President Bush got a great deal of media attention when he ended the American Bar Association’s special role in evaluating federal judges- but a few weeks later, the press largely overlooked Bush’s slap at another white-collar professional group, the American Medical Association. Bush gave his first important health-care address to the American College of Cardiologists, even though presidents traditionally reserve this speech for the AMA. The decision was occasioned principally by concern about the AMA’s political tilt, which has diminished the once-revered organization’s influence and damaged its reputation for protecting the interests of doctors and patients.

Many Republicans, including those at the White House, see the AMA leadership as just another Democratic party constituency. Not so long ago, the AMA was a reliable GOP ally: In 1965, the AMA stood with Republicans in denouncing Medicare as “socialized medicine,” and in strongly resisting excessive regulation of health care; after a brief flirtation with President Clinton’s health-care overhaul in 1993, the AMA helped Republicans crush it. But AMA leaders no longer consider the Republican party the vehicle to advance their interests; in fact, these interests now converge with those of the most liberal wing of the Democratic party.

The AMA’s realignment has had consequences: The association now represents just 32 percent of American physicians, down from a peak of nearly three-fourths in the early 1970s. Much of the decline stems from the increasing specialization of medicine, which has forced doctors into specialty groups better equipped to represent them; but another important factor is the AMA’s strange alliance with trial lawyers. The AMA and the American Trial Lawyers Association favor legislation permitting unlimited lawsuits against HMOs. Together, they helped defeat three GOP senators who held a different view. As a crucial member of the “Patient Access Coalition,” the AMA financed television ads against Sens. Slade Gorton (Wash.), Spencer Abraham (Mich.), and John Ashcroft (Mo.), all of whom opposed the AMA on HMO liability. “Tell your senators to stand up for patients and let America’s doctors make your health-care decisions-not HMO bureaucrats,” the ads proclaimed.

The American Medical Directors Association (AMDA) 2002 survey of its members found that more than 433 nursing home medical directors have had to stop working in facilities because they lost their liability coverage. Also, more than 1,450 nursing home physicians responsible for 168,000 residents are reducing resident care hours, not providing certain services, or are referring more complex cases in reaction to medical liability concerns. Many of these physicians report facing annual premium increases averaging 154%, and 5.6% of medical directors say they are unable to get medical malpractice coverage at all because they work in nursing homes.

“The [AMDA] is closely monitoring the medical liability crisis because of its unfortunate impact on long-term care patients,” said AMDA President Jacob Dimant, MD, CMD, reacting to President Bush’s State of the Union call for liability tort reform. “We are seriously concerned that many frail, elderly Americans are losing access to vitally important long-term care services due to the unavailability of medical liability insurance for our members. As nursing home physicians lose their malpractice coverage, they are being forced out of long term care, leaving their patients with fewer options for quality healthcare.”

According to data released by the Association of American Medical Colleges (AAMC), the number of applicants to U.S. medical schools this year increased by 3.4 percent for the first time in six years. Almost 35,000 persons applied to attend medical school in the 2003-2004 school year compared with 33,625 last year. The main reason for the increase was the number of female applicants (17,672) who made up more than one half of medical school applicants for the first time. The number of black applicants overall rose almost 5 percent to 2,736, but the number of blacks who entered medical school declined by 6 percent to 1,056. Black female applicants increased by almost 10 percent to 1,904. Hispanic applicants increased by less than 2 percent to 2,483, while the number who entered medical school declined by almost 4 percent to 1,089. Included in the applicant pool were 26,160 persons who were applying to medical school for the first time. The data also showed that the sharp decline in male applicants, a trend that started in 1997, leveled off this year with a total of 17,113 applicants, which was slightly more than last year. The number of applicants applying to medical school peaked at around 47,000 in 1996 and reached the lowest point last year.

The Emergency Cardiovascular Care Committee of the American Heart Association (AHA) has published a policy statement on medical emergencies in schools. “Response to Cardiac Arrest and Selected Life-Threatening Medical Emergencies: the Medical Emergency Response Plan for Schools” appears in the January 6, 2004 issue of Circulation. The policy statement introduces a public health initiative to help schools prepare to handle life-threatening medical emergencies.

Life-threatening emergencies can occur in any school, at any time. They can be caused by preexisting health problems, violence, injuries, and other unexpected events. They can affect students or the adults who teach and supervise them. At the same time, schools now employ fewer nurses than before, leaving teachers, coaches, and other staff in charge of first aid before the arrival of emergency medical services (EMS) personnel. Yet, in one recent Midwestern survey, one third of teachers had no training in first aid, and almost one half had never completed a course in cardiopulmonary resuscitation (CPR).

The following five key elements are recommended by the AHA for medical emergency response plans in schools:

1. Effective and Efficient Communication Throughout the School Campus. The statement recommends establishing a rapid communication system that links all parts of a school campus, including outdoor facilities and practice fields, to the local EMS system.

2. Coordinated and Practiced Response Plan. Schools are encouraged to develop a response plan applicable to a variety of common medical emergencies. Potential resources for developing a plan include the school nurse, athletic team physicians and trainers, and the local EMS agency. The emergency response plan should be practiced at the beginning of each school year and periodically throughout the year.

3. Risk Reduction. The statement emphasizes injury prevention with appropriate precautions in classrooms and on playgrounds. It suggests identifying students, faculty, and staff members who have medical conditions that might increase their risk of life-threatening emergencies. School personnel should be trained and equipped to respond to the emergency conditions.

It’s already that time of year again–by now you’re wrapping up your training runs for the Boston Marathon and getting mentally prepared to tackle the race course. And once again, the American Medical Athletic Association (AMAA) will be there to support your efforts and provide you with an educational and fun weekend.

The following details outline the AMAA-sponsored events for the Boston Marathon weekend and address questions frequently asked by runners and/or meeting attendees.

The AMAA’s 33rd Annual Sports Medicine Symposium at Boston: The Runner’s Body

The symposium is scheduled for April 17 and 18 and will be held at The Colonnade Hotel (Huntington Ballroom), 120 Huntington Avenue, Boston.  Following that date, call 800-776-2732 to register. Onsite registration begins at 7:00 a.m. on April 17; however, be prepared to pay an additional onsite registration fee.

ACPM Continuing Medical Education

The 33rd Annual Sports Medicine Symposium at Boston has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American College of Preventive Medicine and the American Medical Athletic Association. ACPM designates the lecture portion of the educational activity for a maximum of 10.6 Category 1 credits. This activity has been approved for American Medical Association Physician’s Recognition Award credit. This activity has been reviewed and is acceptable for up to 10.75 prescribed credits by the American Academy of Family Physicians. 1.1 CEUs will be awarded for athletic trainers through the NATA.

Good communication is the bridge that spans the gap between the mind of the doctor and the patient. In this paper, the scope of the term communication skills has been broadened to include the knowledge, attitude and skills that enable a doctor to know and respond to the totality of the disease process as it affects the body and mind of the patient.

Communication is effective only when it is a two way process. Good communication draws upon knowledge of psychological, cultural, social, educational and economic influences upon the patient and disease. It requires that intellect and emotion be yoked together in the service of the alleviation of suffering and the promotion of health.

At the heart of the practice of medicine is a dynamic process seeking the best fit between the patient’s needs, the physician’s perception of the patient’s needs and what the physician has to offer. Fine tuning of this process requires knowledge of the patient’s values, attitudes and beliefs and therefore the social, cultural, religious and economic milieu of the patient. The ability to respond effectively is determined by the extent to which the doctor understands the working of the human mind, can discriminate between the subjective and objective aspects of human experience and can read between the lines of verbal expression.

The bed rock of good communication is the ability to ‘feel with’ the distress caused by the disease process. Once this ability is in place the trainee becomes motivated to fine tune communication and re-orient service towards a more patient centered approach. In the absence of the ‘feeling’ element , the ‘knowledge’ element of communication may never translate into action.

Special challenges in communication

While some basic rules of communication apply across cultures and continents, communication must be sensitive to individual variations. Culture, religion, social systems, and economic structure are some of the influences that determine the manifestations of disease and expressions of distress.

Socio-cultural variations

The economically deprived patient with little or no formal education does not come to the consultation alone. He is accompanied by his family or even members of his village unrelated to him. He is also accompanied by an invisible host of authority figures who influence his beliefs, attributions, preferences, values and hopes. The doctor ignores these at his own peril.

Technology will play an ever-increasing role in the medical arena as physicians prepare to enter the 21st century. To compete in that arena and to provide high-quality comprehensive, continuous, and coordinated care to patients, physicians must be able to process large and varied amounts of information. Computerization of the medical record is the best way in which the physician can more readily manage and retrieve important information about patients.

The technology to computerize the complete medical record is available and increasingly accessible and affordable. (1) The cost of mass storage, which has heretofore been a major limiting factor in medical record computerization, is decreasing. Two recent developments–the compact disc-read only memory (CD-ROM) and the write once read many optical disc (WORM)–offer gigabyte mass storage capability at affordable prices. (2,3) A growing number of computerized medical record systems have been tried and tested in the ambulatory care setting and are available for purchase. (1,4) The Computer-Stored Ambulatory Record system (COSTAR) was developed by the Laboratory of Computer Science at Massachusetts General Hospital and is the most widely disseminated system of its type. (1) Other available systems include the following:

1. The Medical Record (TMR), developed at Duke University Medical Center (5)

2. The Regenstrief Medical Information System (RMIS), developed at Indiana University Medical Center (6)

3. The Summary Time-Oriented Record (STOR), developed at the University of California Medical Center, San Francisco (7)

4. THERESA, a computerized medical record and decision support system developed by Grady Memorial Hospital in Atlanta (8)

Although the technology is available, (2) a completely paperless electronic medical record (to include electrocardiograms, correspondence, radiographic images, etc) is not necessary or practical at this time. But the electronic paperless office is a future reality, and physicians can and should begin moving their practices in that direction. Currently components of the medical record that can be computerized include reason for encounter, symptoms, signs, diagnostic and therapeutic procedures, test results, diagnoses or problems, and prescribed therapies.

* OBJECTIVES To determine (a) the respondents’ perceptions of 4 unclear or conflicting cancer screening guidelines: prostate-specific antigen (PSA) for men over 50, mammography for women 40-49, colorectal screening by fecal occult blood testing (FOBT), and colonoscopy for patients over 40; and (b) the influence of various factors on the decision to order these tests.

* STUDY DESIGN National Canadian mail survey of randomly selected family physicians.

* POPULATION Family physicians in active practice (n=565) selected from rural and urban family medicine sites in 5 provinces representing the main regions in Canada.

* OUTCOME MEASURED Agreement with guideline statements, and decision to order screening test in 6 clinical vignettes.

* RESULTS Of 565 surveys mailed, 351 (62.1%) were returned. Most respondents agreed with the Canadian Task Force recommendations, and most believed that various guidelines for 3 of the 4 screens were conflicting (PSA 86.6%; mammography 67.5%; FOBT 62.4%). Patient anxiety about cancer, patient expectations of being tested, and a positive family history of cancer increased the odds that the 4 tests would be ordered. A good quality patient-MD relationship decreased the odds of ordering a mammogram. Screening decisions were also significantly influenced by the respondents’ beliefs about whether screening was recommended and whether screening could cause more harm than good. A physician’s sensitivity to his or her colleagues’ practice influenced screening decision, s regarding PSA and mammography.

* CONCLUSIONS These results suggest a conceptual framework for understanding the determinants of screening behavior when guidelines are unclear or conflicting.

* OBJECTIVES The goal of this study was to develop a psychometric instrument that classified physicians’ response styles to new” information as seekers, receptives, traditionalists, or pragmatists. This classification was based on specific combinations of 3 scales: (a) belief in evidence vs experience as the basis of knowledge, (b) willingness to diverge front common or previous practice, and (c) sensitivity to pragmatic concerns of practice. The instrument will help focus efforts to change practice more accurately.

* STUDY DESIGN This was a cross-sectional study of physician responses to a psychometric instrument. Paper-and-pencil survey forms were distributed to 3 waves of physicians, with revision for improved internal consistency at each iteration.

* POPULATION Participants were 1393 primary care physicians at continuing education events in the Midwest or at primary care clinic sites in the Veterans’ Health Administration system.

* OUTCOMES MEASURED Internal consistency was measured by factor analysis with orthogonal rotation and Cronbach’s alpha.

* RESULTS A total of 1287 usable instruments were returned (106, 1120, and 61 in the 3 iterations, respectively), representing approximately three fourths of distributed forms. Final scale internal consistencies were a = 0.79, b = 0.74, and c = 0.68. The patterns of scores on the 3 scales were consistent with the predictions of the theoretical scheme of physician types. The “seeker” type was the rarest, at fewer than 3%.

* CONCLUSIONS It is possible to reliably classify physicians into categories that a theoretical framework predicts will respond differently to different interventions for implementing guidelines and translating research findings into practice. The next step is to demonstrate that the classification predicts physician practice behavior.

* KEYWORDS Patterns, physician’s practice; education, medical, continuing; practice guidelines; decision making; psychometric instruments. (J Fam Pract 2002; 51:938-942)

KEY POINTS FOR CLINICIANS

* One size probably does not fit all when bringing physicians new information that might change their practice.

Physicians differ measurably in what they consider credible sources of information, the weight they assign to practical concerns, and their willingness to diverge from group norms in practice.

One of the benefits of hosting a visiting professor from England has been access to the British Medical Journal, and perhaps less esteemed but equally fascinating publications like GP. This tabloid, similar to FP News, highlights the striking similarities between our practices–once you get beyond the discussion of “list sizes,” the NHS (National Health Service), and of course, the term “GP” itself.

There are calls for GPs to ban together to fight kidney disease, obesity, and hypertension, to provide mammography on request, and to more effectively treat atrial fibrillation. Judged by my rigorous scientific sampling over tea and scones (well, maybe it was a Starbucks and a bagel) the clinical issues are immediately recognizable: screening for occult problems, effectively managing chronic disease, improving quality of care.

But what about the social and economic fronts? There are debates about maintenance of certification and “revalidation,” struggles to reduce hospitalization and rein in costs, and pharmaceutical advertising galore. Editorials reflect on whether physicians should be salaried, the demise of 24-hour responsibility of physicians, the influx of nurse practitioners–I could lift the copy verbatim for JFP. Underlying these discussions are debates about financing healthcare, workforce composition, and the eroding lifestyle and incentives to GPs.

As I get to know my new GP colleague, it is clear our hopes, struggles, and challenges are quite similar. Although, I do admit to wistfully dreaming about the “paper-light practice with no out-of-hours or weekend work, with 10,000 patients all very well trained.”