Family practice in the United States is under threat. Patient demand for direct access to specialists is growing, which reflects the population’s insatiable appetite for high-technology medicine and may also be indicative of a backlash against the gatekeeper model imposed by managed care. The hospitalist movement is further removing family physicians from the inpatient care setting. The number of advanced nurse practitioners and physicians’ assistants claiming to deliver primary medical care of equivalent quality to and lower cost than family physicians is also growing. Patients also have ready access to a broad army of health and medical care information services through the Internet, which may provide the opportunity for them to decide what kind of specialized medical care they need.

Many managed care organizations (MCOs) have instituted demand management programs that give patients direct access to telephone triage centers staffed by nurses 24 hours. MCOs have also instituted chronic disease management programs for managing patients with specific chronic diseases (diabetes, asthma, heart failure) in a more cost-effective manner, often “carving out” that part of their care away from the primary care physician.

There are more and more published studies that purport to show that the outcomes of care for patients with certain chronic diseases are better when provided by specialists compared with generalist physicians.[2] Wagner and colleagues[3] believe that improved outcomes of care by specialists are probably related to better-organized processes of care and not necessarily to superior specialist knowledge or expertise. They note that studies comparing usual generalist care with usual specialist care have found no differences in care outcomes.

Family physicians find that their level of reimbursement is decreasing, while the amount of regulation, paperwork, and office overhead is increasing. They have to see more patients in less time to maintain their incomes. Sometimes feeling like hamsters on a wheel, they are becoming more dissatisfied with their practice. This is not going unnoticed by medical students; the number of US medical school graduates matching in family practice residency programs has declined for 4 years in a row. Family practice as we know and practice it today is in peril.

Clinical Quiz questions are based on selected articles in this issue. Answers appear in this issue.

American Family Physician has been approved by the American Academy of Family Physicians as having educational content acceptable for Prescribed credit hours. Term of approval covers issues published within one year from the beginning distribution date of December 2001. This issue has been approved for up to 2 Prescribed credit hours. Credit may be claimed for one year from the date of this issue.

The American Academy of Family Physicians is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The AAFP designates this educational activity for a maximum of 2 hours in Category 1 credit toward the American Medical Association Physician’s Recognition Award. Each physician should claim only those hours of credit that he or she actually spent in the educational activity.

AAFP Credit

Each copy of AFP contains a Clinical Quiz answer card. AAFP members may use this card to obtain the designated number of Prescribed credit hours for the year in which the card is postmarked.

AMA/PRA Category 1 Credit

AAFP members who satisfy the Academy’s continuing medical education requirements are automatically eligible for the AMA/PRA.

Physicians who are not members of the AAFP are eligible to receive the designated number of credit hours in Category 1 of the AMA/PRA on completion and return of the Clinical Quiz answer card. AFP keeps a record of AMA/PRA Category 1 credit hours for nonmember physicians. This record will be provided on request; however, nonmembers are responsible for reporting their own Category 1 CME credits when applying for the AMA/PRA or other certificates or credentials.

For health care professionals who are not physicians and are AFP subscribers, a record of CME credit is kept by AAFP and will be provided to you on written request. You are responsible for reporting CME hours to your professional organization.

With more than 1000 new guidelines produced annually over the past decade, it is impossible for the practicing family physician to determine which ones should be adapted into their clinical practice. The Ontario Ministry of Health and Long-Term Care and the Ontario Medical Association formed the Guideline Advisory Committee (GAC) in 1997 to assess and disseminate guidelines that would improve the quality and utilization of health care services in the province. Over the past 3 years the GAC has developed a strategy to identify important topics, to rank guidelines published on these topics based on the quality of their development, and to reformat guidelines as necessary to make them user-friendly for implementation in clinical practice. The GAC is currently assessing a number of strategies to enhance the dissemination of selected guidelines to improve the quality of care delivered in the province.

A method of selecting, reviewing, and endorsing clinical practice guidelines has been established in the province of Ontario, Canada. Recommended guideline summaries are posted on a Web site with links to full text for easy access by practicing physicians (www.gacguidelines.ca).

Strategies for the successful implementation and impact evaluation of recommended guidelines are currently in development.

Clinical practice guidelines are statements that are systematically developed to assist physisican and patient decisions about appropriate health care for specific clinical circumstances. (1) Published guidelines have become widely available through Internet technology; it has been estimated that more than 2500 exist. Most are produced by specific interest groups (eg, national societies and pharmaceutical companies), disseminated by publication in a medical journal or traditional mail, and seldom demonstrate any effect on clinical practice. (2) Such a large volume of guidelines creates confusion for clinicians who often do not follow any of them because of the time required to assess their quality.

* OBJECTIVE Our goal was to compare the content of family practice in different countries using databases containing information on reasons for encounter, diagnoses, and interventions that are coded with or can be addressed by the International Classification of Primary Care (ICPC).

* STUDY DESIGN In the Netherlands, Japan, and Poland data were collected identically with an electronic patient record (Transhis). For all face-to-face encounters the reasons for encounter, diagnoses, and interventions were coded according to the ICPC within an episode of care structure; prescriptions were coded with the ICPC drug code. Data were collected for research purposes and cannot be considered representative for family practice in these countries. We derived comparable estimates for the United States using visit data from the National Ambulatory Care Survey (NAMCS), with specific emphasis on the contribution of family physicians. NAMCS data were mapped to the ICPC and the ICPC drag code, and Dutch, Polish, and Japanese data were directly standardized for the 1996 US population. Data on utilization, reasons for encounter, encounters per episode of care, new episodes of care, and prescriptions were compared. We also present World Health Organization and Organisation for Economic Co-operation and Development data on health care delivery, efficiency, expenditure, and health status for each country.

* POPULATION We included the following: from the Netherlands: 10 family physicians, 48.640 patient years, 1995-2000; from Japan: 6 family physicians, 17.082 patient years, 1996-1999; from Poland: 22 family physicians, 11.315 patient years, 1997-1999; and from the United States: NAMCS 1995-97, 30.991 patient years, 91395 visits (26% with a family physician).

Clinical Quiz questions are based on selected articles in this issue. Answers appear in this issue. American Family Physician has been approved by the American Academy of Family Physicians as having educational content acceptable for Prescribed credit hours. Term of approval covers issues published within one year from the beginning distribution date of April 2002. This issue has been approved for up to 4.5 Prescribed credit hours. Credit may be claimed for one year from the date of this issue.

The American Academy of Family Physicians is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The AAFP designates this educational activity for a maximum of 4.5 hours in Category 1 credit toward the American Medical Association Physician’s Recognition Award. Each physician should claim only those hours of credit that he or she actually spent in the educational activity.

AAFP Credit

Each copy of AFP contains a Clinical Quiz answer card. AAFP members may use this card to obtain the designated number of Prescribed credit hours for the year in which the card is postmarked.

AMA/PRA Category 1 Credit

AAFP members who satisfy the Academy’s continuing medical education requirements are automatically eligible for the AMA/PRA.

Physicians who are not members of the AAFP are eligible to receive the designated number of credit hours in Category 1 of the AMA/PRA on completion and return of the Clinical Quiz answer card. AFP keeps a record of AMA/PRA Category 1 credit hours for nonmember physicians. This record will be provided on request; however, nonmembers are responsible for reporting their own Category 1 CME credits when applying for the AMA/PRA or other certificates or credentials.

For health care professionals who are not physicians and are AFP subscribers, a record of CME credit is kept by AAFP and will be provided to you on written request. You are responsible for reporting CME hours to your professional organization.

NOTE: The full text of AFP is available online (www.aafp.org/afp), including each issue’s Clinical Quiz. The table of contents for each online issue will link you to the Clinical Quiz. Just follow the online directions to take the quiz and, if you’re an AAFP member, you can submit your answers for CME credit.

The medical uniform sector is a bedrock industry that unlike many other healthcare manufacturing segments has seldom felt the urge to merge. But this spring Medline Industries pulled off an acquisition that at once changes the shape of the field, broadens its product offering and takes a century-old uniform name and competitor out of play.

The events began in late March when agreement was announced between Medline and Angelica Corp., the St. Louis-based manufacturer that has provided uniforms for healthcare workers since the 1800s originally as Angelica Uniform Company, to sell the healthcare apparel portion of Angelica’s Manufacturing and Marketing unit to Medline, itself a decades-old operation in the segment. The deal, valued at approximately $17 million, was finalized in mid-May. Tossed into the mix was Medline’s acquisition of an Angelica distribution center located in Alamo, TN, for $1.3 million in cash.

In a larger part of Angelica’s sell-off, Cincinnati-based Cintas Corp. agreed to purchase for some $22 million certain assets of Angelica’s nonhealthcare business, which includes sales to hospitality, gaming and food service industries.

Angelica had for several years been struggling with a range of issues related to its uniform business, among them an exodus of key personnel, the advent of large-scale offshore manufacturing and a business strategy that seemingly drifted far from what had been a respected leadership position in its core sector. Traded on the New York Stock Exchange under the symbol AGL, Angelica Corporation provides textile rental and laundry services to healthcare institutions, and operates a national chain of retail uniform and shoe stores. Telephone calls to Angelica for comment on the Medline deal and other issues were not returned.

Medline had been a relatively small customer of Angelica-manufactured goods prior to the sale and bad been a supplier of Angelica Textile Services, according to Mark Whitaker, senior vice president of textile sales for Medline, which is based in Mundelein, IL. He said that Angelica was already in the uniform side of the industry, a segment that vexed Angelica, but one that Medline targeted for sales growth. That segment includes lab coats and fashion scrub wear for women. For example, nurses had been buying those outfits direct from Medline as part of a product line sold direct to hospitals.

PORT WASHINGTON, N.Y. — ProfitCenter Software Inc. (PCS), a wholly owned subsidiary of Systemax Inc. (NYSE: SYX), and a provider of web-based business automation software, announced today that Tafford Manufacturing, Inc. has entered into a hosting agreement with PCS for the deployment of its web based Profitability Software Suite(TM), an integrated multi-channels sales and fulfillment solution.

“Tafford Manufacturing is the medical uniform industry’s leader in service, style and innovation. We pride ourselves on our responsiveness to the needs of the contemporary medical professional, as well as our on-going endeavor to provide our customers with the very latest in apparel options and customer service,” stated Robert Schoenfeld, CEO of Tafford Manufacturing, Inc. “Paramount service is a hallmark from which we do not stray, and we are constantly reevaluating our performance and procedures to make the purchasing experience pleasant and informative for our customers. The PCS solution offers us the ability to continue our company’s growth while expanding the customer’s experience and increasing operational efficiencies.”

Tafford’s growth for the future dictated that they find a vendor with leading edge functionality built on a very strong technology platform. PCS earned Tafford’s confidence with superior technology and solutions that will enable Tafford Manufacturing to address customer needs well into the future.

The Profitability Software Suite(TM) will give Tafford Manufacturing and its customers:

–Improved Customer Service via direct and web interaction.

–An open database and real-time report engine that provides high-level to granular detail.

–Enable sales and call center personnel to easily search for product information by specific attributes including product description, style, color and design.

–Automate current manual processes.

–Improve the workflow of orders by having a single unified solution to manage the sales continuum from customer product inquiry to finance, start to finish.

BALTIMORE — Federal agencies disagree about whether Medicare should continue to have two types of coverage policies: local coverage decisions that affect only a certain geographic area, and national coverage decisions that affect beneficiaries nationwide.

Representatives of the Centers for Medicare and Medicaid Services tout the value of having two types of decisions.

“If your {scientific] evidence is not mature, it’s better to go local,” said Dr. Stephen Phurrough of CMS’ Office of Clinical Standards and Quality said at a meeting sponsored by the Advanced Medical Technology Association (AdvaMed). But at the national office, we want mature evidence that’s fairly consistent.” If there’s a lot of confusion among various regional Medicare carriers about the value of a device or whether it should be covered, it may be better to seek a national coverage decision to settle the issue, he noted.

Local coverage decisions were necessary because they enhance flexibility, said Dr. Charlotte Yeh, CMS regional administrator for Region I, based in Boston. For instance, state laws and regulations differ; oxygen is considered a drug in some states and not in others, and so it is regulated–and paid for-differently.

In addition, “in the Northeast we have major clinical centers, and sometimes new technology is used in our region when it’s not available in the rest of the country,” she said. One example would be if a medical center offered a treatment for a rare disease, such as primary amyloidosis. The high rate of treatment for that disease might warrant a local coverage policy.

The U.S. General Accounting Office (GAO) disagrees, and in May it issued a report concluding that the local coverage process should be abolished.

“Because contractors can determine coverage for beneficiaries being treated in their jurisdictions, coverage inequities for beneficiaries with similar medical conditions have resulted,” the report noted. “For example, until recently coverage for a new treatment for debilitating tremors, called bilateral deep brain stimulation, had been allowed only for beneficiaries treated in some states.” In another case, coverage for certain tests to monitor patients’ response to cancer treatment varied by state, with one test covered by carriers in Rhode Island and Pennsylvania but not by Florida and New Jersey carriers.

A recent voluntary survey of 410 personnel from the U.S. Armed Forces Medical Departments and the Public Health Service indicated that humanitarian service experience has positive effects on recruitment and retention: 48% of respondents indicated that the opportunity to provide humanitarian service was a factor in their decision to join a uniformed service and 62% indicated that humanitarian service opportunities positively influenced their decision to remain in uniform. Humanitarian service requirements were a disincentive to remain in uniform for 25%. Pending further study, these preliminary implications can be applied to personnel policies and programs to recruit and retain uniformed health care professionals.

Introduction

Although the original project did not include recruitment and retention aspects, information from humanitarian after action reports and interviews suggested that humanitarian experiences profoundly affected some personnel, prompting the survey.1

Study Design

Uniformed health care personnel of many specialties voluntarily completed anonymous, short surveys about whether humanitarian service opportunity influenced their joining or remaining in uniform (i.e., recruitment and retention). Surveys were circulated in the fall of 2001 via personal contact and e-mail to individuals, at professional conferences, in newsletters, on the internet, and to units, including the medical student body of the Uniformed Services University of Health Sciences. A variant of the questionnaire also asked about the effect of humanitarian service on professional development, morale, and esprit de corps. Responses, collected through late winter of 2002, included 158 Navy, 105 Army, 64 Air Force, 79 Public Health Service, and 4 unspecified persons, 410 people in all. Respondents ranged from junior personnel on initial tours to senior officers who had led humanitarian missions. Two hundred thirty-one cited previous humanitarian experience(s).

Q: BECAUSE OF AN INJURY, my doctor told me to stop going to the gym. But doesn’t it make more sense to train around the pain?

A: Good question. The answer: It depends. When you have an injury–sports-related or otherwise–you can generally expect that exercise will either help you overcome the injury or make it worse. The trick is in knowing when to follow your doctor’s advice and when to override it, seeking expert advice from someone in the field of your specific injury or simply following your own common sense.

“Keep in mind that a doctor’s first job is to do no harm,” says Tom Seabourne, PhD, author of Pocket Idiot’s Guide to a Great Upper Body (Alpha, 2006). “That means that the advice you get may not always be the best advice for overcoming an injury. A doctor can always safely advise you to take time away from the gym without concern that his advice will worsen your condition.” If you want to keep training and work to overcome your injury, Seabourne makes the following recommendations.

>> Seek an expert’s advice. “Rather than relying on general medical advice, seek out a specialist,” suggests Seabourne. “Sports-med physicians and physical therapists want what you want–to get you back into the gym, pain-free, as soon as possible. Most PTs will show you exercises that increase the strength and flexibility of the muscles surrounding your injury so you’ll prevent future injuries.”

>> Train opposing muscles. “Often, the problem comes not from the injured muscle but from a weakness in the opposing muscle group,” notes Seabourne. “Your body is a kinetic chain of muscles that work together in harmony: quads-hams, biceps-triceps, chest-back. When you’re injured, consider emphasizing the opposing muscle group to develop muscle balance.”

>> Find substitutes. “If a particular exercise is bothering you, eliminate it. Replace bench presses with machine presses; rather than squats, try leg presses,” Seabourne advises. “Use other techniques, too; for example, if heavy weights are a problem, switch to lighter weights and higher reps. Work with very light weights for stabilizing moves such as overhead dumbbell presses, then use slightly more weight for machine presses, which don’t require stabilization.”