An Update on Sinusitis This condition affects 30-35 million Americans and accounts for over 25 million office visits. Learn the latest treatment recommendations. Call for Resolutions and Nominations The House of Delegates needs to hear your voice. See page 16 to learn how you can be part of setting the direction for the Academy Planning for the Future What’s NEW in AAFP’s Effort to Implement the New Model of Family Medicine A View of Family Medicine in New Jersey • Volume 4, Issue 1 • Jan/Feb/March - 2005 Journal of the New Jersey Academy of Family Physicians Perspectives now accredited with AAFP Prescribed credit. See page 35 for details
Transcript
An Update on Sinusitis
This condition affects 30-35 million Americans and accounts for over 25 million office visits. Learn the latest treatment recommendations.
Call for Resolutions and Nominations
The House of Delegates needs to hear your voice. See page 16 to learn how you can be part of
setting the direction for the Academy
Planning for the FutureWhat’s NEW in AAFP’s Effort to Implement
the New Model of Family Medicine
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Journal of the New Jersey Academy of Family Physicians
Perspectivesnow accredited with
AAFP Prescribed credit.See page 35 for details
Remember When….Not long ago the official communication of the NJAFP was calledNJAFP News Notes. It was an 8-page, black and white piece thatcontained news of the Academy. As the Academy grew, NewsNotes grew into New Jersey Family Practice. The Academy keptgrowing and Ray Saputelli, CAE, Executive Vice President of theNJAFP and the Executive Committee visualized what New JerseyFamily Practice could become. And so began the process of movingfrom a newsletter format to a magazine containing informationspecific to the practice of family medicine in New Jersey. For fouryears we have been building the reputation of our state journal andtoday Perspectives: A View in Family Medicine in New Jersey hasgrown to a respected magazine with strong clinical content.
As the Managing Editor, I have had the pleasure of workingwith members of the Academy who have pulled together to makethis journal what it is today. It is because of the efforts of the writ-ers, editors and other contributors to Perspectives that I am pleasedto be able to say that as of this issue, Perspectives: A View of FamilyMedicine in New Jersey will now carry CME Credit. Special acknowl-edgements go to Joseph Wiedemer, MD, the first Executive Editorof Perspectives, who lent his vision to the development of the mag-azine and shepherded the beginnings, and to current ExecutiveEditor, Jeff Zlotnick, MD, and Medical Editors Richard Corson, MD;Cindy Barter, MD; Jeanne Ferrante, MD; and John Ruiz, MD whosededication led to the accreditation.
In this issue you will find CME offerings in respiratory medicinetopics, as well as in medical information and quality topics. Look forthis symbol to find those articles that carry accreditation. Infuture issues we hope to also add EB-CME for certain articles.
Besides the CME articles, you will also find stories on what ishappening with the Future of Family Medicine (courtesy of theTexas AFP chapter), information about the upcoming SummerCelebration and Scientific Assembly, a review of the recent NJAFPLeadership Retreat, stories on what different members have accom-plished in their careers, and much, much more.
To continue to build on its success, Perspectives needs authorswho are willing to write on clinical topics and on other issues thatare relevant to family medicine in New Jersey. If you are interestedin becoming a contributor to Perspectives, please contact me in theNJAFP office (609-394-1711) or email me at [email protected].
On The Cover Sinusitis is the third most common diagnosis for which an antibioticis prescribed. Though most physicians agree that antibiotics are over-prescribed, 50% ofpatients are given an antibiotic when presenting with cold-like symptoms. Learn aboutnew recommendations for treating sinusitis on page 9.
The NJAFP has won the Award of Excellence in the 2005Associations Advance America (AAA) Awards program for itsMedFest Program. The award is part of a national competitionsponsored by the American Society of Association Executives(ASAE), Washington, D.C.
MedFest is a volunteer physician program organized by theNJAFP in partnership with Special Olympics New Jersey (SONJ). Thepurpose of MedFest is to qualify people with developmental disabil-ities to participate in Special Olympic activities. All athletes, no mat-ter what their abilities, must receive pre-participation examinationsprior to engaging in organized sports. Program Chair and currentNJAFP Vice President, Jeff Zlotnick, MD noted, “The inspiration forthe program stemmed from the fact that our special needs popula-tion is a tremendously underserved community that encountersgreat difficulty obtaining even basic medical care. Many individualslive in group homes with limited access to health care, or are shut-tled between specialists without the benefit of a medical home.”
The MedFestprogram notonly gives ath-letes access tothe games, butalso offers themthe opportunityto establish arelationshipwith a FamilyPhysician whowill provide the
coordinated care that so many special needs patients lack – a true“medical home.” In addition, through CME courses designed by Dr.Zlotnick (or just “Dr. Z” to many of his patients) volunteer FamilyPhysicians participate in additional specialized training in workingwith this complex population.
Now in its 15th year, the prestigious Associations AdvanceAmerica (AAA) Awards program recognizes associations that pro-pel America forward—with innovative projects in education, skillstraining, standards-setting, business and social innovation, knowl-
edge creation, citizenship, and community service. Although asso-ciation activities have a powerful impact on everyday life, theyoften go unnoticed by the general public.
“It is an honor and an inspiration to showcase this activity astestament to the heart and soul of Family Physicians, as well as anexample of the many contributions associations are making toadvance American society,” remarked Ray Saputelli, CAE, NJAFPExecutive Vice President.
The MedFest program is now in the running to receive aSummit Award, ASAE's top recognition for association programs,to be presented in ceremonies at ASAE's 6th Annual SummitAwards Dinner Sept. 27, 2005, at the National Building Museum inWashington, DC.
ACADEMYVIEW
NJAFP Wins ASAE's 2005 Associations Advance America Award of Excellence
Perspectives NowCarries CME Credit
Your state journal, Perspectives: A View of Family Medicinein New Jersey has made another exciting leap forward, addingeven more value to your membership. Having grown from an 8-page newsletter to a full-color magazine with clinical contentunder the direction of Executive Editors, Joe Wiedemer, MD andJeff Zlotnick, MD and Managing Editor, Theresa Barrett, MS,Perspectives now has the distinction of being CME accredited.Beginning with this issue, Perspectives is now a peer-reviewedjournal that carries AAFP Prescribed CME Credit.
Members of the 2005 Editorial Review Board are RichardCorson, MD; Cindy Barter, MD; Jeanne Ferrante, MD; and JohnRuiz, MD, Jeff Zlotnick, MD (Executive Editor), and TheresaBarrett, MS (Managing Editor).
Articles on clinical topics, practice management, quality andtechnology, as well as personal insights into the practice of fami-ly medicine are welcome. Interested authors should contactTheresa Barrett, MS at [email protected] or 609-394-1711 for infor-mation on submitting material.
What has the NJAFP Done For You Lately?Dr. Jeff Brenner (Camden) and Dr. Tom Ortiz (Newark) testi-
fied on behalf of the NJAFP before the Senate Health Committeeon January 24, 2005 in favor of legislation that proposes to reformthe New Jersey Family Care Program. Drs. Brenner and Ortiz pro-vided the committee with the perspective of private practice fam-ily physicians with respect to their experience in their communitieswith the current program and the difficulties and confusion forFamily Care beneficiaries. The focus of the proposed legislation ison increasing access to the program by allowing adults to qualifyfor the program again, improving enrollment by streamlining theadministrative process for applicants, and expanding the opportu-nities for educating the population about the program.
Who is representing you at the AAFP?New Jersey is becoming a well-respected presence at AAFP.
Aside from Delegates Robert Pallay, MD and Richard Cirello, MDand Alternate Delegates Richard Corson, MD and MaryCampagnolo, MD, New Jersey is represented on the followingCommittee and Commissions:Commission on Scientific Programs
Richard Corson, MDCommission on Quality and Scope of Practice
Mary Campagnolo, MDCommission on Student and Resident Issues
Ray Saputelli (reappointed for a second term)Commission on Education
Contributing PhotographersTheresa J. Barrett, MS, CMPJeffrey A. Zlotnick, MD
Perspectives: A View of Family Medicine inNew Jersey is published four times a yearby the New Jersey Academy of FamilyPhysicians. Deadlines for articles andadvertisements may be obtained from theNJAFP office. The Editors reserve the rightto accept or reject any article or advertisingmaterial. Some material may be submittedto the Board of Trustees for review.
The views, opinions and advertisements inthis publication do not necessarily reflectthe views and opinions of the members orstaff of the New Jersey Academy of FamilyPhysicians unless stated.
Subscriptions for non-NJAFP members areavailable for $50 per year. Contact theNJAFP office for information.
New Jersey Academy of Family Physicians112 West State Street, 2nd FloorTrenton, NJ 08608Phone: 609/394-1711Fax: 609/394-7712Email: [email protected]: www.njafp.org
STAFFExecutive Vice PresidentRAYMOND J. SAPUTELLI, [email protected]
Deputy Executive Vice PresidentTHERESA J. BARRETT, MS, [email protected]
Vice-PresidentJEFFREY A. ZLOTNICK, MD 609/394-1711
TreasurerTHOMAS S. BELLAVIA, MD201/288-6781
SecretaryJOHN D. RUIZ, MD973/746-7050
BOARD MEMBERS Board ChairTERRY E. SHLIMBAUM, MD609/397-3535
Board of TrusteesCindy Barter, MD 2007Salvatore Bernardo, MD 2007Annabelle B. Dimapilis, DO 2006Amparito I. Fiallo, MD 2005Anthony G. Miccio, MD 2006Stephen A. Nurkiewicz, MD 2006Thomas R. Ortiz, MD 2005Marty D. Sweinhart, MD 2007John F. Tabachnick, MD 2005
Resident TrusteesVicky B. Tola, MD 2006 Christopher P. Zipp, DO 2005
Student TrusteeSarita A. Bharadwaj 2005Molly Cohen 2006
Voting Past PresidentsKenneth W. Faistl, MD 2005 Arnold I. Pallay, MD 2005
AAFP DelegatesRichard Cirello, MD 2006Robert M. Pallay, MD 2005
AAFP Alternate DelegatesMary F. Campagnolo, MD 2005Richard L. Corson, MD 2006
Perspectives: A View of Family Medicine in New JerseyThe Journal of the New Jersey Academy of Family Physicians
PRESIDENT’SVIEW
Caryl J. Heaton, DO is President of theNew Jersey Academy of Family Physiciansand Vice Chair of the Department ofFamily Medicine at UMDNJ-New JerseyMedical School in Newark, NJ.
his past fall I traveled to threenational meetings and I thoughtI would share the lessons I have
learned. Each meeting has been important and significantly differ-ent from the others, each with its own “take home” message.
AAFP Congress of DelegatesIn October the New Jersey delegation traveled to the AAFP
Congress of Delegates and Annual Scientific Assembly in Orlando,FL. The Congress is similar to our own House of Delegates in manyways, with representation of all states, resolutions brought anddebated, and elections of national officers. The process for resolu-tions is that each state submits them to the national office bySeptember, after that they are forwarded to what are known asReference Committees. Any delegation member, or for that matter,
any AAFP member, can come to the Reference Committee meetingand “testify” for or against a resolution. The process is formal, youare only given five minutes if there will be”extensive testimony” ie.,there are lots of people there. When speaking to a resolution, themember identifies their role in the Academy and then stateswhether they are speaking on behalf of themselves, their state chap-ter or their delegation. I noticed that the timing of our NJ Board ofTrustee meetings could be scheduled better in order to give us theopportunity to discuss these resolutions, among ourselves at least,before the national meeting. We will do this next year. Next year wewill also make every effort to put a “response page” on the NJAFPwebsite, so members can write us with their opinions.
The most contentious resolutions of this year’s meeting wereresolutions to stop or modify the Maintenance of Certification(MOC) process of the American Board of Family Medicine. Staterepresentatives from Michigan and Indiana lead resolutions to stopthe process all together, other resolutions asked for a slow down,or some other mechanism to substitute for the computerized SelfAssessment Modules. I had not taken the Diabetes module at thetime, so could not speak to how difficult it was or how slow the
“Ideal” and “Real”by Caryl Heaton, DO
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Perspectives 1Q05 5
6 Perspectives 1Q05
downloads were. I have since taken it, and although it was hard, itwas fair and “do-able,” it just takes some time. (I will be speakingat our annual meeting on Diabetes and will share most of what Ilearned about taking a SAM at that time.)
We can’t forget that the Maintenance of Certification was aprocess change made by the American Board of Family Medicine.The Academy does not have control over the ABFM, it is an inde-pendent entity. The ABFM is a member of the American Board ofMedical Specialties and each one has committed to some form ofMOC. To review the Congress’s resolutions on the Maintenance ofCertification visit http://members.aafp.org/members/PreBuilt/con-gress_2004summary.pdf, page 15.
Annual Conference on Patient EducationThe 26th Annual Conference on Patient Education is a joint
meeting sponsored by the Academy of Family Physicians and theSociety of Teachers of Family Medicine. The meeting this year washeld in San Francisco and co-chaired by New Jersey’s own CindyBarter, MD. A pre-conference addressed “How to Make Money forYour Practice: Billing for Patient Education” by AAFP Speaker-electTom Wieda, MD of Pennsylvania. Other great presentations includ-ed how to set up an effective asthma program, and how to usethe National Diabetes Education Program’s website.
This conference is useful for doctors who want to do morepatient education, but aren’t sure where or how to get started. It’sa low-key meeting. You can pick and choose the areas of interest. Iwas happy to see next year’s theme as “Patient Education: YourRole in the New Model for Health Care.” I believe that this confer-ence can and should be a meeting that is devoted to presentationson the New Model. Most of our low cost CME has been fundedthrough pharmaceutical companies and we are grateful for theirsupport. But the result of this is that most CME, at least at locallevels, has more to do with medical treatments i.e., therapeutics,than with how we must effectively change our offices and the waywe work.
16th National Forum on Quality Improvement inHealth Care
Changing medical care to improve quality is the focus of theInstitute for Healthcare Improvement’s 16th National Forum onQuality Improvement in Health Care. This meeting attracts over6,000 physicians, nurses, administrators and insurance executives,despites its hefty price tag. The meeting is so pricey that primarycare docs who may just want to improve their practice wouldn’tgenerally be able to afford it…another reason to look to thenational Academy to “home grow” this kind of CME.
The IHI had presentations from many well known authorsfrom Family Practice Management. There were presentations on EdWagners Chronic Care Model (http://www.improvingchroniccare.org)and some limited sessions on advanced access. There was almostnothing on computerized medical records. This group generallyassumes that all physicians have them. Dr. David Wasson andCharles Kilo asked us to think about two questions for ourpatients; 1) Are there things about your medical care that could be
better, and 2) How confident are you that you can manage andcontrol your health problems or health concerns? I’m afraid thatin my patients, the answer to those questions would not beresoundingly positive.
While this meeting was very exciting (to me at least), I couldn’thelp but notice that there was a big discrepancy between the“ideal” and the “real.” I could see how large, well-to-do health con-glomerates can buy EMRs and the consultants to operate them effi-ciently. But what wasn’t clear was how individual small groups ofpractitioners should make these changes. Should we take baby stepsor make sweeping changes? If we take small steps, in what ordershould we take them? Will the benefit of these changes in the longrun be less than the cost? In this month’s Perspectives we includedan overview article from the Texas Academy about the Future ofFamily Medicine’s Task Force VI: Report on Financing the New Modelof Family Medicine by Stephen J. Spann (Ann. Fam. Med, Nov 2004;2: S1 - S21.) It’s a great introduction to the issue of why to make thefinancial decision to go for the New Model of care.
Be assured that the NJAFP will continue to explore ways tobring these types of presentations to New Jersey. We are in theplanning stages for an Electronic Health Record (EHR) Summit sothat members can start to compare the costs and value of popularcomputer software programs. The NJAFP is also presently workingwith the Commission on Quality and Scope of Practice to bring aQuality Improvement program to NJ. You will be hearing moreabout that, next summer.
In all of these meetings, and in many of the activities and initiativesof the Academy, there is “ideal” and there is “real.” We would like tothink that these two things match, but they don’t always. Still, as leaders,we work to close the gap between what the ideal world would look likeand what the real world is. We do that through resolutions, life-longlearning, quality improvement, initiative and perseverance. It may taketime and it definitely will take patience, but as a “family” of familyphysicians we are moving forward.
NEW JERSEY DELEGATION TO THEAAFP HOUSE OF DELEGATES
DelegatesRichard Cirello, MDRobert Pallay, MD
Alternate DelegatesRichard Corson, MD
Mary Campagnolo, MD
Board Chair - Terry Shlimbaum, MDPresident - Caryl Heaton, DO
President-Elect - Robert Spierer, MDVice President - Jeffrey Zlotnick, MD
Executive Vice President - Ray Saputelli, CAEDeputy Executive Vice President- Theresa Barrett, MS, CMP
“Ideal” and “Real”Continued…
8 Perspectives 1Q05
EXECUTIVEVP’S VIEW
Raymond J. Saputelli, CAE is the ExecutiveVice President of the New Jersey Academyof Family Physicians and the ExecutiveDirector of the New Jersey Academy ofFamily Physicians Foundation.
I missed the deadline for this article. I hadlots of valid reasons (ok, a few reasonable excuses):I was sick, I was backed up with other important“stuff,” I had writer’s block... The truth: I didn’tknow what I wanted to say. It’s important to me to use this editorial to add value toyour life. I feel that if you’re taking the time to read it, I ought to write somethingworth reading. So I struggled. Today I started three more versions… none made itpast the first paragraph before falling victim to my delete key. Then I asked myself,“Why are you having such a problem? There are plenty of issues our members aredealing with, lots of areas where staff and leadership are working hard to ease theburden. What’s the trouble?” The answer came to me somewhere between my thirdcup of coffee and my younger daughter’s second attempt of the morning to rid theworld of her older sister. The trouble was that there is TOO MUCH to say…a monu-mental number of issues to discuss and work on, both good and challenging. I wasfeeling overwhelmed with all we had yet to accomplish. Then it occurred to me thatwe are all so focused on moving forward that we seldom stop and look back on allthe good we’ve done. With my writer’s block dissolving I decided to provide you witha retrospective of the past year’s achievements. This is by no means a complete list ofour activities, but a sampling of our most notable accomplishments.
2004 Summer Celebration and Scientific AssemblyAfter several years of “up and down” performance, which left staff and leader-
ship feeling we hosted the “best party that no one came to,” we made the decision inmid-2003 to get out of the annual meeting business. After a great deal of discussion,and the requisite gnashing of teeth, the NJAFP Board agreed to outsource the produc-tion of our annual event to a company who suggested that they could produce ourmeeting with complimentary CME. It seemed too good to be true, but the companywas credible and we took the chance. In late 2003 the company realized it could notproduce the meeting as planned and after several weeks of negotiation we mutuallyagreed to dissolve the partnership. In December 2003, leadership charged staff withthe production of our meeting – with less than 6 months to do so. They set specificgoals in the area of revenue, CME, and attendance, and then allowed the staff thefreedom to build the event. The outcome was a meeting that offered over 14 pre-scribed CME credits for a modest fee ($49). Our attendance topped our previous 5-year high, and the meeting was financially successful. Member feedback – accordingto meeting evaluations – was excellent, and more than 20% of our active membershipreported that they found value in the event. For information on our 2005 meeting,(May 20-22 in Atlantic City), see page 16 in this issue or go to www.njafp.org and clickon the 2005 Summer Celebration and Scientific Assembly.
Perspectives: A View of Family Medicine in New JerseyOur premier success story for the past 3 years has been this magazine, and this
held true in 2004. Perspectives is now published in full-color, is revenue neutral, and asof this issue carries AAFP Prescribed CME. It is our signature communication vehicle.Much of the credit for these accomplishments goes to Managing Editor TheresaBarrett, MS, CMP, original Executive Editor Joe Wiedemer, MD, and current ExecutiveEditor Jeff “Z” Zlotnick, MD. With the assistance of the new editorial board,Perspectives will continue its evolution by increasing the amount of CME content whileproviding information that is specific to family doctors in New Jersey. I encourage anymember interested in writing to contact the editors at [email protected].
Legislative Victory – Health Enterprise ZonesSo often our legislative action consists of reaction. In late 2003, the NJAFP decid-
ed that in order to truly bring value to members in the legislative arena, we needed tobe proactive in Trenton. Using an idea and the boundless energy provided by TomOrtiz, MD and the skill of our Government Affairs Director, Claudine Leone, Esq., theNJAFP drafted what became known as the Health Enterprise Zone bill which wassigned into law in 2004. This law provides incentives for primary care medical and den-tal practices to remain located or to locate in -- or within 5 miles of -- designatedHealth Enterprise Zones (HEZs). HEZs are medically underserved areas as identified bythe NJ Department of Health and Senior Services through the state’s Primary Care LoanRedemption Program. More information on the HEZ law and its potential benefits canbe found in the Government Affairs View (p. 24) in this issue, at www.njafp.org, or bycalling the NJAFP Office.
MedFest–A partnership between NJAFP and Special Olympics of NJ (SONJ)Under the efforts of Program Coordinator, Candida Taylor and Program Chair, Dr.
Z, the NJAFP has partnered with SONJ to produce MedFest. This program brings FamilyDocs to developmentally disabled athletes wishing to participate in Special OlympicActivities. On the surface this seems like a worthwhile but simple event: athletes needpre-participation physicals to participate in the games; Family Docs provide the physi-cals. There is, however, so much more to it than that. This event provides participatingNJ family physicians with education in dealing with this complex population, sendsthose docs into the community, offers the athletes the opportunity to make, what formany, is their first true contact with a physician who can provide their “medicalhome,” and allows for close to 100 special needs athletes to be cleared to participatein Special Olympics in just one morning. To say that this event improves the lives of allwho participate is an understatement. The value to the athletes and caregivers is clear,and one needs only to look at the tired smiles on the faces of the staff and volunteersto know what it meant to the members who participated. However, there is value evento those members who have not participated. In 2004, MedFest won a Summit Awardfrom the American Society of Association Executives (ASAE). This national recognitionallowed us to showcase the value that Family Physicians bring to their communities.The positive impact this recognition has had on the publics’ perception of Family Docsis priceless. The next MedFest is scheduled for April 15. Contact Candida in the NJAFPOffice to participate in this wonderful event.
Under the efforts of Program Coordinator, Candida Taylor and Program Chair, Dr.Z, the NJAFP has partnered with SONJ to produce MedFest. This program brings FamilyDocs to underserved athletes wishing to participate in Special Olympic Games. On thesurface this seems like a worthwhile but simple event: athletes need pre-participationphysicals to participate in the games; Family Docs provide the physicals. There is, how-ever, so much more to it than that. This event provides participating NJ family physi-cians with education in dealing with this complex population, sends those docs intothe community, offers the athletes the opportunity to make, what for many, is theirfirst true contact with a physician who can provide their “medical home,” and allowsfor close to 100 special needs athletes to be cleared to play in the games in just onemorning. To say that this event improves the lives of all who participate is an under-statement. The value to the athletes and caregivers is clear, and one needs only to lookat the tired smiles on the faces of the staff and volunteers to know what it meant tothe members who participated. However, there is value even to those members whohave not participated. In 2004, MedFest won a Summit Award from the AmericanSociety of Association Executives (ASAE). This national recognition allowed us to show-case the value that Family Physicians bring to their communities. The positive impactthis recognition has had on the publics’ perception of Family Docs is priceless. The nextMedFest is scheduled for April 15. Contact Candida in the NJAFP Office to participatein this wonderful event.
An Aerial View By Raymond J. Saputelli, CAE
Perspectives 1Q05 9
CLINICALVIEW
Richard Levine, MD is a faculty member at West Jersey-MemorialFamily Practice Residency Program.
inusitis is a condition that affects 30-35 million Americans andaccounts for over 25 million office visits. With direct costs of$2.4 billion per year, and an additional $1 billion for surgical
costs, it is a huge problem. Sinusitis is the third most common diagno-sis for which an antibiotic is prescribed. Even though most physiciansagree that antibiotics are over-prescribed, 50% of patients are givenan antibiotic when seeing the doctor for cold-like symptoms.
To review, sinus health depends on mucous secretion of normalviscosity, volume, and composition; normal mucociliary flow to pre-vent mucous stasis and subsequent infection; and open sinus ostia toallow adequate drainage and aeration. Not only do sinuses providemucous to the upper airways for lubrication and to trap viruses, bac-teria, and foreign material, but they also give characteristics to ourvoices, lessen skull weight, and are involved in olfaction.
Why do people with upper respiratory infections complain ofsinus infections? The most likely explanation is that the sinus mucosais contiguous with the nasal mucosa, so that people with a cold feelpressure and congestion in their sinuses. Further confounding thediagnosis of an acute bacterial sinusitis are allergic symptoms. Peoplewith allergic rhinitis tend to suffer from nasal congestion, clear rhinor-rhea, itching red eyes, and possibly a nasal crease. Distinguishing viralrhinosinusitis from bacterial sinusitis is more difficult. Bacterial sinusitiscan be classified into four categories:
• Acute Bacterial – lasts four weeks, symptoms resolve completely• Subacute Bacterial – begins at week 4, lasts up to 12 weeks• Chronic – symptoms last more than 12 weeks• Recurrent Acute – episodes lasting fewer than 4 weeks, separat-
ed by at least 10 days, or 3 episodes in 6 monthsWhile a viral URI tends to be worse at the beginning of the ill-
ness and last no more than 10 to 14 days, a bacterial sinus infectionpersists for more than 10 days. Although not very specific, physicalfindings include mucopurulent nasal discharge, swelling of the nasalmucosa, sinus pain, and possibly periorbital swelling. A history of“double sickening,” in which the symptoms were getting better aftera few days and then became severe again often points to a bacterialsinus infection.
The objectives of treating a bacterial sinus infection are todecrease the recovery time, prevent chronic disease, decrease exacer-bations of asthma, and to do so in a cost-effective way.Antihistamines are recommended if there is an allergic component tothe sinusitis, while topical and/or oral decongestants can help withthe symptoms of congestion. Keep in mind that nasal decongestants,while helpful, should only be used for three or four days to preventrebound congestion. Nasal irrigation may be helpful but is not donein the majority of primary care offices. Guaifenesin, at a dose of200mg to 400mg every six hours, might help symptoms as well.Finally, if indicated, an antibiotic may be prescribed. The decision touse an antibiotic is still controversial, since many cases of clinicallydiagnosed sinus infections are viral and the literature is still reluctant
to state that antibiotics provide an overwhelming advantage in thetreatment of sinusitis. Factors such as cost, side effects, antibioticresistance, and antibiotic reactions should be factored in when decid-ing on prescribing an antibiotic.
Amoxicillin is still a good first-line agent at a dose of 500mgevery eight hours for ten to fourteen days because 80% of patientswill respond. If the patient is penicillin allergic, then clarithromycin orazithromycin would be a good choice. Unfortunately, erythromycindoes not provide adequate coverage, and there is too much pneumo-coccal resistance to recommend trimethoprim, sulfamethoxazole. Ifthere is no response to the antibiotic within three days, then astronger antibiotic may be used if the patient’s symptoms have notchanged. Depending on the situation, the patient may need to bereassessed. The Cochrane Library reviewed acute maxillary sinusitis in2002 and found that, although the evidence is limited, confirmedcases of sinusitis, either by aspiration or radiographs, could be treatedwith amoxicillin for seven to fourteen days.
In children and young adults aged one to twenty-one, a taskforce of the American Academy of Pediatrics has proposed recom-mendations in treating acute sinusitis:
• Recommendation 1 – The diagnosis of acute bacterial sinusi-tis is based on clinical criteria with patients presenting with URIsymptoms that are either persistent or severe
• Recommendation 2a – Imaging studies are not necessary toconfirm a diagnosis of clinical sinusitis in children younger thansix (older than six is controversial)
• Recommendation 2b – CT scans of the paranasal sinusesshould be reserved for patients in whom surgery is being con-sidered, patients who do not respond to medical regimenswhich include adequate antibiotic use, or in assisting in thediagnosis of anatomical changes interfering with airflow ordrainage
• Recommendation 3 – Antibiotics are recommended for themanagement of acute bacterial sinusitis to achieve a morerapid clinical cure, but patients should meet requirements ofpersistent or severe disease
As you can see, bacterial sinusitis is a difficult diagnosis to make.The British Medical Journal found no evidence that amoxicillin waseffective in reducing or curing symptoms when the diagnosis of sinusi-tis was not confirmed by radiographs or aspiration. Therefore, it is upto the physician, in conjunction with patient input, to decide on theuse of antibiotics when acute bacterial sinusitis is suspected. Manypatients are willing to ride out the symptoms when physicians discussthe side effects often experienced by patients taking antibiotics.
Bibliography:• Sheldon L. Spector, MD “Parameters for the Diagnosis and Management of
Sinusitis” Journal of Allergy and Immunology 102(6), 1998 • James E. Leggett, MD “Acute Sinusitis: When – and when not – to prescribe
antibiotics” Postgraduate Medicine 115(1) Jan. 2004. 13-19• Kim Ah-See “Sinusitis (acute)” American Family Physician 69(11) 2635-2636
See CME test on page 35.
AN UPDATE ON SINUSITIS By Richard Levine, MD
S
10 Perspectives 1Q05
Perspectives for Patients: SinusitisAre you one of the 37 million Americans affected by sinusitis
every year? If so, here is some information from your family physicianto help you understand this condition.
What is Sinusitis? Sinusitis simply means your sinuses – the air chambers in the bone
behind your cheeks, eyebrows and jaw - are infected or the lining of oneor more of the sinus cavities in the facial bones around your nose isinflamed. What is not simple is the pain that this condition can cause.Sinusitis can make life miserable, causing tenderness in your face,aching behind your eyes and difficulty breathing through your nose.
Healthcare experts usually divide sinusitis cases into two cate-gories: Acute and Chronic.
What’s the Difference Between Acute and ChronicSinusitis?
Acute Sinusitis usually lasts 3 weeks or less and responds well toantibiotics and decongestants. Chronic sinusitis usually lasts for 3 to 8weeks but can continue for months or even years.
How do I Tell if I have Sinusitis?Because your nose can get stuffy when you have a cold, you
may confuse simple nasal congestion with sinusitis. A cold, however,usually lasts about 7 to 14 days and disappears without treatment.Sinusitis often lasts longer and typically causes more symptoms thanjust a cold.
Symptoms for acute sinusitis include facial pain/pressure, nasalobstruction, nasal discharge, diminished sense of smell, and coughnot due to asthma (in children). Additionally, you could have fever,bad breath, fatigue, dental pain, and cough. The doctor may deter-mine sinusitis to be present if you have two or more of these symp-toms and/or the presence of thick, green or yellow nasal discharge.
How Did I Get Sinusitis?Most cases of acute sinusitis start with the common cold, which
is caused by a virus. Colds do not cause symptoms of sinusitis, butthey do inflame the sinuses. The sinuses - the air chambers in thebone behind your cheeks, eyebrows and jaw - make mucus thatcleans bacteria and other particles out of the air you breathe. Eachsinus has an opening into the nose for the free exchange of air andmucus, and each is joined with the nasal passages by a continuousmucous membrane lining. Because of this, anything that causes aswelling in the nose - an infection, an allergic reaction, or a cold -can also affect the sinuses. Air and mucus are trapped behind thenarrowed sinus openings. When these openings become too narrow,mucus cannot drain properly and this sets up prime conditions forbacteria to multiply.
Most healthy people harbor bacteria in their upper respiratorytracts with no problems until the body's defenses are weakened ordrainage from the sinuses is blocked by a cold or other viral infec-tion. The bacteria that may have been living harmlessly in yournose or throat can multiply and invade your sinuses, causing anacute sinus infection.
What are the Symptoms of Sinusitis?You should see your family physician if your “cold” has lasted
longer than a week, you're still having trouble breathing throughyour nose and when you lean forward, you feel throbbing pain inyour face.
You may also have a stuffy nose, fever, thick green or yellownasal mucus, and an ache in your upper teeth. Other symptoms youmay notice include:• Headache when you wake up in the morning • Pain when your forehead is touched over the frontal sinuses • Swelling of the eyelids and tissues around your eyes, and pain
between your eyes.• Tenderness when the sides of your nose are touched, a loss of
smell, and a stuffy nose• Earaches, neck pain, and deep aching at the top of your head. • Fever • Weakness or tiredness • A cough that may be more severe at night
What is the Treatment?Acute sinusitis is generally treated with 10 to 14 days of antibi-
otics. Antibiotics are effective only against sinus problems caused bya bacterial infection. It is important to take this medicine exactly asyour doctor tells you and to continue taking it until it is gone, evenafter you’re feeling better.
Taking Care of Yourself When You Have Sinusitis• Get plenty of rest. • Drink plenty of fluids. • Apply moist heat by holding a warm, wet towel against your face
or breathing in steam through a cloth or towel. • Talk with your doctor before using an over-the-counter cold medicine.
Some cold medicines can make your symptoms worse or causeother problems.
• Don’t use a nose spray with a decongestant in it for more than 3days. If you use it for more than 3 days, the swelling in your sinusesmay get worse when you stop the medicine.
• Use an over-the-counter medicine such as acetaminophen for pain. • Rinse your sinus passages with a saline solution. You can buy an
over-the-counter saline solution or ask your doctor how to makeone at home.
Where Can I Get More Information About Sinusitis?Additional information about sinusitis can be found at:
• American Academy of Family Physicians– www.familydoctor.org
• The National Institutes of Allergies and Infectious Diseases– http://www.niaid.nih.gov/factsheets/sinusitis.htm
• MedLine Plus (The National Library of Medicine):– http://www.nlm.nih.gov/medlineplus/sinusitis.html
• The Mayo Clinic.com: Acute Sinusitis– http://www.mayoclinic.com/invoke.cfm?id=DS00170
Reviewed January 2005 by Richard Corson, MD
PERSPECTIVESFOR PATIENTS
The NJAFP realizes that being able to provide your patients with good patient educationmaterials is important to you. The Internet is a valuable resource for education, but somepatients do not have access to the Internet, are not computer savvy or may not be able todistinguish valid information from commercial hype. In an effort to provide you with addi-tional resources to help you educate your patients, the NJAFP has made the followingpatient education piece available on the “Members Only” section of www.njafp.org.Simply log in using your AAFP member ID number and download this 1 page, pdf file.
Perspectives 1Q05 11
ollowing the recent dramatic increase in antibiotic resistancein the United States and the availability of new, highly potentantibiotic drugs, the Sinus and Allergy Partnership (SAHP),
along with leading experts, updated its guidelines for the diagnosisand treatment of acute bacterial rhinosinusitis (ABRS), commonlyknown as sinusitis. The original guidelines were issued in 2000.
Differentiating bacterial from viral rhinosinusitis is often a chal-lenge because the clinical features of the two diseases are similar.Antibiotics kill bacteria, not viruses, and growing misuse of antibioticsto treat viral illness such as colds, flu and viral sinusitis is a leadingcause of antibiotic resistance.
The Centers for Disease Control and Prevention (CDC) reportthat the rate of penicillin resistance in Streptococcus pneumoniae (themost common respiratory tract pathogen) has increased more than300 percent in the United States during the past five years. The SAHPhas updated the guidelines to help physicians distinguish betweenviral and bacterial sinusitis and treat the disease appropriately.
The national average penicillin resistance level is recorded at22% in 2004, but many states and cities have a higher percentage.Louisiana (48%), Texas (41%), Florida (39%), Arizona (38%) andMississippi (34%) have the highest rates in the continental UnitedStates. Of the top ten cities with the highest resistance levels, five areFlorida urban areas, and two are Texas cities. The highest recordedresistance percentage was recorded in Jacksonville, FL (60%).
Bacterial sinusitis is usually a complication of a viral upper res-piratory infection (URI), such as the common cold. The updatedguidelines suggest that bacterial sinusitis be diagnosed in adults orchildren when a viral URI remains unimproved 10 days after onset(or worsens after five to seven days), and exhibits the followingaccompanying symptoms: nasal drainage, nasal congestion, facialpressure/pain (especially when the pain occurs on one side and isfocused in the region of a particular sinus), post-nasal drainage,reduced sense of smell, fever, cough, fatigue, dental pain in thejaw, and ear pressure or fullness.
To enable appropriate choice of treatment for bacterial sinusitis,the guidelines use the Poole Therapeutic Outcomes Model to groupcommonly used antibiotics into categories based on efficacy againstbacteria that cause ABRS – Streptococcus pneumoniae, Haemophilusinfluenzae or Moraxella catarrhalis. The Poole Therapeutic OutcomesModel is a mathematical model that predicts the efficacy of theantibiotics based on pathogen distribution, resolution rates withouttreatment and in vitro microbiologic activity.
In addition to presenting efficacy criteria, the guidelines proposethat physicians use antibiotic treatment for sinusitis in accordance withdisease severity, disease progression and risk factors for infection witha resistant pathogen, including recent antibiotic exposure. (See foot-note below table for more risk factors.) The guidelines separate sinusi-tis diagnosis into two categories: “mild” and “moderate.” Since eachpatient’s recent history of antibiotic use significantly affects the risk ofinfection due to resistant organisms, the guidelines also divide patientsinto groups based on antibiotic exposure in the past 4-6 weeks.
Approximately 20 million sinusitis cases appear in the U.S.annually, with an estimated annual economic impact of $3.5 billion.Sinusitis is the fifth most common diagnosis for which an antibioticis prescribed.
The Sinus and Allergy Health Partnership is a not-for-profitorganization created jointly by the American Academy of OtolaryngicAllergy, the American Academy of Otolaryngology–Head and NeckSurgery and the American Rhinologic Society.
The guidelines were originally published in the journalOtolaryngology-Head and Neck Surgery. They are available by mailfrom The Sinus and Allergy Health Partnership, 1990 M Street NW,Suite 680, Washington, DC, 20036, or online at www.sahp.org.
See CME test on page 35.
Sinus and Allergy Partnership Updates Sinusitis Guidelines: Recent Increase In Antibiotic Resistance Plays Prominent Role In Changes
F
Based on disease category and recent antibiotic exposure, the guidelines recommend:
Mild ABRS with No Recent Antibiotic Use (Past 4-6 Weeks)
• amoxicillin/clavulanate (1.75g-4g/250mg/day) *
• amoxicillin (1.5g-4g/day) *
• cefpodoxime proxetil
• cefuroxime axetil
• cefdinir
*Higher daily doses of amoxicillin (4g/day) are recommended for patients with risk factors for infection with a resistant pathogen. These risk factors include:recent antibiotic use, exposure to young children, living in areas with a high prevalence of penicillin-resistant S. pneumoniae or DRSP, and living in areaswith a high volume of pediatric antibiotic use.
Mild ABRS with Previous Antibiotic Use or Moderate Disease
Vincent E. Green MD is the Medical Administrator for the FamilyMedicine Center at Lumberton and a faculty member at WestJersey-Memorial Family Practice Residency Program.
As Family Physicians we want our practices to meet the needsof our patients. However, many of us struggle to identify the issuesthat matter most to patients. How do we know what our patientsexpect from a visit to our office? More importantly, how wellwould our patients rate us at meeting their needs?
Practices have used many methods to monitor patient satisfac-tion. One method is the patient survey. Patient satisfaction surveyscan help you identify ways of improving your practice and candemonstrate an interest in quality and in doing things better.1
There are several commercially available satisfaction surveys. Thesesurveys are typically mailed directly from the vendor to a randomsampling of patients. The completed surveys are returned to thevendor who then analyzes the data and sends the practice a reportdetailing the results. These externally developed surveys have twoprimary advantages: 1) The vendor does the data analysis and 2)the vendor can provide data from other similar practices againstwhich you can compare your performance. These surveys also havesome disadvantages. For example, if your practice has features thatmake it dissimilar to other practices in the databank, there may beno meaningful benchmark data for comparison. The cost of thistype of survey could also be prohibitive to smaller practices.
An alternative to using a survey developed by an outside ven-dor is to develop your own patient survey. This is a manageabletask, but it can be time consuming and you should keep in mindthe pressure you may be placing on your internal staff. If youdecide to develop your own survey, follow a stepwise approachand keep a few guiding principles in mind.
The first step in the process is deciding whom you want tosurvey and how frequently to survey. When you distribute yourquestionnaire, try to survey the largest group possible. This willimprove your chances of getting an adequate number of responses.1
The greater the number respondents, the more likely you are toget a true assessment of patient satisfaction In my experience withour patient survey, approximately one third of the patients who aregiven surveys will complete them. Therefore, you should keep theexpected response rate in mind when determining the number ofsurveys to distribute. Evelyn Eskin, MBA of HealthPower AssociatesInc, in Philadelphia states that the number of surveys depends onthe size of your practice, but the ideal would be to get at least 200surveys per physician (assuming a response rate of 25 percent, thatwould mean sending out 800 surveys). If the ideal is out of reach,collect as many surveys as your resources will allow.2
When deciding how frequently you want to survey yourpatients, I would suggest asking yourself, “What do I want to do
with the data I collect?” If your goal is to develop an improvementplan based upon the results, you should allow enough timebetween surveys to implement the plan and measure its success.Our practice surveys patients twice yearly: in the spring and fall.
Once you have decided when you want to conduct the survey,the next step is deciding how you want to distribute the survey.When distributing the survey, you should make every attempt tomaintain the anonymity of respondents. Patients are more likely toanswer questions truthfully if they feel their responses are anonymous.1
One distribution approach is to mail surveys to patients to completeand mail back. Another approach is to distribute surveys in theoffice and request that patients return the completed survey to aconfidential dropbox at the end of their visit. Regardless of thedistribution method you choose, I would suggest including a state-ment on the survey assuring patients that their responses are trulyanonymous and that the results will be used to help the practicecontinue to provide them with the best possible service.
Now you need to decide what you want to measure. Avoidthe trap of asking questions pertaining only to the physicians inthe practice. According to Mertz’s3 article citing The Horizon GroupLtd., 1997 Survey of Family Practice, physicians finished fourth ona list ranking the top four factors influencing patient satisfaction.Obviously, there are several other aspects of a medical practice thatpatients feel are important when rating their level of satisfaction.Typically, the most common areas covered are: access (gettingthrough on the phone, ease of getting an appointment, waitingtimes); communication between patient and office (quality ofhealth information materials, getting a return phone call, gettingback tests results); staff (courtesy of the receptionist, caring ofnurses and medical assistants, helpfulness of people in the busi-ness office); and the interaction with the doctors (whether thedoctor listens, thoroughness of explanations and instructions,whether the doctors take time to answer questions, how muchtime the doctors spend with the patient).4 Most surveys alsoinclude a category assessing the Practice as a whole. Patients con-sider all of these factors when rating satisfaction; therefore eachcategory measured by your survey should be weighed equally. Forinstance, questions regarding wait time and office staff should begiven equal importance to questions pertaining to physicians.
The final step is writing questions. Once you have decided thegeneral categories you want to assess you can now begin writing
QUALITYVIEW
“Patient satisfaction surveys can helpyou identify ways of improving yourpractice and demonstrate an interestin quality...”
The Basics of Measuring Patient Satisfaction in a Primary Care Practice
By Vincent E. Green, MD
Perspectives 1Q05 13
questions for each category. There should be enough questions toget an assessment of what you are trying to measure, but thereshould not be so many questions that completing the surveybecomes a burden to your patients. As a general rule of thumb,two or three questions for each of the categories being measuredshould be sufficient. Rather than simply assessing whether yourpatients are satisfied, your survey questions should attempt togauge their level of satisfaction. For this reason, surveys utilizescales for responses. We use a Likert scale consisting of StronglyAgree, Agree, Disagree, and Strongly Disagree, and assign anumerical value to each response. The most generally used andaccepted scale that you'll see quoted in the literature and utilizedby the NCQA is the five-point scale ranging from excellent topoor.1 Due to variations in patient educational backgrounds, we tryto use questions that are at a sixth grade reading level. When writ-ing questions remember that each question should be used toassess only that factor being measured. Questions should be short,easy to read, and easy to answer.
You are now ready to begin developing a patient satisfactionsurvey that should meet the needs of your patients and your practice.In the upcoming issues I will be examining how to analyze the dataand how a practice can then use the data to implement a plan thatimproves patient satisfaction. Based upon my experience with ourpractice’s survey, the information obtained will give you valuable
insight into your patients’ perception of your practice. It will alsoprovide you with the information necessary to ensure that yourpatients are receiving the service that they both desire and deserve.
Additional ReadingBaker SK. Improving Service and Increasing Patient Satisfaction.Family Practice Management. July/August 1998.
Mertz, M. What Does Walt Disney Know About Patient Satisfaction?Family Practice Management. November/December 1999.
White, B. Measuring Patient Satisfaction: How to Do It and Whyto Bother. Family Practice Management. January 1999.
References1. White, B. Measuring Patient Satisfaction: How to Do It and Why to
Bother. Family Practice Management. January 1999. 2. Ask FPM. Family Practice Management, June 1998. Patient Satisfaction
Surveys. Available at http://www.aafp.org/fpm/980600fm/askfpm.html.Last Accessed, January 2005.
3. Mertz, M. What Does Walt Disney Know About Patient Satisfaction?Family Practice Management, November/December 1999.
New National EHR Systems Initiative: Using Electronic Health Records to Positively Impact Physician Practices and Patient Care
By: Cari Miller: PRONJ Mary Campagnolo, MD; Chair NJAFP Quality Committee
PRONJ, The Healthcare Quality Improvement Organization of NewJersey, Inc., is implementing a national electronic health record (EHR) initia-tive for physicians in our state. The Doctor’s Office Quality – InformationTechnology project, or DOQ-IT, is sponsored by the Centers for Medicare &Medicaid Services (CMS) and designed to meet the following objectives:• To foster the implementation and use of EHR systems in small- to medium-
sized physician offices• To improve outcomes for patients with chronic illnesses by using EHR sys-
tems and health information technologyIn mid-2004, the U.S. Department of Health and Human Services
(DHHS), CMS’s parent organization, released an outline for a 10-year plan totransform the delivery of health care by building a new health informationinfrastructure, including EHRs and a network to link health records nation-wide. At that time, former DHHS Secretary Tommy G. Thompson emphasizedthat America needs to move much faster to adopt information technology inour healthcare system. “Electronic health information will provide a quantumleap in patient power, doctor power, and effective health care. We can’t waitany longer.”
The pilot phase of the DOQ-IT initiative is already occurring. PRONJ start-ed recruiting physician offices in November 2004 to participate in the first stageof the project. As participants, physicians and their office staffs will:• Receive free assistance in enhancing current EHR systems, or in selecting,
purchasing, and implementing one
• Hear from experts currently using these systems in their practices• Improve patient outcomes, staff satisfaction, and practice performance
measures• Receive evidence-based guidelines for practice redesign and care manage-
ment, as well as obtain suggestions and techniques on how to effectivelyapply these guidelines in your practice
PRONJ is looking for family physicians or internists who are committedto developing or strengthening computer expertise in EHR systems andwhose practice population includes Medicare patients. Through on-site visitsand office assessments, PRONJ staff members will help participating physi-cians and their office staffs develop processes for EHR system implementa-tion, as well as practice and workflow redesign.
Key national partners working with CMS on DOQ-IT include theAmerican Academy of Family Physicians (AAFP), the American MedicalAssociation (AMA) and the American College of Physicians (ACP).
DOQ-IT should prove to be an important project for making headway inproviding EHR systems that are interactive, standardized, and compatible,thereby improving healthcare communications among medical facilities andproviders. You can be part of this effort by contacting PRONJ to participate inDOQ-IT. Visit http://www.pronj.org/projects/3/19 to obtain information or callCarolyn Hezekiah Hoitela, MLS, Project Leader, by phone (1-732-238-5570,ext. 2012) or E-mail ([email protected]).
The NJAFP Quality Committee will also be in contact with PRONJ on theprogress of this important project. Contact Ray Saputelli at 609-394-1711or [email protected] if you are interested in joining the Quality Committee orwould like to learn more about its activities.
14 Perspectives 1Q05
Kennedy Ganti, MD is a 2nd year resident in Family Medicine atthe UMDNJ-Robert Wood Johnson Medical School program in NewBrunswick. He is also involved with the UMDNJ Informatics Group.Email him with questions or correspondence [email protected].
lectronic Health Records. PDAs. Electronic prescriptionwriting. PACS. Are these buzzwords merely the latestfad to hit clinical medicine or a harbinger of things tocome? For those professionals who concern themselves
with the balance of cost and the delivery of the highest possiblequality of health care, these tools represent a new foundation in thepractice of medicine. Moreover, they represent a fundamental shiftin how physicians practice medicine. Why are these changes hap-pening? Where can a family physician go to find tools to handlethe change?
The InfoTech View, a new column in Perspectives, seeks toanswer these and many more questions about computers in medicine.This first issue will address what informatics is, why it is important,and introduce tools that family physicians can use to improve dif-ferent aspects of their delivery of care. The beginning of this articleis intended as a fundamental introduction; tech-savvy readers mayfind this a bit basic.
What is medical informatics? Medical informatics is an emerging discipline that has been
defined as the study, invention, and implementation of structuresand algorithms to improve communication, understanding andmanagement of medical information.1 Simply put, it is the interdis-ciplinary study of how to manage medical information electronical-ly. Medical informatics is a branch of the larger biomedical infor-matics, which also includes biological sciences and clinical healthand services research.
Why all the hype around medical informatics? In 1999, the Institute of Medicine (IOM) published their now
famous report To Err is Human: Building a Safer Health System.This report, as part of a larger focus on the quality of healthcarepractice and delivery, addressed fundamental pitfalls and systemicerrors in the healthcare system that resulted in a loss of between17 and 29 billion dollars in hospitals nationally. Moreover, between44,000 to as many as 88,000 people lost their lives as a result ofthese errors.2 This report, needless to say, stirred up quite a bit ofcontroversy.
In 2001, the Institute of Medicine released the follow up to ToErr is Human called Crossing the Quality Chasm: A New HealthSystem for the 21st Century. In this report, the IOM called for adetailed plan “where health care should be supported by systems
that are carefully and consciously designed to produce care that issafe, effective, patient-centered, timely, efficient, and equitable.”3
Since then, medical informatics (as a discipline) has gainedmomentum in terms of the amount of attention and monies that itreceives resulting in a push by both private sector and governmentauthorities. Here in New Jersey, the PRO-NJ organization, a func-tionary of CMS (the Centers for Medicare and Medicaid) are seekingto help physicians throughout the state, with family physicians inparticular, to adopt informatics initiatives in an overall strategy forquality care improvements to Medicaid and Medicare recipients.[See Sidebar article: DOC-IT] This phenomenon has since percolatedthrough the everyday practice of medicine.
Different kinds of computers now permeate the medical envi-ronment delivering an unprecedented amount of computing powerinto the hands of physicians. Notebook PCs and Personal DigitalAssistants (PDAs) are now quickly gaining favor among physicians.Along with new choices in hardware, what kinds of resources areavailable to family physicians?
INFOTECHVIEW
Introduction to Medical Informaticsfor the Family Physician by Kennedy Ganti, MD
E
Perspectives 1Q05 15
Resources for physicians: The most prevalent applications are found on the Internet.
These tools can be broken down into websites and online applica-tions. Of the websites, there are ones that are specific to familymedicine and ones that are intended for a larger audience. Thewebsites are either free to access or have a membership chargeassociated with them.
Websites: Two important websites for family physicians arethe American Academy of Family Physicians (www.aafp.org) aswell as our very own NJAFP website (www.njafp.org). Both sitesare rich in information related to not only to the practice of familymedicine, but also in all the various activities, initiatives and part-nerships that the AAFP and NJAFP are involved in. The NJAFP has a“Members Only” section with information that is specific to familyphysicians in New Jersey.
Another resource for family physicians is Family PracticeNotebook at www.fpnotebook.com. At printing, this website fea-tures clinical information based on body system and disease stateswith 4316 topics organized into 616 chapters in 31 subspecialtybooks. This website has a free version that contains advertisementsfrom sponsors, and a subscription based version that is ad-free andhas a downloadable component, which allows the website to beplaced on a PDA. More complete information is available on thewebsite.
www.familypractice.com is another website of value to familyphysicians. This website contains information about issues of prac-tice management, earning CME, and disease specific information.Familypractice.com also has ABFP style board review questions thatare modeled after questions from the boards and can serve as avaluable resource for those taking the exam for the first time aswell as those who are going for re-certification.
Literature searches have always been popular among the gen-eral physician community. Medline, once restricted to medicallibraries, is available through the National Library of Medicine’sPubMed resource at http://www.ncbi.nlm.nih.gov/entrez/query.fcgi.Many other websites also now integrate Medline searches withintheir site. Medical websites for general information retrieval (news,simplified Medline searches and original articles) can be accessedthrough free physician memberships made available throughMedscape (www.medscape.com), a division of WebMD. Anothervaluable free site for clinicians is www.medicalstudent.com.Though initially assembled for medical students,medicalstudent.com serves as a great resource for fundamentalmedical information for all physicians.
The MerckMedicus website (www.merckmedicus.com) is anadvertising-free medical portal consisting of comprehensive med-ical resources available on the Internet. It contains a combinationbreaking medical news, online learning resources, diagnostic tools,and patient's perspective on the world of medicine. Membership isfree to physicians but requires registration with a state licensenumber. Also available on Merckmedicus.com is access toHarrison’s Online, the online version of Harrison’s Principles ofInternal Medicine, as well as other popular specialty based text-books. MerckMedicus has versions for both Palm and Pocket PCPDAs that integrate the famous Merck Manual as well as otheruseful programs like Theradoc, a PDA guideline based program
that helps make point of care decisions regarding appropriate useof antibiotics. The PDA version of MerckMedicus also features a‘handbook’ of laboratory diagnostic tests.
There are some fee-based websites and applications that canserve as valuable tools for family physicians. Medical publishinggiant Elsevier has MDConsult (www.mdconsult.com) a large web-site that combines a website with robust offerings such as onlineversions of popular textbooks (like Rakel’s Textbook of FamilyPractice and Nelson’s Textbook of Pediatrics), expanded Medlinesearches that includes actual articles in online and PDF formats, aswell as a large section on patient handouts. MDConsult also has aPDA version that integrates daily medical and drug news, journalabstracts and Mosby’s Drug Consult Interaction tool. Go towww.mdconsult.com for various subscription offers.
InfoPOEM Inc. offers InfoRetriever, an evidence basedresource created by family physicians. It features the entire main-stream 5 Minute Clinical Consult series, clinical calculators, ICD-9code lookup and POEMs (Patient Oriented Evidence that Matters).The site offers InfoPOEMs review monthly and updatesInfoRetriever several times a year. As a part of the subscription,family physicians have access to the Windows version of the soft-ware, Pocket PC and Palm versions as well as the online version.As of the publication of this article, a yearly subscription toInfoRetriever was $249.
A final resource that family physicians may find useful is asubscription to UpToDate (www.uptodate.com). This is an authori-tative source on the latest concepts and practices in InternalMedicine, Surgery, Pediatrics, OB/GYN, and Family Medicine.UpToDate features information that delves into the basic scienceaspects of diseases and works on up through the latest clinicaladvances. UpToDate is evidence based, but in a different mannerthan InfoRetriever. UpToDate cites more disease oriented evidencethan patient oriented evidence. As a part of the subscription,physicians are given access to Windows, Macintosh, Internet andPocket PC versions of the software. As of the publication of thisarticle, the cost of UpToDate was $395 per year.
The resources mentioned in this article are those that are mostused in New Jersey academic circles. There are many more infor-mation resources available for family physicians. Many individualfamily physicians, departments of family medicine residency pro-grams and organizations have websites and new applicationsbecome available everyday.
The next column in this series will discuss the Electronic HealthRecord and some of its advantages and tips for implementation.The key to successful change is in understanding the key aspectsof what new ideas and technologies bring.
References1. Zakaria, A. (2004) What is Medical Informatics? Retrieved December
28,2004 from http://www.faqs.org/faqs/medical-informatics-faq/ .2. Institute of Medicine(1999) Report Brief. To Err is Human, Building a
Safer Health System. Retrieved on December 28,2004 fromhttp://www.iom.edu/includes/dbfile.asp?id=4117
3. Institute of Medicine(2001) Report Brief. Crossing the Quality Chasm:A New Health System for the 21st Century Retrieved on December28,2004 from http://www.iom.edu/report.asp?id=5432
16 Perspectives 1Q05
EDUCATIONALVIEW
Information for Todayby Jeffrey A. Zlotnick, MD CAQ
Vice President, NJAFP Annual Meeting Chair
This year, I have the opportunity to be the Chair of the2005 Summer Celebration and Scientific Assembly. As in pastyears, I am proud to invite you to THE meeting that brings togetherexperts to provide you with cutting edge information on familymedicine.
Last year, we revamped our educational program and it was anamazing success! We also lowered our registration fee to make themeeting quite affordable for our membership. I am happy to reportthat again this year, if you register early you can attend the entiremeeting for $49. You would find it difficult to get this kind of highquality, family medicine oriented CME while having a great timeinteracting with your peers for that kind of price. Apparently, about185 of your colleagues agreed and attended last year’s meeting.
We have two incredible keynote speakers this year: VictorDeNoble, PhD, the man responsible for shining the light on thetrue nature of nicotine addiction and what the tobacco companiesknew about that; and Larry Greene, MD from the Robert GrahamPolicy Center in Washington D.C. Dr. Green will be speaking onthe “how” of implementing the Future of Family Medicine. Thesetwo powerful speakers are guaranteed to be talking about sub-jects that you’ll want to know more about.
Our educational offerings this year will focus on the hot issuesimportant to family docs. We will be offering sessions on child-hood obesity, adult ADHD, updates in the treatment of osteoporo-sis, cardiovascular disease, pain management, and many othertopics. Some educational sessions will carry EB-CME, which is nowworth double credit.
The 2005 meeting will be held at the Sheraton Atlantic CityConvention Center Hotel and the Atlantic City Convention Centerin Atlantic City, NJ on May 20th through the 22nd. Atlantic Cityhas just gone through some major renovations. Now, besides thebeach, the boardwalk, and the entertainment, there is the outdoor“Walk” featuring great shopping and dining. While you are in ses-sions, there will be no lack of opportunities for your family toexplore and have fun.
You should have received your registration materials in themail. Online registration is available on the NJAFP website atwww.njafp.org. Click on the link for the 2005 Summer Celebrationand Scientific Assembly. You will also find up-to-the-minute devel-opments on the agenda, special guests and other activities.
Educating our members is one of our prime missions. Througheducation we assist our members in being the best physicians theycan be thereby helping to improve overall patient care for the citi-zens of New Jersey.
I hope this year’s meeting will provide something a little uniquein Academy CME; the best, most varied, most useful information youcan get in two and a half days. I look forward to seeing you there!
ONE VOICE…YOUR VOICE…CAN CHANGE THE WORLDSubmit a Resolution for the House of Delegates
When one person cares enough to make their voiceheard, the world can change. When one person has thecourage and the passion to take a stand, the world canchange. When one person makes an effort – not waiting forsomeone else to do it – the world can change.
Are you ready to be part of the change? If so, take thefirst step and write a resolution for the 2005 House ofDelegates.
Resolutions are a request to establish Academy policy,request implementation of Academy programs, address issuesof interest or concern to family physicians and the specialty offamily medicine, or request the elimination of Academy activi-ties considered non-essential. In addition, there are special res-olutions of commendation or in the memory of deceased offi-cers or delegates.
Writing a resolution follows a specific protocol, but it iseasy to master. For a complete guide to writing resolutions forsubmission to the House of Delegates, go to the MembersOnly section of www.njafp.org and follow the links for theHOD Information page under “Member Services.” Click on thedocument “Call for Resolutions 2005.” You can also call theNJAFP office at 609-394-1711.
Resolutions may be sent by regular mail, fax or email:New Jersey Academy of Family Physicians Attn: Speaker of the House112 West State Street, Trenton, NJ 08608Fax: 609-394-7712 • Email: [email protected]
2005 Summer Celebration and Scientific Assembly
✓
Resolutions will be heard at the House of Delegates
The House of Delegates convenes at 8:00am on Friday, May 20, 2005 at the Sheraton Atlantic City
Convention Center Hotel in Atlantic City, NJ
Deadline for Resolutions is Friday, April 15, 2005
Emergency resolutions submitted after April 15th will be considered received at the House of Delegates and presented
to the Delegates at the discretion of the Speaker.
CALL FOR FAMILY PHYSICIAN OF THE YEARThe Family Physician of the Year Award provides a means for
recognition of individuals who embody the principles of excellencein family medicine. It is the Academy’s most prestigious award.
The Selection Committee is making its first call for nomineesfor this award. Please consider family physicians you know whowould represent New Jersey as the “best of the best.”
County chapters, other groups or individuals have the oppor-tunity to submit nominations. The physician selected will be recog-nized in the public relations efforts of the NJAFP, and will be for-warded as the New Jersey nominee for the prestigious AAFP“Family Physician of the Year” award.
GUIDELINES FOR SELECTION:• Provides his/her community with compassionate, comprehensive
and caring medical service on a continuing basis• Is directly and effectively involved in community affairs and activi-
ties that enhance the quality of life in his/her home area• Provides a credible role model, emulating the family physician as
a healer and human being to his/her community, and as a pro-fessional in the service and art of medicine to colleagues, otherhealth professionals, and especially to young physicians in train-ing and to medical students
Specific to New Jersey:• Has been in Family Practice in New Jersey at least five consecutive
years• Must be board-certified in Family medicine• Must be a member in good standing in his/her community• Must be a member in good standing of the NJAFP
Members wishing to place a candidate in nomination shouldsubmit the following material to the Selection Committee,care of the NJAFP Office, no later than April 15, 2005.
NOMINATION MATERIALS TO BE INCLUDED:The following materials must be included to be considered:
• Name, address and phone numbers of the nominee• Name address and phone numbers of the nominating individual• A letter of nomination (no more than two pages)• A current CV• Three letters of support – two (2) from colleagues and one (1)
from a person in his/her community.• Other supportive material, as appropriate (not over 15 pages)
Mail to:Family Physician of the YearNJAFP112 West State StreetTrenton, NJ 08608
The NJAFP Needs You! Call for Nominations for the Board of Trustees
Nominations are being sought for the Board of Trustees forthe 2005-2006 year. Your involvement is needed…Your voice isneeded…Your views are needed…You are needed.
We anticipate that three full-term positions for Board Trusteeswill be open in 2005. Also open are the Vice-President, theSecretary and the Treasurer positions, one position for AAFPDelegate and one position for AAFP Alternate Delegate, as well asone Resident and one Student Trustee position. Depending on theoutcome of the elections partial terms may need to be filled. Visitwww.njafp.org/membersonly and click on HOD for more information.
Members in good standing of the NJAFP may be consideredon the slate of nominees upon submission of the following docu-ments and the approval of the Nominating Committee:
1. A letter of interest indicating the position for which youplan to run
2. Your current CV3. Two letters of recommendation/nomination from members
of the Academy4. A declaration of any conflict of interest (form available
through NJAFP Office)
Individuals who have not served on a committee or on theBoard in previous years may be asked to interview with theNominating Committee.
Elections will be held at the House of Delegates, which convenesat 8:00 a.m., on Friday, May 20, 2005 at the Sheraton Atlantic CityConvention Center Hotel in Atlantic City, NJ. The meeting is opento all members.
Trustees’ duties include attending approximately five meetingseach year (with additional preparation time of approximately 2-4hours prior to each meeting) and possibly serving on other com-mittees at the discretion of the President. More specific duties andresponsibilities for each position are available through the NJAFPoffice or on the web at www.njafp.org in the Members Section.
Nomination materials may be sent by regular mail, fax or email:Nominating CommitteeC/O Ray Saputelli, CAENJAFP, 112 West State Street, Trenton, NJ 08608Fax: 609-394-7712Email to: [email protected]
Deadline for Nominations for Family Physician of the Year is April 15, 2005
CALL FOR FAMILY PHYSICIAN OF THE YEAR
Call for Nominations for the 2005 House of Delegates
Deadline for Nominations is April 15, 2005
Perspectives 1Q05 17
18 Perspectives 1Q05
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Cox 2’sMyth vs. Reality
TBD
Town HallMeeting
7pm - 9pm
ExecutiveCommittee
Meeting 4pm - 6pm
House of Delegates8:00am - 3:00pm
Sheraton
Delegates Lunch
3:30 - 4:25Migraines
TBD
4:30 - 5:25Restless Leg
SyndromeE. Schalm
5:30 - 6:25Lipid Therapy
to Reduce RiskP. Altus
SA Registration -ACCC
3:30-4:25Updates in
DermatologyE. Schlam
4:30 - 5:25Adult ADHD
D. Baron
5:30- 6:25Improving
Diabetic Care C. Heaton
Exhibitor's Reception
6:30pm - 8:00pm
Resident Knowledge Bowl
8:00pm - 11:00pm
6:15 am-7:30AIM for Fitness
(Breakfast CME)
8:00 - 8:55Metabolic Syndrome
TBD
9:00 - 9:55Insln Resist &
B Cell DysM. Sandburg
10:30 - 12:00Tales from the
Dark SideDeNoble
1:15 - 2:15From
What to WhatGreen
2:15 - 3:10Osteoporosis
UpdatesJ. Levine
3:30 - 4:25Update HepatitisA. De La Torre
4:30 - 5:25Vaccine Update
S. Barone
Breakfast & Exhibits
4:30 - 5:25Men’s Health
TBD
3:30 - 4:25Fibromylaigia
R. Podell
2:15 - 3:10Update Allergy
and AsthmaTBD
9:00 - 9:55HPV
Bhattacharyya
8:00 - 8:55TBD
Breakfast
Better BonesWorkshop
Assmbly Concludes
10:45 - 11:40Child Obesity
May
9:30 - 10:25Am I Hungry
May
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drugsTBD
DelegateRegistration and
Breakfast
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Break 3:00 -3:15
Lunch and Exhibits
President's Reception 6:15pm - 7:00pm
President's Gala7:00pm - 11:00pm
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THURSDAY FRIDAY SATURDAY SUNDAY
Educational Offerings at the 2005 Scientific AssemblyVisit www. njafp.org and click on the links for the Scientific Assembly to see the most up-to-date agenda and faculty listing.
Register online at www.njafp.org. Follow the links for the 2005 Summer Celebration and Scientific Assembly.
Perspectives 1Q05 19
Vicky B. Tola, MD is a Resident Trustee ofthe Board of Directors for the NJAFP and aPGY 2 at Hunterdon Medical Center inFlemington.
he annual NJAFP Leadership confer-ence in November 2004 was a com-plete success. Terry Shlimbaum, MD
spoke about leadership and why we werethere. Tom Ortiz, MD exemplified for ushow a “Can Do” attitude and dedicationand belief for a cause will take you to greatheights and inspire others to follow yourfootsteps. He related to us his vision ofhelping the underserved populations bynurturing an idea that developed into thebill on Health Enterprise Zones. ClaudineLeone enthralled us with the adventuresand perils they faced as that bill journeyedthrough the legislature. Mary O'Halloran,former Iowa state legislator, political activistand media consultant, spoke of “effectivelycommunicating your message.” She inter-viewed some of us unsuspecting volunteerson “live TV” and gave us constructive criticismand feedback. In essence, this conferencereviewed leadership and identified languageas its main tool.
Ms. O’Halloran quoted James C.Humes, the noted speech writer: “The lan-guage of leadership is the language of theheart.” She said that “In order to commu-nicate this language you must arm yourselfwith knowledge and understanding. Whenyou speak to an audience, 70% of whatthey remember will be your appearance,20% will be how you delivered your messageand 10% will be the message. Therefore,
we must enhance our communication skillsby being confident. If you are confident, youare there in the moment, you are present. Tobe present, you must be fearless. To befearless, you must be prepared.” Marywent on to explain how we must “frame”our topic, choose our “main message”and be ready with “sound bytes.”
As part of an exercise were handedsome current medical issues that would bediscussed by a group of panelists. Little did Iknow what was instore for me when Ivolunteered to par-ticipate in the “onthe air” interviewswith Mary. There Iwas, the only resi-dent on a physicianpanel made up ofseasoned familyphysicians who haveprobably been inter-viewed before. Thetopics of discussionwere worthy ofhours of debate andpreparation but what did we intervieweesget? Fifteen minutes! Certainly not enoughtime for what our facilitator espoused asthe most important aspect of conveying amessage: preparation. It was an anxiety-pro-voking and nerve-wrecking experience. Butit was also heartening, edifying and a wholelot of fun!
Mary gave us all insight into littlethings we could change or improve in ourphysical presence to enhance the chancesof our message getting across to the masses,
such as “do not cross your legs; smilemore, fidget less; do not fold your armsacross your chest, instead rest them onyour lap; and look at the interviewer whenanswering questions. When critiquing our4C's of competent, compassionate, com-prehensive and cost-effective quality care,Ms. O’Halloran pointed out that compe-tence and compassion were a given andassumed by the patient. To call attention tothese qualities would query their existence.
Here are a few more sound bytesfrom our conference as food for thought:“People don't care how much you knowuntil they know how much you care.”…“You must know the audience. Who arethese people who are going to listen toyou? What do they care about? What doyou care about?”… “Confidence is thephysical manifestation of the ease andgrace in your heart and mind. The enemyof confidence is fear and anxiety.Preparation liberates you from fear!”
The panel discussion made us examinethe question: what's so special about familymedicine? Distilled answer: by virtue of thefact that we take care of a myriad ofdiseases we must possess and hone our
clinical skills in order to recognize and treatthe gamut of medical illness amidst abroader biopsychosocial picture.
By the end of the conference, we lefta little wiser and reinvigorated with theenergy to better the world, amelioratesuffering, and heal the system startingwith our own communities. To communicateour value and affect any kind of change toour current system we will need the gifts ofleadership and language and this conferencewas a fine start.
Learning to CommunicateBy Vicky Tola, MD
T
20 Perspectives 1Q05
Learn How toDefend Yourselvesin a LawsuitCME seminars Sponsored by NJ PURE
Subpoenas, interrogatories, depositions…these are termsphysicians never expected to study. After all, physicians arehealers--not lawyers. But with the sharp increase in medicalmalpractice lawsuits, doctors find they must study the finerpoints of legal defense or risk losing their practices.
In order to help physiciansunderstand what they mayface in a malpracticesuite, NJ PURE, a not-for-profit medicalmalpractice recipro-cal exchange, issponsoring“Preventing andDefending Claimsand Lawsuits,” Theseminar is part of NJPURE’s ongoing LossControl Risk ManagementSeries, “Knowledge is Power,”designed to empower and educate physicians in the areas ofmalpractice claims and lawsuit prevention/process management.
The presentation stresses those actions a physician cantake to prevent being sued in the first place: practicing empa-thy, communicating effectively, disclosing complications, anddocumenting all aspects of patient care. It then reviews what todo if you are faced with a lawsuit, and covers pre-litigation,affidavit of merit, interrogatories, and depositions.
NJ PURE is a reciprocal exchange focused on providingat-cost solutions to the current crisis in medical malpracticeinsurance in New Jersey. Costs are minimized through theprocess of writing directly to responsible physicians eliminat-ing the high costs associated with commissions for agents.NJ PURE also lowers their risk by capping the number of doc-tors who practice in certain high-risk specialties. Other cost-saving strategies include handling all claims administrationin-house, adopting a portfolio of liability limits of $1 mil-lion/$3 million, and eliminating the added costs of agentsand brokers.
NJ PURE’s 2005 “Knowledge is Power” seminars willtake place on Thursday, May 12 at the Eatontown Sheraton;Thursday, September 8 at the Clarion Hotel in Egg HarborTownship; and Wednesday, November 2 at the Holiday Inn inMonroe Township.
For further information about the seminars or about NJPURE, call 877-2NJ PURE (877-265-7873), or visit the compa-ny’s website at www.njpure.com.
ABFM Moves to Online RegistrationThe American Board of Family Medicine is offer-ing online registration for its 2005 certification, recertification andsports medicine exams. The online application process has stream-lined registering for the examination. In many instances, the physi-cian can complete the entire process in minutes at a single sitting.
The online application process began December 1, 2004 andtest center selection came online 2 weeks later. The online regis-tration and test center selection applications can be accessed atwww.theabfm.org. With the move to computer-based testing lastyear, the ABFM is now able to offer nine exam dates, includingSaturdays, at over 200 test centers throughout the United States,Puerto Rico and U.S. territories.
Diplomates are encouraged to visit the website to completetheir applications as early as possible to increase the probability ofselecting the test center of their choice. All eligible candidates forthe 2005 exam can login to their Physician Portfolio and followthe “Online Application” link to access the application. Once anapproved application has been completed, the Diplomate will thenbe able to choose a test center. The link to Test Center Selection isalso found in the Physician Portfolio.
For more information, please contact the ABFM Help Desk at(877) 223-7437.
The Board of Trustees, members, and staff ofthe New Jersey Academy of Family Physicians
are pleased to announce the Candidacy ofRobert M. (Butch) Pallay, MD, FAAFP for
position of Director of the American Academyof Family Physicians. Learn more about Butch,
ask questions, or make suggestions at www.DrButch.com.
Butch PallayStraight Talk, Solid Leadership
22 Perspectives 1Q05
NEW JERSEYVIEW
NJAFP Members in the News…The State of theUnion….
When medical liabili-ty reform was spotlighted inthe State of the Union addressin January, Family Medicinestepped into the front line. OnFebruary 2nd Arnold Pallay, MD, ofMontville, NJ (Past President of the NJAFP) was featuredon the Paula Zahn Now program immediately before the live broad-cast of the President’s address.
President Bush has made tort reform — including medical liabil-ity reform — one of his second-term priorities. Expecting a referenceto the issue in the state of the union address, CNN dispatched JeffToobin, senior law correspondent, to Pallay’s office for a six-hourinterview. The result: a five-minute segment on CNN in which Pallayexplained the effects of skyrocketing malpractice insurance premi-ums on medical practice. In his case, the impact was loss of obstetri-cal services for his patients when Pallay’s premium ballooned from$7,000 a year to $60,000.
“If this continues at this present trend, I’m very afraid familyphysicians will stop delivering babies,” said Pallay. “And goodOB/GYNs will stop. So who’s delivering our babies?”
The Honorable WilfredoCaraballo is awarded the2004 Edward A. Schauer, MDPublic Policy Award
The NJAFP awarded New Jersey Asssemblyman WilfredoCaraballo the Edward A. Schauer, MD Public Policy Award. ThePublic Policy Award seeks to recognize those individuals who pro-mote constructive engagement between family medicine advocatesand governmental leaders for the purpose of delivering high qualityhealthcare services. Assemblyman Caraballo was recognized for hissupport of the Health Enterprise Zone legislation (See GovernmentAffairs View, p. 24).
Wilfredo is the Assemblyman for New Jersey’s 29th District thatincludes the Township of Hillside and Newark City (partial). He wasfirst elected to the Assembly in 1995 and has been re-elected fivetimes. He is Parliamentarian, also Chairman of theTelecommunications and Utilities Committee and Vice-Chair of theTransportation Committee. His legislative office is located in Newark.
Edward A. Schauer, MD Public Policy AwardIn 2003 the NJAFP instituted the Edward A. Schauer Public
Policy Award. This award is to be presented each year to anindividual who has made significant efforts to use public policyto advance opportunities for access to comprehensive healthcare and promote high quality standards for family physicianswho are providing continuing health care to the public. Anyappointed or elected public official or leader in the healthcarecommunity is eligible to receive the award. If you would likedetails on the Award or would like to nominate a candidate toreceive the Award, contact Claudine Leone, GovernmentAffairs Director at 609-394-1711 or [email protected].
Assemblyman Caraballo with NJAFP Leadership (l to r), Board Chair, Terry Shlimbaum, MD;President Caryl Heaton, DO; Assemblyman Caraballo; Board Trustee, Tom Ortiz, MD
Other Members in the News…
Caryl Heaton, DOUPN local news in Secaucus (Channel 11) on how to prevent,recognize, and treat flu and similar illnesses. (January 2005)
Richard Paris, MDHerald News Article on the struggle primary care physiciansface in a managed care environment (Health of doctors’incomes: November 9, 2004).
Arnold Pallay, MDDaily Record on the Presidential Debates (Morris reacts to pres-idential debate: October 9, 2004)
Robert Spierer, MDStar Ledger in an article on the prevalence of flu-like viruses inthe area. (Variety of viruses putting many in flu-like misery:January 07, 2005)
Congratulations to…David Swee, MD, who has been named Acting Senior AssociateDean for Education at UMDNJ-Robert Wood Johnson MedicalSchool. In this new position Dr. Swee will have responsibility forStudent Affairs.
David Swee, MD on his appointment to the AccreditationReview Council of the ACCME.
Alfred Tallia, MD, MPH, who has been named Acting Chair ofthe Department of Family Medicine, UMDNJ-Robert WoodJohnson Medical School.
Richard Corson, MD on the re-opening of his private practicein Hillsborough, NJ
Degree of Fellow ConferredThose candidates receiving the Degree of Fellow have
been members of the AAFP for a minimum of six years, havecompleted extensive continuing medical education, participat-ed in public service programs outside their medical practice,conducted original research and have served as teachers offamily medicine.
The following NJAFP members have been awarded theDegree of Fellow of the American Academy of Family Physicians.
• Adity Bhattacharyya, MD; Hoboken, NJ • Dennis A. Cardone, DO; New Brunswick, NJ• Josette C. Palmer, MD; Glassboro, NJ• Elisabeth F. Spector, MD; Somerville, NJ• Anna E. Sweany, MD; Neptune, NJ
There are over 4,000 support groups that meet in New Jerseyfor just about any type of stressful situation that affects the wellbeing of an individual. Persons seeking support groups often expresstheir desire to meet others who share similar experiences, pooltogether practical information, exchange coping strategies, and bepart of a community that understands. C. Everett Koop, MD, formerU.S. Surgeon General once said, “My years as a medical practitioner,as well as my own first-hand experience, have taught me howimportant self-help groups are in assisting their members in dealingwith problems, stress, hardship and pain…Today, the benefits of mutu-al aid are experienced by millions of people who turn to others witha similar problem to attempt to deal with their isolation, powerless-ness, alienation, and the awful feeling that nobody understands.”
The New Jersey Self-Help Group Clearinghouse operates astatewide toll-free help-line providing contact information to self-help groups, toll-free specialty help-lines, community help-lines, andlocal psychiatric emergency lines. The support groups cover a broadspectrum of stressful life situations and adversities such as addictions,bereavement, disabilities, mental health, families of the mentally ill,parenting, illness, care giving, and much more. Many callers to theClearinghouse are surprised to learn that support groups have been
developed for very specific concerns. For example, within the listingof support available for parents there are groups for: single parents,foster parents, parents of disabled children, parents of toddlers, parentsof adolescents, parents of children with emotional difficulties, parentsof children with illness, and “stay at home” parents, among others.
The Clearinghouse also provides free consultation and trainingservices to persons developing no-fee support groups. Consultantsprovide free assistance with the “how to” of starting a group:finding a meeting space, reaching prospective members, creating aflyer, writing a press release, establishing group discussion guidelines,structuring a meeting, and more. Consultants can also provide awide range of printed materials related to self-help groups such as:how to deal with difficult people, how to be a contact person fora group, developing listening skills, and facilitation skills. In conjunctionwith the consultation services the Clearinghouse provides freetraining workshops on the development and facilitation of self-help groups.
For information on finding or forming a support group, call theNew Jersey Self-Help Group Clearinghouse at 1-800-367-6274 or973-326-6789. Trained volunteers and staff are available to handlerequests Monday thru Friday, 8:30am-5pm.
Rx4NJ:Prescription-Drug Assistance Program for Your Patients
Rx4NJ is a new prescription-drug assistance program that links low-income or medically uninsured individuals with sources of morethan 1,800 medications at vastly reduced prices.
Pharmaceutical manufacturers have sponsored low-cost drug programs for economically disadvantaged Americans, and charitableorganizations have done the same. But these organizations have operated independently of one another. With Rx4NJ, these resources areplaced in one accessible site, providing patients with a single source to most of the prescription drugs they need.
Rx4NJ is supported by the NJAFP and many other non-profit organizations. The website, www.rx4nj.org, is a portal providingaccess to more than 300 patient-assistance programs and their free or low-cost medicines. Rx4NJ can also be reached by telephone at1-888-RXFORNJ. The site is user-friendly and trained specialists are available to help applicants.
For more information on Rx4NJ visit www.rx4nj.org.
Helping People Find and Form Support Groups
Perspectives 1Q05 23
24 Perspectives 1Q05
Municipalities with Populations of 30,000 or more
Claudine Leone, Esq is the Director ofGovernmental Affairs for the NewJersey Academy of Family Physicians.
n 2004 the Health EnterpriseZone bill was signed into law.
This law was an NJAFP supported ini-tiative providing incentives for primarycare medical and dental practices toremain located or to locate in HealthEnterprise Zones (HEZs). NJAFP sup-ported this initiative with the leader-ship of its sponsors; Assembly Speaker Sires, AssemblymanCaraballo, and Senators Rice and Buono, and is pleased to provideNJAFP members with guidance on how to benefit from this meas-ure in their own community.
BRIEF DESCRIPTION OF THE LAWHealth Enterprise Zones are state-designated medically under-
served areas identified by the New Jersey Department of Healthand Senior Services through the state’s Primary Care LoanRedemption Program. While we will refer to practices located inHEZs, the law also allows practices located within 5 miles of anHEZ to access the same benefits under the law with some restric-tions. There are three main sections of this law:
1. Gross Income Tax Deduction - A primary care medical anddental practice located in an HEZ will be allowed to deduct fromthe taxpayer’s gross income in a taxable year an amount equal toamounts received for services from the Medicaid program, includ-ing amounts received from managed care organizations under con-tract with the Medicaid program, the Family Care CoverageProgram and the Children’s Health Care Coverage Program, forproviding health care services to eligible program recipients. Thistax deduction begins for the taxable year 2005. Talk to youraccountants!
2. Low Interest Loans - A primary care medical or dental practicelocated in an HEZ will have access to a state administered lowinterest loan program for the purposes of constructing and reno-vating medical offices in HEZs, and purchasing medical equipmentfor use by primary care providers at practices located in HEZs. TheNew Jersey Economic Development Authority will be administeringthis program and information will be made available to membersas soon as the NJEDA is ready to receive applications under theprogram. The NJEDA website is www.njeda.com and their phonenumber is (609) 292-1800.
3. Property Tax Exemption - The final part of this law requiresproactive measures by NJAFP members to pursue a municipal
ordinance providing for the property tax exemption authorized bythis state law. The law only authorizes municipalities identified asmedically underserved (or HEZs) to pass an ordinance allowing fora property exemption for the portion of a structure or building thatis used to house a primary care medical or dental practice. Theexemption can only be achieved if an ordinance in your municipalityis introduced and approved. Once the ordinance is approved, thelaw provides that the landlord of these properties submit an annualapplication to the tax assessor for this exemption. The amount ofthe exemption must be rebated to the primary care medical ordental practice tenant and proof of that rebate must be providedto the municipality annually for the property to continue receivingthe exemption. The burden is on individual family practices toeducate their landlords of this ordinance. There is no direct benefitto the landlord (except where you are your own landlord) from thisexemption since it is passed along to the tenant. Keep in mindwhen speaking to your landlord or local representative, that whilethere is no direct benefit to the landlord, this incentive can be usedby them to encourage primary care medical practices to leasespace in their building and therefore increase access to primarycare physicians in the town.
WHERE ARE THESE HEALTH ENTERPRISE ZONES?The municipalities listed below are on the state designated
medically underserved areas list and qualify as HEZs under the law.
Geographic areas that are not designated on the Index can beconsidered by the Department of Health and Senior Services on acase-by-case basis to support the designation.
GOVERNMENTAFFAIRS VIEW
A “How To” on Realizing the Benefits ofthe Health Enterprise Zone Law By Claudine M. Leone, Esq.
I
Newark City Trenton City Passaic City Union City City West New York TownAtlantic City City
Paterson City Irvington Township Lakewood TownshipCamden CityJersey City City New Brunswick City
Plainfield CityEast Orange CityPerth Amboy City Elizabeth CityVineland City
Municipalities with Populations of 5,000 to 29,999Bridgeton CityFairfield Township
(Cumberland)Asbury Park CityPaulsboro BoroughSalem CityBuena Vista TownshipPleasantville CityLower TownshipCity of Orange Township Phillipsburg TownEgg Harbor City CityKeansburg Borough
(Ocean County)Lodi BoroughRiverside Township Pine Hill BoroughUnion Beach BoroughFranklin Borough
our municipality will draft an ordinance according to therequirements of the HEZ law signed by the Governor [SeeSidebar “Draft ordinance for the Health Enterprise Zone
Property Tax Exemption” as a guide to what this ordinance mightlook like.] We recommend presenting this ordinance proposal asone that would benefit the community as a medically underservedarea for primary care practices. Many local officials are not awarethat their communities are on this state designated underservedlist. As a result, you may be surprised how simple a process thisreally can be when a community has the opportunity to betterprovide for its constituencies.
There are a variety of ways to have an ordinance introduced inyour municipality, however here is a basic “How To.”
1. Call you local municipal representative (council members,mayor …etc.) directly and request a meeting to discuss theintroduction of an ordinance to encourage primary care medicalpractices to be established in the municipality. They may not befamiliar with the HEZ law and you may be the first to educatethem on the law. If all goes well, the local official will requestthe ordinance be drafted and put on the agenda for a futuremeeting and vote. If you are successful, you must stay connect-ed to the council member or staff to know when a hearing willbe held on the ordinance so that you can provide informationto the entire council on the subject.
2. Also, you may want to call your state representative (state senatoror state assemblyperson) to help educate the municipal officials intheir district about their designation as a state designated medically
underserved area for primary care medical and dental services.Important to note is that this measure was strongly supported bythe Legislature with 114 out of 120 votes in favor of the bill andnot a single “no” vote cast – so your state representative will likelybe supportive of your advocacy on this issue.
3. As always there is power in numbers. Join forces with otherprimary care practices in your community as advocates for theapproval of these ordinances. Be prepared and know theapproximate number of family physicians in your municipality(NJAFP can help with this information). Give references to familyphysicians or other primary care physicians who are no longeraccepting new Medicaid patients . . .etc. This type of informa-tion may be new to a local official and help them advance thistype of ordinance. Remember, this law is about patient accessto primary care services and is intended to keep existing familypractices in your community and encourage new ones.
We hope you will take advantage of the HEZ law and encourageyour colleagues to do the same. We believe this HEZ law will providesome necessary financial relief to those family physicians who wish tocontinue practicing in these communities and hopefully encouragethe establishment of new practices, as well.
If you have any questions or need additional information orassistance, please contact me at (609) 394-1711 or [email protected]
For an example of an HEZ Ordinance visit www.njafp.org, clickon “Members Only” and scroll down to “HEZ Model Ordinance”under Member Resources or call the NJAFP office at 609-394-1711,or email us at [email protected].
HOW TO GET A MUNICIPAL ORDINANCE INTRODUCED?
Y
26 Perspectives 1Q05
RESIDENT &STUDENT VIEW
Molly Cohen is a fourth-year medical student at UMDNJ-RWJ MedicalSchool in Camden and an NJAFP Student Trustee. She was the 2003-2004 Student Director of the HOP clinic.
The Healthcare Outreach Project (HOP) Clinic is a primary carecenter run by the third-year medical students of Robert WoodJohnson Medical School in Camden. Started in October 2000 bythree RWJ students, it provides free health care and medications tothe uninsured of Camden. In 2003, HOP expanded to include a pedi-atric clinic. Since the project began hundreds of uninsured Camdenresidents have benefited from free, accessible health care.
The goals of the HOP are to provideaccess to quality health care for unin-sured patients in the City of Camden,promote the value of continuity of careamong RWJMS- Camden students,reduce health care disparity in the city ofCamden, and promote community healthadvocacy skills in the student bodythrough exposure to the healthcare sys-tem and its disparities.
The adult HOP Clinic is openWednesday evenings at the Health andHuman Services Center of the LEAPAcademy Charter School and currently serves 110 Camden residents.The pediatric HOP clinic is open two Thursdays a month in the samelocation. There are approximately 45 student doctors - almost theentire third-year class of RWJMS-Camden. Patients are assigned theirown student doctor who acts as their sole primary care provider, fos-tering in the student a sense of responsibility for continuous patientcare. Beside providing primary care, the student doctor accompaniestheir patient to specialist visits, diagnostic tests, procedures, surgeries,and financial assistance offices, participating in all aspects of theirpatient’s care.
HOP provides a comfortable environment for students practiceprimary healthcare skills such as performing full histories and physi-cals, writing notes and HOP prescriptions, formulating plans, andeducating patients. Students practice technical skills such as vaccineadministration, pap smears, and glucose checks. Students also pre-pare and present lectures to their peers, discussing topics such asgeneral medicine, healthcare policy, biopsychosocial issues, andhealthcare economics.
Each week a faculty preceptor oversees the HOP clinic. Nineteenfaculty members volunteered to precept during the 2003-2004 aca-demic year. Students present their history, physical exam and plan -including medication suggestions - to the faculty preceptors.
HOP patients receive regular primary care and free medica-tions as well as free consultation visits. The clinic has specialistsfrom many of the hospital departments who have volunteered tosee HOP patients free of charge. From June 2002 to September2003, HOP referred patients for 20 different specialty visits. Thestudent doctor referrers the patient, schedules the appointment
and accompanies the patient to the visit. The HOP clinic is managed by the HOP steering committee. The
HOP steering committee, comprised of one student director and six stu-dent organizers, gain exposure and insight into the healthcare systemthrough the management of a primary care facility. They are responsiblefor scheduling patients, recruiting and assigning student doctors, andrecruiting and scheduling faculty preceptors for each clinic session Theycompile and actively maintain all patient charts, as well as collect patientinformation, specific diagnoses and specialist referrals for statistical pur-poses. The committee guides student doctors through the protocol forpatient referrals including specialist visits, diagnostic tests, and billing
processes. They act as liaisons between theclinic, the dean, the faculty advisors and thehospital administration. Committee mem-bers run a pharmacy within the HOP clinic.They compile a drug formulary, order allmedications, dispense medications duringclinic hours, help student doctors makeinformed decisions on drug therapy foreach patient, and instruct students on howtheir patients can apply for the indigentdrug program. The steering committee alsooversees all financial aspects of the HOPclinic, including grant writing, balancing the
budget, and implementing innovative ways to increase funding for HOP.The HOP Clinic is currently funded by grants from the AAMC,
Campbell Soup Company and the Dean’s Department of Robert WoodJohnson Medical School - Camden. The majority of the grant money isused to purchase all medications and medical supplies for HOP patients.
The students at RWJMS- Camden are proud of the work that theyare doing at their clinic, as are the faculty and the Dean. They havedescribed it as an incredible educational experience - learning patientmanagement skills and the humanism behind the practice of medicine.
For more information contact HOP Student Director Marie-Laure Geffrard at [email protected] or Urban HealthInitiative Coordinator Maya Yiadom at [email protected].
Students Succeed with HOPBy Molly Cohen
Listserve Now Available for ResidentsResident members of the NJAFP now have exclusive access to a listserve
designed for Residents in NJ Family Medicine Residency programs. This mem-ber benefit is for NJAFP RESIDENT MEMBERS only - any postings to the listserveARE and WILL BE just between residents. The listserve is a valuable resource forresident communication. Get involved by sharing your thoughts and ideas.
There are currently 179 members subscribed to the listserve. If you are aNJ Resident and don’t have access to the listserve, it means we do not haveyour email address on file. If you would like to join your colleagues in this elec-tronic forum, contact Ray Saputelli at [email protected] and let him know youwould like join the resident’s listserve.
If you have questions, contact Resident Board Trustees Chris Zipp, DO orVicky Tola, MD or EVP Ray Saputelli, CAE. All can be reached through the NJAFPoffice at 609-394-1711.
Student Doctors plan for patient care (L to r) Doris Fadoju, Anit Mankad, Chiagozie Adibe, Molly Cohen
28 Perspectives 1Q05
Diana Carvajal is a fourth-year medical student at RWJMS-Camden.
I’d always heard fourth year ofmedical school is the best, so I was lookingforward to my final year as a time to relax,enjoy, and plan for the years to come. Asfourth year approached, I decided toexplore my interest in international medi-cine and global health. I wanted to achievemy goal of traveling to different lands; Iwanted to learn more about how othercultures practice medicine. Never in a mil-lion years would I have imagined theincredibly amazing experience awaiting mein my final year.
It wasn’t until late in my third yearthat I had the opportunity of a lifetime. Aphysician from the OB/GYN department atthe hospital with which my medical schoolis affiliated has been planning mission tripsto Ghana, West Africa for the past severalyears. This year, he was offering a scholar-ship for one student to come along! Thetrip was described as a medical missionwith the goal of improving women’s healthand health care in an underserved area ofGhana. This was the perfect opportunityfor me to study and explore many of theinterests I’ve always had but never had thetime or resources to discover. I immediatelyfound out what had to be done. Therewas a lengthy application process, requir-ing an essay and several interviews, but Inearly fainted when I heard the news that Iwas the lucky student selected to go onthe mission trip to Africa!
I geared up, went to all the preparato-ry meetings, got the necessary vaccines,closed my eyes, held my breath, and thenext thing I knew, I had landed in Accra,Ghana. It was the great continent ofAfrica, one that I had seen and appreciat-ed only in my dreams. We arrived in thelate evening on a Sunday night, gatheredour heaps of luggage, and prepared forthe subsequent three hour road trip whichwas to lead us to our final destination:Cape Coast, Ghana. Cape Coast is a townlocated on the southwestern coast ofGhana; it is the town from which the
group’s leader hails. Theroad trip was long,incredibly bumpy(an understate-ment!), and dark.Yet, I was amazed,grateful, and incred-ulous at the idea that Iwas actually in Africa. From theold, dilapidated van, eventhough night had fallen severalhours before, I could see the vast,intriguing land before us under theAfrican moonlight.
I spent the next two weeks, withseveral doctors, nurses, and anesthetistsworking at one of two hospitals in town; itis the newest and was built by the UnitedNations several years ago. Although thehospital is considerably more contemporaryand technologically advanced in compari-son with others, the structure and arrange-ment of the buildings are unlike those inthe U.S. It is a very simple and standardbuilding in appearance. The in-patientunits of the hospital consist of separatebuildings outside of the main hospital,termed “wards.” Several patients (betweensix and twelve) are housed in each sectionof the ward. The operating room is also aseparate building situated close to thewards and is referred to as “the theater.”The beds and medical equipment are alsoquite basic; I saw nothing new, shiny, or“state of the art,” as is custom in manyU.S. hospitals. Although it is the newestand more modern of the hospitals in CapeCoast, there seems to be an impression ofan archaic and perhaps dilapidated place.
Each day, I experienced something dif-ferent. I scrubbed in on surgeries, sawpatients in the Gynecology clinic, wit-nessed ultrasounds, and even had thechance to attend a midwifery conference. Iworked with very dedicated nurses andprimary care doctors including FamilyMedicine physicians, OB/GYN’s, internists,and also general surgeons. We saw manypatients, several with incredible pathology–conditions that we Americans only readabout in books. Most of the patients were
of quite meager means and came withlong ignored ailments simply
because resources were unavail-able not only to the patientsthemselves, but also to thosetreating them. I learned andsaw a great deal of physicalillness, but I also witnessedmuch emotional ailment asconsequence of the diseaseswith which many were
plagued. Although I experi-enced extraordinary learning, I
found it extremely difficult to carefor some patients as their illnesses
were often times advanced beyond med-ical help. I experienced personal momentsof distress, sadness, and even helplessnessat the reality of many situations. Still, therewere instances of triumph and joy whenwe were truly able to help someone, and Idrew the greatest pleasure from the warm,friendly faces and grateful attitudes of ourGhanaian patients.
My trip was amazing; it was all I hadenvisioned and more. I learned so muchfrom every single person I met includingdoctors, patients, and others I happenedto meet and befriend. They welcomed usto their homeland with open arms andincessant gratitude. However, my learningexperience would not have been completewithout equal exposure to the harsh reali-ties and unfortunate economic disparitiesof this third world nation. I witnesseddeath, misfortune, devastation, hunger,and extreme need during the few days Ispent in Cape Coast. Many events and sit-uations were especially heart-wrenchingbecause they were circumstances I hadnever before encountered during my briefyears of medical training in the UnitedStates. I learned theirs was a very differentway of life from ours; there is a distinctand unique practice of medicine based onsocial and cultural environment, economicresources, and technological capacities. Iwas happily amazed and sadly stunned; Iwas emotionally enthralled and yet psycho-logically fatigued. And, it was an experi-ence I would not trade for the world.
FROM MYVIEW
An Experience Not To Be Traded By Diana Carvajal
Platinum Level Donors
Michael Doyle, MD
John Tabachnick, MD
Theresa Triebenbacher
Gold Level Donors Theresa Barrett
Ken Faistl, MD
Amedeo Scolamiero, MD
David Swee, MD
FOUNDATIONVIEW
The Foundation is supported through the generouscontributions of the following members. It is throughtheir gifts that the Foundation is able to support itsmany programs and services.
Donors Severino Ambrosio, MD
Julio Araoz, MD
Thomas Armbruster, MD
Maria Auletta, MD
Christopher Ballas, MD
Nahum Balotin, MD
Kevin Anthony Barry
Salvatore Bernardo, MD
Peter Boyer
Jeffrey Brenner, MD
Theresa Bridge-Jackson, MD
John Brown, MD
John Bucek, MD
Max Burger, MD
Elise Butkiewicz, MD
Doina Cherciu, MD
Mugurel Cherciu, MD
Deborah Clarke, MD
William Cribbs, DO
Liana Dao, MD
George Dendrinos, MD
John Domanski, MD
Elaine Douglas, MD
Joseph Duffy, MD
Leo Fabbro, MD
Kennedy Ganti, MD
Mark Gassemi, MD
Ron Gelzunas, MD
Kevin Gillespie, MD
Ben Glaspey, MD
Jennifer Glassman, MD
Ana Gomes, MD
Ahmad Haddad, MD
Mary Haflan, MD
Caryl Heaton, DO
Mary Ellen Hoffman, MD
Carla Jardim, MD
Sergiusz Kaftal, MD
Ohan Karatoprak, MD
Irving Kaufman, MD
Alan Kelsey, MD
Yoonjoo Kim, MD
Elise Korman, MD
Douglas Krohn, MD
Frank Lasala, MD
Richard Levandowski, MD
Paul Madonia, MD
Raymond Marotta, MD
Paul Marquette, MD
Anthony Miccio, MD
John Mifsud-Navaro, MD
Giulio Mondini, MD
Lisa Morton, MD
Lisa Neumann, DO
William Newrock, MD
David Niedorf, MD
Dennis Novak, MD
Robert Pallay, MD
Vincent Palmisano, MD
John Pastore, MD
Richard Paris, MD
Anthony Picaro, MD
John Pilla, MD
Mary Previty, DO
Jamie Reedy, MD
Carl Restivo, MD
Marlene Rodriguez, MD
Alfred Santangelo, MD
R. Santiago, MD
Joseph Schauer, MD
John Scott, MD
Melissa Selke, MD
Carol Sgambelluri, MD
Catherine Sharkness, MD
Terry Shlimbaum, MD
Valentino Sica, MD
Andrew Sokel, MD
John Sonzogni, MD
Seymour Taffet, MD
Joseph Termini, MD
Kathleen Thompson, MD
Peter Tierney, MD
John Tinker, MD
Vicky Tola, MD
Christopher Tolerico, MD
June Vecino, MD
Robin Winter, MD
Frances Wu, MD
Michael Yoong, MD
Silver Level DonorsMary F. Campagnolo, MD
Frank Kane, MD
Darryl Kurland, MD
Robert Maro, MD
Carl Meier, MD
Alfred Tallia, MD
Mary Willard, MD
Century ClubAlbert Almeda, MD
Anna Chen, MD
Gerald Corn, MD
Ann Dimapilis, DO
Amparito Fiallo, MD
Betty Hammond, MD
Stephen Land, MD
George Leipsner, MD
Dennis Novak, MD
Ginia Pierre, MD
Frank Snope, MD
Robert Spierer, MD
Rebecca Steckel, MD
Samir Sulayman, MD
Marty Sweinhart, MD
Perspectives 1Q05 29
The New Jersey Academy of Family Physicians Foundation
would like to extend its sincereappreciation to its 2005 Corporate
New Jersey’s progress in Tobacco ControlAmerican Lung Association State of Tobacco Control 2004
Data Snapshot - The State of Tobacco Control 2004 grades federaland state tobacco control laws and regulations. The completesnapshot summarizes data in each of the four categories of tobac-co prevention and control: spending, smokefree air, cigarette excisetax and youth access. The report lists New Jersey as one of thestates that increased Cigarette Excise Taxes in 2004. The excise taxincreased from $2.05 to $2.40.
The American Lung Association State of Tobacco Control 2004report shows that most states failed to fund tobacco control andprevention programs at the minimum level recommended by theCenters for Disease Control and Prevention (CDC). Five states -Arkansas, Delaware, Hawaii, Maine and Mississippi - received agrade of A, representing a funding level of 90 percent or more ofthe CDC minimum for each state. Rather than face worseningbudget shortfalls in the future, these states will see their health-related costs gradually drop as prevention and cessation programsreduce the prevalence of smoking and tobacco-related disease.Unfortunately, 36 states and the District of Columbia received agrade of F in 2004, representing a funding level of less than 60 per-cent of the CDC minimum. Three states - the District of Columbia,New Hampshire and South Carolina - provided no funding at all.
American Lung Association State of Tobacco Control 2004Report Card gives New Jersey the following scores
The report shows few states made improvements to theiryouth access laws. Oklahoma enacted a law prohibiting sales oftobacco products by self-service display, and made changes toother youth access laws governing random, unannounced inspec-tions and graduated penalties to retailers. New Jersey passed a lawprohibiting the sale of single cigarettes or cigarettes in packs ofless than 20. Seven states received a grade of A for youth accesswhile 23 states received a grade of F based on criteria developedby the National Cancer Institute. Every day, 6,000 children underthe age of 18 start smoking for the first time and close to 2,000 ofthem become established daily smokers. Enactment and enforce-ment of policies to restrict the sale and distribution of tobaccoproducts to minors are effective components of a comprehensivetobacco control program.
Another step in a comprehensive tobacco control programand one that you can take immediate advantage of is Tar Wars.
Tar Wars was founded in response to this growing, yet preventable,health crisis. Targeting fourth and fifth grade students, this award-winning, youth tobacco-free education program and poster contestof the American Academy of Family Physicians adopts an effectiveand innovative approach to teaching tobacco prevention. Theprogram focuses on the short-term, image-based consequences oftobacco use and how to think critically about tobacco advertising.A follow-up poster contest at the school, state, and national levelsis conducted to reinforce the Tar Wars message.
For more information on the American Lung AssociationState of Tobacco Control 2004 visit www.lungusa.org.
For more information on Tar Wars visit www.tarwars.org
SPECIAL PROJECTS VIEW
There is a new national quitline number: 1-800-QUIT NOW. This toll-free number (1-800-784-8669) is a single access point to theNational Network of Tobacco Cessation Quitlines. The AAFP is verysupportive of both the national quitline number and the websiteresources which can be found at http://www.smokefree.gov. In the“For Health Professionals” section you will find a number ofresources to assist you with helping your patients to quit smoking.Among them is the National Cancer Institute's Handheld ComputerSmoking Intervention Tool (HCSIT). This tool is designed for cliniciansto assist with smoking cessation counseling at the point-of-care.This easy-to-use program can be used with both Palm® andMicrosoft™ Pocket PC handheld computers.
Tobacco Prevention& Control Spending Smokefree Air Cigarette Tax Youth Access
F F A F
Dr. Jeff Kane with the winners of the 2004 Tar Wars Poster Contest
Become a Tar Wars Volunteer – visit www.njafp.org, click onthe Tar Wars link and then “Become a Tar Wars volunteer”
Tars Wars in sponsored in part by a grant from:
Perspectives 1Q05 31
Smiles abound at MedFestIt’s Time to Register for MedFest4!
Are you ready to be a part of helping an athlete reach their dream of participating in Special Olympics? If so, sign up for MedFest, scheduled to take place on April 15, 2005 from 9am-2pm at Special Olympic headquarters in Lawrenceville, NJ.
Plan to spend the day with some truly outstanding people and earn some smiles of your own.
For information on how you can become a volunteer contact Candida Taylor in the NJAFP office: 609-394-1711 or [email protected].
Register o
nline at
www.njafp.org
32 Perspectives 1Q05
++ ++
SPECIALFEATURE
Jonathan Nelson is the editor for Texas Family Physician. This article wasoriginally published in Texas Family Physician, Oct./Nov./Dec. 2004, Vol. 55No. 4. and is reprinted with permission.
“Unless there are changes in the broader healthcare system and within the specialty, the positionof family medicine in the United States will beuntenable in 10 to 20 years.”This statement appears in the report of AAFP’s Task Force One, one of fiveoriginal task forces commissioned to participate in the Future of FamilyMedicine (FFM) project, an ambitious effort to examine the state of thespecialty in the context of the current health care system and recommenda new vision and direction for family medicine.
The authors of the report came to this conclusion after reviewingthe results of an exhaustive research campaign that constituted the firstphase of the FFM project. The research showed that family medicine isfacing some major challenges: a lack of understanding of the specialtyamong the general public, a lack of respect in academic circles, low reim-bursement and other challenges in the managed care environment thatmake running a profitable practice difficult, to name a few.
To bring about the changes the authors deemed necessary, they pro-posed the development of a new model of family medicine, an idea thatbecame the centerpiece of the FFM final report and recommendations,published in a supplement to Annals of Family Medicine last April. As TaskForce One described it, the new model would be a medical practice “forpeople of all ages and both genders that emphasizes patient-centered,evidence-based, whole-person care provided through a multidisciplinaryteam approach in settings that reduce barriers to access and use advancedinformation systems and other new technologies.” The new model wouldprovide better, more consistent care for patients and it would have tomake the practice of family medicine more rewarding for physicians.
The new model requires redesigned offices, retooled schedulingstrategies and new avenues of patient/doctor communication, not tomention the implementation of electronic health record systems. Withpractice margins stretched to the breaking point, the question many fami-ly physicians have is how are we going to pay for all of this? That’s alsothe question AAFP has been working to answer since before the FFMreport was published. A sixth task force was commissioned early this yearto work with health care consulting firm, The Lewin Group to construct afinancial model that would sustain the new model. The chair of the newtask force was Steve Spann, M.D., chair of the Department of Family andCommunity Medicine at Baylor College of Medicine and one of the reportauthors of Task Force One. The much-awaited Task Force Six report shouldbe published in the November/December issue of Annals of FamilyMedicine, but the prognosis looks good.
Spann says if you take a practice today with the current reimburse-
ment system and you implement all of the elements of the new model,the task force estimates you should see an increase in physician compen-sation by about 26 percent. Part of the increase comes from adoptingopen access scheduling. “One of the issues that we talk a lot about in thenew model is elimination of barriers to access,” Spann says. If a patientcan call today for what he or she wants today, the models show theintensity of the visit codes should rise and the number of no-shows shoulddecrease. Physician Web portals will allow patients to view the day’s avail-ability and schedule their appointments online. Patients should also beable to download education materials and find links to trustworthy med-ical information on the Web portal.
Adding asynchronous communication, like secure e-mail, canincrease office efficiency as well. The physician could review symptoms fora cold, bladder infection or other simple problems that could be solvedwithout examination through an e-consultation and still get paid.Facilitating prescription refill requests online could boost efficiency, too,especially if the physician is using an electronic health record.
According to the FFM report, the new model depends on EHRs. “Wereally see the EMR as the central nervous system of the new model prac-tice,” Spann says, using the term electronic medical record instead of elec-tronic health record. “We believe that the EMR ultimately can make docsmore efficient, can for example cut down on medical records staff, med-ical records cost, paper cost, eliminate transcription cost, can improve E-and-M coding — so there’s evidence out there that using an EMR actuallycan improve the bottom line.”
Along with shoring up the financial viability of family practice, thesechanges help fulfill one of the central tenants of the new model — put-ting the patient at the focal point of the provision of care. Of course mostfamily doctors would probably argue that they’re already providingpatient-centered care. According to James Martin, M.D., of San Antonio,chair of the AAFP Board of Directors, the new model requires a paradigmshift. “Right now, everything – doctor/patient contact – is totally based onthe physician’s schedule, the physician’s preferences,” says Martin, whohas spearheaded the FFM project and the initial implementation effortsduring his term as AAFP President and in his position as board chair. Openaccess scheduling, e-mail communications, phone consultations, groupvisits and expanded clinic hours should allow patients to have more say inwhen and how they receive care.
Patient-centered care in the new model definition also means thatcare will be culturally and linguistically appropriate. “The key is that thefamily physician or whoever is doing the new model has to be very awareof the patient’s preferences and value system,” Martin says, adding thatphysicians have to help patients become active participants in their care.“Let’s say for example, someone comes in with high cholesterol. In thepast, most doctors routinely just say, ‘Here, start taking statin and I’ll seeyou back in X period of time.’” In the new model, doctors will accessreports and graphs online to show patients the anticipated results of dif-ferent alternatives. “Here’s the percentage of success if you exercise and
ADDING IT UPADDING IT UPCan the Future of Family Medicine recommendation to build a new model of family practice improve the bottom line? By Jonathan Nelson
Perspectives 1Q05 33
++diet. Here’s the percentage if you take niacin. Here’s the percentage if youtake Lipitor, so that the patient has more information to help be a partnerin making those decisions,” Martin says.
The 26-percent increase in physician reimbursement that Task ForceSix estimates for new model implementation assumes there is no changein the way physicians are currently paid, but the task force has been work-ing on another financial model that includes some new twists for the U.S.health care system. Martin says along with traditional fee-for-service reim-bursement plus payment for e-consultation and group visits, the Academyis pursuing a blended payment model including patient managementfees, chronic care management fees and pay for performance initiatives.
AAFP recently adopted a new policy position that could help bringabout a blended payment system. The policy has been published in a
document called “The New Model of Primary Care: Knowledge BoughtDearly,” which is acknowledged as a synthesis of existing literature andnew analyses by the Robert Graham Center: Policy Studies in FamilyMedicine and Primary Care. The document describes the burden of chron-ic care on the Medicare system and some devastating predictions for thenear future. Currently, less than 20 percent of Medicare patients have fiveor more chronic diseases, yet that population accounts for more thantwo-thirds of Medicare spending.
“The purpose of the Graham study was to demonstrate that if youhave a family physician managing the chronic disease of a patient, thenA.) the patient satisfaction goes up; B.) the quality is extremely high; andC.) it costs less,” Martin says. The document backs up those claims, show-ing possible savings of over $50 billion to the Medicare system if familyphysicians serve as the usual source of care for Medicare patients withchronic diseases.
In a letter to AAFP chapter presidents that accompanied the docu-ment, Martin writes: “Effective delivery of care requires consultation withthe patient, organization of the patient’s care and encouragement of thepatient to become a partner in that care. Our payment system penalizesphysicians for taking each of those actions.” The document goes on torecommend that changes be made to the way family physicians are paidthat would include the adoption of a patient management fee and achronic care management fee.
Martin says the argument is bolstered by a recent article published inHealth Affairs by two Dartmouth professors entitled “Medicare Spending,the Physician Workforce, and Beneficiaries’ Quality of Care,” which com-pares Medicare spending and quality of care among the states. The studyreports that in states with higher Medicare spending and a higher concen-tration of specialists delivering the care, the quality of care and the level ofpatient satisfaction are lower and the cost is higher than in states whereprimary care physicians deliver more of the care.
Other AAFP initiatives are working to interest payers in providingfinancial incentives to physicians for reaching a set of quality standards. “Ifthe physician is able to lower the cholesterol to certain standards or lowerthe hemoglobin A1c to certain standards, then there are extra payments,bonuses paid to the physician for doing those things,” Martin says.
Dr. Spann believes the use of advanced information systems champi-oned in the new model holds the promise of greatly improving the qualityof care family physicians deliver, particularly in cases of chronic disease andprevention. “We believe that in the long term, insurance companies are
going to be willing to reimburse us for practicing better quality, and so inthe long run, we think that will reap revenues,” Spann says.
According to Martin, payers are interested in the possibilities prof-fered by the new model. He says he’s had talks with insurance companyrepresentatives who are so impressed with the new model that some maygive support to a number of clinics as part of a demonstration project.And it’s not just insurance companies that are interested.
“We’re getting just tremendous response,” Martin says, even inWashington, D.C. “There are members of the Senate who think the FFMnew model is where they should be going to correct health care dispari-ties rather than [Federally Qualified Health Centers]. There are just somevery powerful people that are looking at this and coming back and saying,‘go forward.’”
For Drs. Martin and Spann, the question now is how does theAcademy begin to implement the new model and do it in a cost effectiveway. Task Force One’s report called for the development of a nationalresource center that might use demonstration projects, or new modelbeta sites to fine tune the practice, and then package the parts in aturnkey solution that would make implementation easy and seamless.AAFP’s Board of Directors asked Spann to serve as a consultant to ateam that has been working on a business plan for the nationalresource center. This plan was presented to the Board at their annualmeeting in October 2005.
The purpose of the center after the initial demonstration project isover will be to act as a consultant service, helping family physicians orwhoever else is interested in transitioning to the new model. For somepractices already meeting many of the new model requirements, theresource center might do as little as pass on some tips via e-mail, or itcould start from the ground up for other practices, providing software andintensive training. Martin says the resource center would have to befinancially viable, so the service wouldn’t be free, but part of the center’spurpose would be to make sure the new model improves a physician’sbottom line. He believes the center could begin to take shape in the nextsix months to a year.
Martin says the new model is necessary to the success of the U.S.health care system, and certainly that of family medicine. “Yes, this is amountain we have to climb, but it’s doable. And the tools will be providedto help get there, but it’s not something that we’re going to have theopportunity to pick and choose on.” He says that in this case, the oldadage “I’ll believe it when I see it” has to be turned on its head. “I’ll see itwhen I believe it,” Martin says. “I think that if we are at a point where webelieve this can happen, it will.”
LINKSwww.annfammed.org/content/vol2/suppl_1/ Future of Family Medicine Report plus the task force reports published inAnnals of Family Medicine
www.aafp.org/x3318.xml >> AAFP Care Management Policy — The NewModel of Primary Care: Knowledge Bought Dearly
www.internetcme.org >>Access audio and slides from Dr. James Martin’sFFM presentation at TAFP’s 2003 Annual Session and Scientific Assembly.
“There are members of the Senate who think the FFM new model is where they should be going tocorrect health care disparities rather than [Federally Qualified Health Centers]. There are justsome very powerful people that are looking at this and coming back and saying, ‘go forward.’ ”
34 Perspectives 1Q05
Jeffrey A. Zlotnick MD, CAQ, FAAFP is VicePresident of the NJAFP and an Assistant ClinicalProfessor of Family Medicine & Primary CareSports Medicine in the Department of FamilyMedicine at UMDNJ – RWJ Medical School in NewBrunswick. He is also the Medical Consultant forthe “Healthy Athletes Initiative” for SpecialOlympics New Jersey.
I’m sitting at the bar with my friend Harry. We’re having an in depthconversation about the ups and downs of our jobs. Harry’s quite aninteresting “bloke” (he’s British, you know). Harry’s a music instruc-
tor specializing in bass and guitar. I’m one of his students. We should bein his studio practicing, but Harry decided I needed a break so we walkedover to the local pub for a drink…or two. Seems kind of odd for me towalk into his studio after work dressed in a suit and run into studentswho are less than a third my age (no age comments). I definitely stick out,but that doesn’t seem to bother Harry.
He has quite an interesting history. When I met him I was certain he
was a blowhard over-indulging in alcohol and inflating small life events.Then he showed me the album covers. Seems Harry was the quite thestudio musician. He’s played with some of the biggest names in classicrock: Pink Floyd, Queen, David Bowie…to name a few. He’s the realthing! As I’ve learned in the few months taking lessons from him, he’s anincredibly bright and talented musician with a personality to match. Whenyou’re with him, it’s difficult to not find yourself laughing.
Unfortunately, Harry’s also an example of what drugs and alcoholcan do. They took a major toll on his health and career. Now he teachesin a small New Jersey studio and no longer plays with those big names.Yet, he’s also a man that is happy and satisfied with life. I can hardlyremember a time where I have not seen him smiling or laughing. He obvi-ously loves his work with students. Harry’s most fulfilled when he sees astudent “get it.” You can see the joy in eyes when talks about thosemoments with his students when “small miracles” occur.
I can hear Theresa… “Z, you’re supposed to talk about FamilyMedicine! “You’re supposed to use your column to help your fellowphysicians not to talk about music!” Well, Theresa, that’s exactly wherewe’re headed.
In my last two editorials I’ve spoken about bringing joy and controlback into being a physician. In these crazy times, it’s easy to lose the senseof why we became family physicians in the first place. We’re so worriedabout controlling the forest we forget the individual trees. That theme hasnot escaped Harry; he takes care of the individual trees and lets the forestreap the benefit.
Many of us become so overwhelmed trying to take care of the forestwe don’t see what we’ve accomplished when we take care of that onetree. I’ve seen this most in the residents and students I’ve worked with. Irefer to it as the “Albert Schweitzer Syndrome.” Many residents and stu-dents go into medicine with the desire to save the world. Then reality hits
and they realize there’s very little chance they’re going to accomplish thatlofty goal. They begin feeling that they’ve failed, they’ll never be thephysician they wanted to be and they’ll never be able to help others. Theybecome jaded and medicine becomes “a job.” They never realize their“small miracles.”
“Small miracles:” those little things you do for a patient that mayseem small, but have a huge impact on their life. Let me tell you aboutEd. Ed was about five years old at the beginning of this story. Ed’s familyhad lost part of their health insurance coverage courtesy of cost cuttingmeasures by their managed care company. Ed’s father called me oneevening because Ed had a rash he had never seen before and he wasrunning a temperature. I was no longer their official doctor because ofthe MCC changes, but Dad was upset and wanted to talk to someonehe knew. I told him to bring Ed in and we’d work out everything elselater. One look and I knew something serious was going on. A fewphone calls and we had Ed admitted to the hospital for an emergencybone marrow biopsy. The results were done stat and the news waswhat I expected: leukemia. A few more phone calls and Ed was on hisway to Sloan Kettering for his initial bout of chemotherapy. Ed’s nowfinishing his senior year in college. All it took was a little caring and afew phone calls. Small miracles.
One Christmas evening I was covering for a fellow physician. Ireceived a call from a dad saying his daughter was having severe ear pain.They were away at relatives and had visited the local ER. Diagnosed withotitis media, they had given her a prescription. What they’d forgotten wasthat all the pharmacies were closed. I know we could have had one openon an emergency basis, but I knew I had samples in my office. I told Dad Iwas out anyway and would put some in a paper bag and leave it in a labboxes outside my door. They could get it and it should hold them until thepharmacies opened. A week later I received one of the nicest letters I haveever gotten telling me how I had saved their holiday with a simple act.Small miracles.
Jim was a star athlete for the local high school when he noticed footand knee pain. He wanted to excel at track and field but the pain wasgetting worse by the day. His father took him to an orthopedic surgeonwho said he’d grow out of it and prescribed OTC NSAID. When he cameto me I saw a very upset young man who wanted to be field and trackstar. What I didn’t know was that he wanted to be that star so he couldearn a college scholarship. For Jim, it was the only way he’d be able to goto college and he was seeing his dream fade away. Upon examination Ifound what we Sports Med folk call Miserable Misalignment Syndrome: atough combination of pes planus, genu valgus, and patellar femoral syn-drome. We started an intense program of physical therapy combined withdifferent types of OTC orthotics, but we finally had to get him fitted witha set of custom made ones. It took a few months but the pain began tofade, his ability to run increased and his time decreased. It wasn’t until Isaw him a few years later for minor injury that occurred in college that Ilearned the full extent of what working with him had done. To me it wasthe day to day routine of seeing patients. It had never occurred to meuntil then how much impact I had on his life. Small miracles.
I could on about Anna with her migraines, Fred with his diabetes,but I’m hoping now you get it. In your day-to-day routine of seeingpatients, you’ll impact someone’s life in a huge way. What you may feel ismundane can be a turning point in a patient’s life. So leave the forest toitself and take care of those individual trees. Be just like Harry and neverlose sight of those “small miracles.”
CLOSINGVIEW
Small MiraclesBy Jeffrey A. Zlotnick, MD, CAQ
I
Perspectives 1Q05 35
Indicate True (T) or False (F)
An Update on Sinusitis
1. ___ Acute Bacterial, Subacute Bacterial, Chronic, and RecurrentAcute are the four categories of Bacterial sinusitis.
2. ___ Bacterial sinus infection persists for more than 14 days.
3. ___ The objectives of treating a bacterial sinus infection are todecrease the recovery time, prevent chronic disease and todecrease exacerbations of asthma.
4. ___ Amoxicillin is not a good first-line agent for treatment ofsinusitis.
Sinus and Allergy Partnership Sinusitis Guidelines Update
5. ___ The clinical features of bacterial rhinosinusitis and viral rhi-nosinusitis are similar, making differentiation a challenge.
6. ___ Bacterial sinusitis is usually a complication of a viral upperrespiratory infection (URI), such as the common cold.
7. ___ The updated guidelines suggest that bacterial sinusitis bediagnosed in adults or children when a viral URI remainsunimproved 5 days after onset.
The Basics of Measuring Patient Satisfaction in a Primary Care Practice
8. ___ Patients are more likely to answer questions truthfully ifthey feel their responses are anonymous.
9. ___ When preparing a survey to measure patient satisfaction,you should focus only on the physicians in the practice.
10. ___ When developing a survey you should not only assesswhether your patients are satisfied, but also their level ofsatisfaction.
Introduction to Medical Informatics for the Family Physician
11. ___ The study, invention, and implementation of structures andalgorithms to improve communication, understanding andmanagement of medical information is called medicalinformatics.
12. ___ An organization that is seeking to help family physicians inNew Jersey adopt informatics initiatives in an overall strate-gy for quality care improvements is PRO-NJ.
Instructions: Read the article designed with the icon andanswer each of the quiz questions. Mail or fax this form within oneyear from date of issue to: NJAFP CME Quiz, 112 West State Street,Trenton, NJ 08608 • Fax: 609-394-7712
Perspectives: A View of Family Medicine in New Jersey has been approved by theAmerican Academy of Family Physicians as educational content acceptable forPrescribed credit. Terms of approval covers issues published within one year fromthe distribution date of 1-1-05. This issue, (volume 4, issue 1- Jan/Feb/Mar 2005)has been reviewed and is acceptable for up to 1 Prescribed credit. Credit may beclaimed for one year from the date of each issue. AAFP Prescribed credit isaccepted by the American Medical Association as equivalent to AMA PRA cate-gory 1 credit toward the AMA Physician's Recognition Award. When applying forthe AMA PRA, Prescribed credit earned must be reported as Prescribed credit,not as category 1.
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$15 made payable to the NJAFP and a self-addressed, stampedenvelope to NJAFP CME, 112 West State Street, Trenton, NJ08608. A certificate of completion will be sent to you.
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