S.C., another presenter at the course. He is professor of family medicine at the Medical University of South Carolina. "I work in the Sun Belt, so I see patients with years and years of sun damage. I think FPs should make sun avoidance more of a priority than reliance on skin protectants."
FPs whose patients use tanning beds also should suggest over- the-counter tanning products.
"You could tell them to quit going, but they won't." Hainer said. "It's an issue of appearance and image, so any future concerns about skin damage aren't important to the patient."
And it's not likely to change anytime soon, Hainer said. "We're going to have to face this as long as we have an image in our society that being tanned is healthy and attractive."
The AAFP will offer the CME course "Common Problems and Diseases of the Skin" again Nov. 2-5 in Tampa, Fla.
By Leigh Anne Bathke, Associate Editor
AAFP has wins in Congress on Title VII, GME, AHCPR
Chalk up three legislative victories for the Academy.
On Nov. 18 and 19, Congress passed measures that bode well for the specialty in three areas: Title VII, graduate medical education, and the Agency for Health Care Policy and Research.
Title VII. Family practice training programs supported under Section 747 of Title VII will have slightly reduced funding next year, compared with the $50.5 million budgeted for 1999. President Bill Clinton had called for zero funding for Section 747, so the Academy lobbied extensively to maintain support close to status quo.
Exact dollar amounts for Title VII were not known at press time. Congress approved funding levels like those of 1999 with a catch: an across-the-board 0.38 percent cut. It will affect discretionary funding (including Title VII), not Medicare and Medicaid.
GME technical amendments. The Academy won some but not all of the technical corrections the specialty wanted in the Balanced Budget Act of 1997. Progress report:
- Hospitals in rural areas may increase the cap on their number of residents by 30 percent.
- Urban hospitals with new, separately accredited rural training tracks may receive direct and indirect GME payments for cost-reporting periods after April 1. This provision allows the cap on rural training tracks to be lifted.
- Hospitals with residents on leaves of absence in 1996 will have their indirect medical education funding restored for then and now.
- Indirect GME payments will be frozen at 6.5 percent through fiscal year 2000, cut to 6.25 percent in 2001, and set at 5.5 percent in 2002 and following years. The Academy supported these provisions; some congressional proposals were lower.
AHCPR. A reauthorization bill confirms the establishment of AHCPR's already existing Center for Primary Care Research and outlines research the center should support. Congress also hiked AHCPR funding from $172.8 million in 1999 to $205 million in 2000. The Academy championed the reauthorization provisions and the escalation in funds.
News From Headquarters
CME deadline for re-election approaches
If you are due for Academy re-election to membership at the end of this year, you must accrue the required CME hours by Dec. 31. All credits earned should then be reported to the AAFP as soon as possible.
Members in the active and supporting categories must accrue at least 150 hours of AAFP Prescribed and Elective credit within each three-year re-election period. Information may be submitted via mail to CME Records, American Academy of Family Physicians, 11400 Tomahawk Creek Parkway, Leawood, KS 66211 or by faxing the completed form to (913) 906-6087. You can also report your CME online at www.aafp.org/cme.
To receive information on CME requirements for continuing AAFP membership, a new CME reporting form, a copy of your personal CME record or assistance in identifying CME opportunities, call a CME records representative at (800) 274-8043.
Copies of the CME reporting form also are available on AAFP Express.
Oregon Gov. John Kitzhaber, M.D., to present 2000 Assembly keynote
Oregon Gov. John A. Kitzhaber, M.D., author of the ground-breaking Oregon Health Plan, will present the keynote lecture at the 2000 AAFP Assembly Sept. 20 in Dallas.
Kitzhaber practiced emergency medicine for 13 years, then began his political career in 1978. He served in the Oregon House of Representatives and the Oregon Senate before his successful run for governor in 1994. Kitzhaber was recognized nationally for writing the Oregon Health Plan when he was president of the Oregon Senate. He also is credited with bringing together diverse interest groups to pass the law, which took effect in February 1994.
During his first term as governor, Kitzhaber oversaw the expansion of the Oregon Health Plan, which reduced the rate of uninsured Oregon children from 21 percent to 8 percent. In addition, Kitzhaber's welfare reform plan, known as the Oregon Option, has reduced the number of welfare caseloads more than 50 percent, saved more than $200 million in the state budget and helped nearly 20,000 Oregonians find work. Kitzhaber was re-elected for a second term in 1998.
Look Back
Look back at specialty's past -- then watch for the new FP Report
This month, say goodbye to an old friend: FP Report in its current form.
In January 2000, FP Report will be reborn, completely redesigned with a new look for the new century. The redesign will enhance other changes we hope you've noticed in the past few months, as we've worked to refocus FP Report on news of family practice, government regulations and legislation, and what AAFP is doing for you, with more analysis and interpretation -- coverage that members want most, according to a recent reader survey.
We're using part of this last old-style FP Report to bring you an expanded AAFP "annual review" -- looking back at the Academy's challenges and achievements not only this year, but also since its inception this century. Watch for the graphic at left for these "look back" stories.
Then with next month's "new" FP Report, we turn our vision forward, with a focus on issues that will impact you and your practice in the year 2000 and beyond.
We hope you'll savor this month's trip through the past -- and that you'll like the reborn FP Report when it hits your mailbox next month. And let us hear from you -- FP Report staff appreciate letters and story ideas from readers! E-mail them to pbinder@aafp.org, fax them to FP Report at (913) 906-6089 or mail them to FP Report, AAFP, 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672. See you in 2000!
New in '99: AAFP products/services
The Academy developed an array of new products and services in 1999, all designed to benefit you and your patients.
A fee for shipping and handling may apply; Kansas residents pay a 6.875 percent sales tax.
The 1999 Annual Clinical Focus on Management and Prevention of the Complications of Diabetes features video CME, monographs and patient education handouts. You can check www.aafp.org/acf for descriptions of the learning tools.
Educating the Community offers ideas, techniques and resources for letting your patients know you deliver babies. #R738, free.
The Academy Collection: Quick References for Family Physicians includes the new book Skin Disorders. #R595, $34.95.
familydoctor.org is a Web site for patients that offers FP-oriented medical information. Give the address to your patients or visit the site with them.
Modules in AAFP-PT, the Academy's Proficiency Testing program, include "Compliance Confirm," to verify the accuracy of your lab test results ($225); "Compliance Proceed," to help your lab staff write and maintain their procedure manuals ($275); and "Compliance Primer," to help you implement quality assurance programs in your lab ($125). As of January 2000, all AAFP-PT modules may be completed by submitting answers via computer software or booklets. Order online at www.aafp.org/pt or call (800) 274-7911 and ask for option #1.
Directors' Newsletter, AAFP's biweekly newsletter for the specialty's leaders, is now available free to AAFP active members by fax or mail. To order, call (800) 274-2237, Ext. 5205.
Online CME records make it possible for you to report your CME online at www.aafp.org/cme.
The Nasolaryngoscopy CD-ROM Program includes audio and video instruction, a color photo atlas, searchable text documents and an interactive test. #R1283, $50.
The CD-ROM Home Study Self-Assessment Monograph Collection contains 72 complete monographs, indexed to help you find materials you want to read or print. Subscribe to the HSSA program and receive this CD-ROM for an added $70. To order, call (800) 274-2237, Ext. 5298.
The Community Provider AIDS Training Web site aims to assist physicians treating people with HIV. Visit the site at http://www.ucsf.edu/hivcntr/ for updates on the latest developments in drugs and articles on HIV and AIDS. The Academy cosponsors the Web site.
Request these resources online at www.aafp.org
or call the AAFP order department at
(800) 944-0000, unless otherwise noted.
From acceptance to opposition: Tobacco fight evolves at AAFP
The days of AAFP Board meetings in smoke-filled rooms with overflowing ashtrays are long gone. A visit to the Scientific Assembly's exhibit floor will no longer yield free cigarettes. In fact, the Academy's position on tobacco use has evolved from passive acceptance to active opposition, and the organization now plays a leading role in promoting a tobacco-free lifestyle.
How did it happen? What did we learn, and where do we go from here?
The early years. Browse through the Academy's archives, and you'll find stacks of photos from the fledgling years when it seemed everybody smoked. CME presenters had cigarettes hanging out of their mouths. Candid shots show physicians chatting, cigarettes pinched between their fingers. Wide-angle pictures feature doctors and their spouses eating dinner with smoke rising from ashtrays. Smoking was part of the social fabric in the United States, and the American Academy of General Practice (AAFP's predecessor) wasn't about to rip apart the seams.
From 1949 to 1969, tobacco companies exhibited at the Academy's Scientific Assembly. This exhibit description illustrates that era's state of mind: "Welcome to the R.J. Reynolds Tobacco Company Exhibit! You are cordially invited to receive a cigarette case (monogrammed with your initials) containing your choice of Camel, Winston Filter, Menthol Fresh Salem or Cavalier King Size Cigarettes."
You've come a long way, baby!
1969 -- a physician smokes while presenting an Assembly casting workshop.
Now -- the winning poster in the 1999 national Tar Wars® poster contest.In 1964, the AAGP Board voted to adopt the AMA's policy on tobacco, essentially refusing to endorse the Surgeon General's Report on Smoking, which had been released earlier that year. In 1965, the U.S. Congress passed the Federal Cigarette Labeling and Advertising Act, which required the surgeon general's health warnings on cigarette packages.
Three years later, a resolution introduced at the AAGP Congress of Delegates aimed to ban the exhibition and free distribution of tobacco products at Assembly. The resolution was tabled after some delegates voiced concern that it "would be a slap in the face to tobacco firms currently exhibiting at the Academy meeting." However, a similar resolution passed the following year.
The tide was turning.
DOC, delegates push for change. Two significant forces pushed the AAFP toward more proactive anti-tobacco initiatives, according to Herbert Young, M.D., Scientific Activities Division director.
Starting in the late '70s, one impetus came in the form of DOC -- Doctors Ought to Care -- an organization of physicians considered radical at the time for their irreverent approach to educating the public about the major preventable causes of poor health and high medical costs. Rather than focus on the dangers of smoking, DOC put the blame squarely on the tobacco industry and urged patients to think critically about tobacco's misleading advertising messages. DOC --which is still a leader in the anti-tobacco effort -- also pressured the Academy to play a key role in preventing tobacco use, especially among young people.
"A lot of what AAFP subsequently did was spurred by DOC's activities," Young said.
Family physician Alan Blum, M.D., now director of the University of Alabama Center for the Study of Tobacco and Society in Tuscaloosa, founded DOC in 1977 and recalls battling the Academy's reluctance to take on the tobacco industry. But his passion and enthusiasm were contagious, particularly with the specialty's up-and-coming leaders -- medical students and residents.
As a family practice resident at the Academy's 1977 meeting for students and residents, Blum tried to announce his new organization and invite his peers to participate. He was told he didn't have permission to speak at that time, but was later assigned a room in which to address interested conference attendees. "We got about 30 people packed into this little room," Blum said. "They were fascinated. Our breakthrough was focusing on patients' attitudes about smoking and, above all, bringing humor to a very serious health issue. Our slogan is 'Laughing the pushers out of town.'"
The message resonated with students and residents, who went home inspired and began implementing the strategies and skills Blum promoted. They shared the DOC concepts with the next generation of FPs-in-training, and the momentum continues to this day.
Pressure to take a stand on tobacco also came from an ongoing grassroots movement among constituent chapters, said Young, with FPs across the country crying out about tobacco's destructive impact on health. Starting in the early 1970s, members raised the issue with their AAFP delegates, who in turn brought a plethora of tobacco-related resolutions to the annual Congress of Delegates.
Major actions taken by the Congress in the '70s and '80s included making AAFP and its meetings smoke-free, recommending that smoking be banned in hospitals and other medical institutions, opposing cigarette sales within health care facilities, commending publications that refuse to accept tobacco advertising and circulating a list of those publications to AAFP members, and accepting a challenge from the American Medical Association to promote a smoke-free society by the year 2000.
Members' booming interest also led to development of the Academy's popular Stop Smoking Kit in 1987. The kit includes brochures for the waiting room, forms and stickers for patient charts, a physician and office staff manual, a patient guide, audiotapes, and other motivational and educational materials for patients.
Tobacco today. As the number one preventable cause of death in the United States, tobacco use now has become one of the Academy's top concerns. For example, AAFP members and staff have testified at state legislatures and the U.S. Congress on the need for laws that protect people -- and particularly youth -- from the hazards of smoking.
Family physicians are leading the charge in many ways. Some examples: Surgeon General David Satcher, M.D., Ph.D., uses the credibility of his office to promote a tobacco-free lifestyle. Karin Husten, M.D., heads the Office of Smoking and Health at the Centers for Disease Control and Prevention. Carlos Jaen, M.D., of Buffalo, N.Y., serves on the task force drafting clinical policy guidelines on tobacco use for the U.S. Preventive Services Task Force. Tom Houston, M.D., is coordinating the AMA's upcoming World Conference on Tobacco. And Robert Higgins, M.D., has spread the anti-tobacco message across the globe as president of WONCA, the World Organization of Family Doctors.
In addition, hundreds of family physicians throughout the United States and abroad participate in the Academy's Tar Wars program, which takes a pro-health tobacco education program into elementary school classrooms.
Family physician Jeffrey Cain, M.D., of Denver launched Tar Wars in 1988 with support from DOC and the Denver Museum of Natural History. "At that time, the approach to tobacco education was 'don't smoke or you'll get cancer when you're 65,'" he said. "That's not very effective with fifth graders."
Tar Wars is a specific tool based on the DOC philosophy, said Cain. Children learn about the short-term consequences of tobacco use and analyze the misleading images portrayed in tobacco ads.
The AAFP endorsed Tar Wars in 1993 and, in 1997, signed a four-year agreement to operate the program. Cain said family physician involvement skyrocketed when Patrick Harr, M.D., of Maryville, Mo., was elected AAFP president-elect in 1996. In a speech at the Assembly that year, Harr challenged every active member to donate "one hour of one day this next year to teach a tobacco education program to a local fifth-grade class." A subsequent letter from Harr to the membership generated more than 15,000 requests for the Tar Wars curriculum packet. The number of AAFP constituent chapters sponsoring the program also has jumped from eight to 32.
Although anyone interested in preventing tobacco use is welcome to present a Tar Wars program, Cain said the involvement of FPs is crucial. "Family doctors are the only physicians who see the initiation and the consequences of tobacco use," he said. "They see the whole life span. As generalists, they also have an overarching perspective to understand the role of tobacco in the family, community and society."
Want more information?
Tar Wars® -- (800) TAR WARS
AAFP Stop Smoking Kit -- (800) 944-0000
Doctors Ought to Care -- (800) DOC-9340
Where do we go from here? The Academy can glean lessons from its history with tobacco, said AAFP Past President Harr. "The main thing is that this is a slow process," he said.
He applauded the Academy for its strong promotion of Tar Wars, but said other at-risk groups must be targeted, too. For example, strong initiatives that promote smoking cessation among teens are essential, he said. "More teenagers smoke now than ever before. The number of young women who smoke is increasing at an alarming rate."
Harr also said he hoped the AAFP will keep the issue of tobacco in the spotlight. "The tobacco industry settlements took some focus away from dangers of smoking and put more focus on the litigation," he said. "People think that the lawsuits took care of the problem. But the industry is still targeting kids, despite what they say. We just have to accept that challenge and step up to the plate."
By Sharon Dent, Associate Editor
Interorganizational efforts
Growing, growing, grown
Over the years, the intensity of AAFP's activities with other medical organizations has steadily increased.
The Academy has high visibility within the AMA -- nine delegates, which is more than any other medical specialty society. Thanks to changes in the delegate selection process, the number of delegates and alternates will almost double next year.
"That gives us more microphone ability," said Daniel Ostergaard, M.D., AAFP vice president for international and interprofessional activities. "We also have more opportunity to place members on various AMA bodies."
AMA candidates from other specialties have discovered the AAFP as a voting bloc. "We now have a moratorium on backing non-FPs, until we sort out criteria and timelines for endorsement," said Ostergaard.
Other specialty groups are increasingly asking to work with the AAFP. "We're cursed and blessed by being the specialty in breadth," said Ostergaard. "We can't accept all the invitations we receive. If we did, we'd 'use up' our volunteer leaders and members."
The Academy does continue to place representatives on interdisciplinary guidelines panels. "We're often asked for nominations, and our candidates are often accepted now, whereas a few years ago, they might not have been," said Ostergaard.
AAFP's interorganizational efforts extend beyond U.S. borders. The World Organization of Family Doctors (WONCA) is led by its second AAFP member president, Robert Higgins, M.D., of Anacortes, Wash. WONCA, founded in 1972 with 18 member organizations, now has organizational members from 54 countries.
Other countries are developing blueprints for family practice training and national societies. "If they're trying to organize a specialty society or residency, we need to be able to assist," said Ostergaard.
Countries where the Academy is offering input and assistance include Russia, Kyrgystan, China, and various countries in Central and South America.
Family practice education: A half-century of growth
1950
AAGP helps organize first general practice residency programs.1969
First 15 family practice residencies are accredited.1971
U.S. Congress initiates line item funding for family practice training.1974
2,671 residents are training in 205 accredited family practice programs.1975
First National Conference of Student Affiliate Members is held in Kansas City, Mo.1985
Family medicine interest groups established at U.S. medical schools.1986
Total graduates of three-year family practice residencies tops 20,000.1988
AAFP student membership totals 9,666.1993
Albert Einstein College in Bronx, N.Y., is the first of the AAFP's "target" schools to create an academic department of family medicine.1997
10,531 family practice residents are training in 457 U.S. programs.1998
3,328 family practice residents graduate - an all-time high.1999
2,697 applicants match into family practice residencies in March (compared with 2,814 who matched in 1998). By July 1, however, the specialty has 3,538 first-year residents -- just 37 shy of record-setting July 1,1998, figures -- for a fill rate of 97.1%.
Academy goes to mat in federal arena for FPs
The coverage on this page explores the Academy's legacy in the federal arena from the late '60s to the present.
1970s to now
Congress funds family practice trainingIn 1970, an administrative assistant to newly elected Rep. Fred Rooney, D-Pa., moved to Washington and couldn't find a family doctor. The assistant complained to Rooney, who introduced a bill to fund the training of more family doctors.
At the time, the Academy had no Washington office. Michael Miller, J.D., the Academy's director of legislation (now deputy EVP), read new bills in Congress to keep tabs on D.C. from a distance. He happened across the training bill and was astonished.
"We took the bill to one of the most influential senators and got him to introduce it in the Senate," said Miller. It passed unanimously in the House and with only one dissenting vote in the Senate.
The Family Practice of Medicine bill went to President Richard Nixon for his approval within 10 days, but that period ended during Congress' Christmas break, and Nixon decided to pocket veto the bill. Such vetoes occur when a president fails to sign a bill within 10 days, and Congress is adjourned and can't override a veto. However, Congress was in recess until January, not adjourned.
"I periodically called the White House to see whether the bill had been signed," said Miller. "One day I called and got a message about the pocket veto. It seemed like something didn't smell right, but I wasn't sure. It ruined my Christmas break."
Eventually, Sen. Edward Kennedy, D-Mass., took the administration to court about the pocket veto and won the case -- but the time for implementing the bill had elapsed. Congress used other legislation, the Health Manpower Training Act, to secure line item funding for family practice training, the basis for the specialty's current Title VII funding.
"The funding provided impetus for creating family practice residencies," said Miller. "The Family Practice of Medicine bill got family practice on everyone's radar screen, and we've been there ever since."
30-year haul
Academy tackles Medicare issuesThe Medicare program was signed into law in 1965, four years before family practice became a specialty with its own certifying board.
In 1970, Rep. Fred Rooney, center, discussed the Family Practice of Medicine bill with AAFP President Edward Kowalewski, M.D., left of Akron, Pa., and Board Chair Robert Quello, M.D., of Minneapolis."The policies from the mid-1960s didn't fit in with the new model of family practice," said Rosemarie Sweeney, AAFP vice president for socioeconomic affairs and policy analysis. "But over time, successful legislative efforts have recognized the shift to increased training for family doctors."
Specialty differential. Medicare regulations from the mid-1960s said physicians should be reimbursed according to their usual, customary and reasonable payments. Carriers would pay a subspecialist more than a generalist for exactly the same service.
The Academy's Michigan chapter, supported by the Academy, filed suit against the government over the specialty differential.
"The government fought us with all its resources," said Miller, then general counsel. The case dragged on for 10 years, until the Supreme Court struck down the specialty differential.
Why was the case important?
For two reasons, said Miller. First, it established the legal precedent that family physicians should not be treated differently from other physicians.
Second, the case dealt with whether Medicare could be sued or whether plaintiffs had to go through the government's own administrative hearings, with the government as prosecutor, judge and jury. "The government said the courts didn't have jurisdiction," said Miller. "The Supreme Court said otherwise. The case has had great influence in the legal profession."
Paving the way for RBRVS. The Academy and the American Society of Internal Medicine joined forces in 1983-84 to win AMA's backing for a fairer Medicare payment system.
"The system based on usual, customary and reasonable payments led to inappropriate pay for cognitive services -- gathering data, analyzing health problems, diagnosing -- much lower pay than for procedural services," said Miller. "We knew we couldn't get the Medicare fee structure overhauled without AMA's support."
The AAFP and ASIM asked their members to introduce in state medical societies a resolution calling for the AMA to support fairer payment for cognitive services. Four societies sent the resolution to the June 1984 AMA House of Delegates. A reference committee recommended studying and not immediately acting on the resolution.
"Let's get this changed on the floor of the AMA house," said Sam Nixon, M.D., of Nixon, Texas, a past AAFP president and a Texas delegate to the AMA.
"Then the politicking started," said Miller. "The AMA was in a tough spot. It was clear the change in the Medicare system would benefit some specialties and work to the detriment of others." AAFP and ASIM leaders at the AMA meeting rallied delegates to the cause, and the AMA house voted for it.
A Harvard University study determined the fee schedule should adopt a resource-based relative value scale, reflecting the real costs involved in providing care. The U.S. Congress approved the RBRVS. Implementation began in 1994 and will be completed in 2002.
"RBRVS is still the subject of argument," said Miller. "I think our members probably don't think the RBRVS is the greatest thing in the world, because of the red tape. But their income has risen significantly because of the RBRVS."
GME funding. Medicare funding for graduate medical education historically favored technical specialties over ambulatory care specialties. Those requiring longer training before eligibility for board certification received more funding, and some fellowships also had federal support.
In 1997, the Academy won a cap on the extent of GME-funded training. The result: More training institutions receive the full amount of direct medical education funding only until residents are eligible for their first certification. More DME funds are therefore available for primary care specialties.
In addition, Medicare regulations proposed in 1995 required the teaching physician's presence in the exam room with the patient and resident in order for the physician to be paid for patient care. The proposed rule could have hampered the family practice resident's relationship with the patient. In a clear-cut victory for the specialty, the final regulation granted an exception to the physical presence rule for family practice and other primary care residencies.
On another front, the AAFP is still seeking Congress' correction of parts of the Balanced Budget Act of 1997 -- provisions that inadvertently disadvantage family practice residencies and rural training.
On the horizon: The Medicare Payment Advisory Commission, unfortunately, recently called for Medicare to pay for enhanced services in teaching hospitals but not in ambulatory sites. "Big GME issues will be on the table in the near future," said Sweeney.
1989 and counting
Academy speaks up for uninsuredA decade ago, the AAFP Congress of Delegates committed the Academy to seeking health care coverage for every American.
The search is far from over.
The Academy backed most of the comprehensive reform plan proposed by President Bill Clinton's administration in 1993, but the plan failed to win Congress' support. The Academy turned its energies to expanding coverage for various groups of uninsured Americans, beginning with support of the Children's Health Insurance Program.
This year, the AAFP Task Force on Universal Coverage began examining anew the question, "How can America achieve universal coverage?" Some answers may lie in the task force's report to the 2000 Congress of Delegates. Stay tuned.
By Jane Stoever, Associate Editor
Target schools -- 12 down, 10 to go
In 1988, the Academy developed a list of 22 "target" schools -- medical schools without academic departments of family medicine.
"We were looking to improve the availability of family practice curricula, teachers and mentors for medical students," said Norman Kahn, M.D., AAFP vice president for education and science.
That initial list had 22 schools, including George Washington University, Emory University, Tulane University and University of Pennsylvania. The first target school removed from the list was Albert Einstein University in Bronx, N.Y., in February 1993. Since then, 12 schools have successfully created academic departments of family medicine and been removed from the list.
To be removed from the AAFP's list, the medical schools must hire a chair and faculty for the family medicine department and have a presence in the curriculum.
"In the beginning, AAFP and chapter leadership and staff visited three schools a year. We talked to them about family practice and how it was important for medical students to know about all the options available to them," said Kahn. "And we depended on students to help their schools see the need for academic family medicine departments."
Medical students have helped in a big way. Family medicine interest groups -- FMIGs -- are active on 131 campuses, including branch clinical campuses and most of the targeted medical schools.
"It's really the students who want a strong family medicine presence on their campuses," said Deborah McPherson, M.D., assistant director of the AAFP Division of Medical Education. "They want to learn more about family practice. Even if they decide not to become family physicians, the students feel it's important to know what a family physician does."
Here are some recent developments at "target" schools:
- The Maryland AFP has instituted a program at Johns Hopkins University in Baltimore, Md., to help interested medical students learn more about family medicine.
- Yale University had its first FMIG meeting of the academic year in September, and 85 students showed up. The Connecticut AFP conducted a "hands-on" night at the request of Yale medical students, and 90 participated in learning more about family medicine.
- Harvard University medical students have met with the dean and spoken with their professors about creating an academic department of family medicine.
AAFP Target School List
Columbia University, New York City
Cornell University, New York City
Harvard Medical School, Boston
Johns Hopkins University, Baltimore
New York University, New York City
University of Chicago - Pritzker
University of New York - Mt. Sinai
Washington University, St. Louis, Mo.
Vanderbilt University, Nashville, Tenn.
Yale University, New Haven, Conn.
2000 AAFP Reference Guide
Are you interested in a particular AAFP service, product or activity? Access the 2000 AAFP Reference Guide by clicking on the title below and then supplying your AAFP ID number and your last name. The guide lists contact persons who can assist you. In most cases, just call Academy headquarters at (800) 274-2237 and dial the corresponding extension.
2000 AAFP Reference Guide
How to reach us
By mail
AAFP Headquarters
11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672AAFP Center for Policy Studies in Family Practice and Primary Care
2023 Massachusetts Ave., N.W., Washington, D.C. 20036AAFP Division of Government Relations
2021 Massachusetts Ave., N.W., Washington, D.C. 20036By phone/e-mail
AAFP Headquarters
(913) 906-6000;
fp@aafp.org;
toll-free (800) 274-2237Order department
(800) 944-0000;
orders@aafp.orgRegistration for AAFP meetings
(800) 926-6890AAFP Center for Policy Studies in Family Practice and Primary Care
(202) 986-5708;
policy@aafp.org;
toll-free (877) 349-0461AAFP Div. of Government Relations
(202) 232-9033;
capitol@aafp.org;
toll-free (888) 794-7481AAFP Foundation
(800) 274-2237, Ext. 4410;
foundation@aafp.orgAAFP Insurance Services
(800) 325-8166;
insurance@aafp.orgSociety of Teachers of Family Medicine
(913) 906-6000, Ext. 5415;
society@stfm.orgWorld Wide Web
www.aafp.orgIn general, use the above e-mail addresses. However, you may type in the first initial and the first seven letters of the last name of a staff member, followed by @aafp.org, to reach someone at AAFP headquarters. For example, the e-mail address jrockufe@aafp.org sends messages to JoAnn Rockufeler.
Resident/Student News
Applicants wanted for graduate education awards
The application period is open for the Mead Johnson Awards for Graduate Education in Family Practice.
Each application must be submitted to the Academy by March 1. Award winners will each receive $2,000 and a free trip to the Academy's Scientific Assembly.
Applicants must be in the second year of a family practice residency approved by the Accreditation Council for Graduate Medical Education when applying for the award.
To obtain an application, contact Penny Fletcher at (800) 274-2237, Ext. 6812, or visit www.aafp.org/members/membership/mead-req.html. The awards are supported by a grant from Mead Johnson, a subsidiary of Bristol-Myers Squibb Co.
Residents, fourth-year students
Vote for AAFP within AMA
If you belong to the AMA, the AAFP wants your vote. Here's why.
For each 1,000 votes cast for a specialty society, the society gains another delegate in the AMA House of Delegates. Fourth-year medical students, residents and physicians are eligible to vote.
To give family practice more clout within the AMA, vote for the AAFP.
Here's how.
- E-mail to ballot@ama-assn.org or call (800) 652-0605.
- Provide the medical education number on your AMA membership card. Lost your card? Call (800) 262-3211 for your ME number.
- Vote for the AAFP, code 060.
Other News
Will others follow suit?
UnitedHealth Group hands control back to doctors
You probably couldn't find a newspaper or television news program Nov. 9 that wasn't reporting on UnitedHealth Group's big decision.
The day before, United -- one of the nation's largest health insurers -- said it would no longer require doctors to get permission before performing tests or admitting patients to hospitals. Control, in other words, was handed back to the doctors.
The company was already approving more than 99 percent of requests for coverage, so the approval system was no longer needed, said Archelle Georgiou, M.D., chief medical officer of United Healthcare, a UnitedHealth Group company.
Prior to the Nov. 8 announcement, she and other United officials briefed AAFP leaders and senior staff and sought the Academy's perspective on the change.
"The erosion of physician control over medical decision making has been one of the sharpest thorns physicians have grappled with in the bramble of managed care," said John Swanson, director of the AAFP Socioeconomics Division. United's decision, if carried out as planned, could be good news for family physicians and their patients over the next few years, especially if other insurers follow suit, he said.
United serves 14.5 million customers in 45 U.S. markets, according to Georgiou.
Academy dedicates new headquarters, fountain
Leawood, Kan., Mayor Peggy Dunn helps AAFP President Bruce Bagley, M.D., of Albany, N.Y., wield giant scissors during the Nov. 4 dedication of AAFP's new headquarters in Leawood, a Kansas City suburb. Board Chair Lanny Copeland, M.D., left, of Albany, Ga., and EVP Robert Graham, M.D., held the ribbon. The fountain at the building's entrance was dedicated to the Academy's first chief executive, Mac Cahal, J.D., 92, who attended the event.
FP Report is published by the AAFP News Department. Copyright © 1999 by American Academy of Family Physicians.
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