Keystone III: Family physicians reflect, refocus

A group of approximately 80 family physicians, half chosen by lottery, met last month for Keystone III, a five-day, intensive discussion of the specialty's past, present and future. The conversation centered on 10 conference papers (available at www.aafp.org), which explored some of the specialty's most difficult questions:

• What is the domain of family practice?

• How will family physicians care for patients in the context of family and community?

• What can technology do to and for family practice?

• What is the science base of family practice, and how will it be developed?

• What does family practice need to do next?

As part of a discussion on the family physician's role in social change, David Loxterkamp, MD, of Belfast, Maine, reminded the group of the essence of family medicine. In his paper titled “A Vow of Connectedness: Views From the Road to Simmons' Farm,” he writes, “The family doctor is rarely an agent of meteoric change. But every day, and closer to the earth, we are its vehicle and eyewitness. Doctors who remain deeply connected to their patients, and to the legacy of service, will know the privilege, as will those who retain the capacity to listen, touch and tether themselves to whatever is wounded in another's life. In modest ways we accomplish the utterly profound long before the prescription is filled or the blood test is taken. We are paid by the patients' periodic return, and by their tokens of friendship and intimacy and trust.”

Family physicians unable to attend the conference were connected by Web cast and can still read the papers and post comments on the site's bulletin board. Conference organizers are preparing a written record of conclusions and charges arising from the conference for broad dissemination.

Keystone I and II, held in 1984 and 1988 at Keystone, Colo., were the brainchild of Gayle Stephens, MD, of Birmingham, Ala., who wanted to create a forum for family physicians to share ideas and strengthen the specialty.

Clinical guidelines vs. reality

Two recent studies from the research company HCIA-Sachs, Evanston, Ill., suggest there are consistent differences between what clinical guidelines propose and what reality presents. Comparing actual pediatric lengths of stay against “goal” lengths of stay published by Milliman and Robertson, HCIA researchers found nearly two-thirds of uncomplicated pediatric patients stayed in the hospital longer than the guidelines allowed.

Student loans

Medical students graduated with a median student loan debt of $92,000 at private institutions and $67,400 at public institutions in 1998, according to a survey sponsored by the National Association of Student Financial Aid Administrators. The debt burdens are troubling, says the USA Group Foundation, a co-sponsor of the survey, because they may limit who strives for medical degrees and may discourage physicians from practicing in poor or underserved communities, which typically offer lower incomes.

Good news for HMOs

HMOs showed substantial, sustained improvement in 1999, according to the findings of the State of Managed Care Quality 2000 Report released recently by the National Committee for Quality Assurance (NCQA). The 466 health plans reporting to the NCQA improved in all 18 measures examined in every region of the country. “In terms of quality, 1999 was by far the best year in the history of managed care,” said NCQA President Margaret E. Kane.

What's an HMO?

A survey of privately insured individuals conducted by the Center for Studying Health System Change found that almost 25 percent of those surveyed were confused about their type of health plan. Thirteen percent of people enrolled in HMOs said they belonged to a different type of plan and rated them relatively high, while 11 percent of those in other plans reported being members of HMOs and rated them relatively low. HSC says its study quantifies for the first time how negative views about HMOs bias consumer ratings of their health care.

Help break the habit

Of Medicare enrollees aged 75 and older who smoke, 71 percent report receiving advice from their physicians to quit smoking, according to the Centers for Disease Control and Prevention. If smoking-cessation advice were increased to 90 percent of Medicare patients who smoke, an additional 25,000 smokers would be encouraged to quit each year.

Cancer risk evaluation online

If your patients want additional information on their personal risk for getting one of the 12 most common cancers and how to reduce their risk factors, direct them to Your Cancer Risk at www.yourcancerrisk.harvard.edu. The site was launched by the Harvard Center for Cancer Prevention and offers immediate feedback tailored to each individual.

Gift-giving ethics

Concerned with what appears to be an escalation of inappropriate gift-giving by pharmaceutical representatives to physicians, the American Medical Association has stepped in with an educational campaign to set everyone straight. For pharmaceutical gifts to be legitimate, says the AMA, they must benefit patients and not be of “substantial” value (defined as more than $100). In other words, cheap and practical are the rules for this gift-giving season.

Patient trust

Although 44 percent of patients believe physicians are influenced to some extent by insurer's rules, 92 percent trust physicians to put their medical needs first, according to a survey from the Center for Studying Health System Change.

Survey uncovers voluntarily uninsured

Forty percent of California's 7 million uninsured reside in households with incomes at least 200 percent above the federal poverty level, or at least $33,000 per year for a family of four, according to a survey from the California HealthCare Foundation. The non-poor uninsured are typically healthy, working adults under age 40 who are not offered employer-sponsored health plans but whose incomes make them ineligible for government programs. Forty percent own their own home.

The biggest reason for their lack of coverage is a misconception about the cost. Seventy-five percent of the non-poor uninsured said they did not believe they could afford health insurance; however, 68 percent estimated the cost of health insurance to be higher than the actual cost. When presented with actual costs, 53 percent said they would purchase health insurance.

Forty-three percent of the voluntarily uninsured said they do not believe health insurance is a good value, and 48 percent cited good health as a reason for not purchasing it.

The California HealthCare Foundation is working to educate this segment of the uninsured population about the benefits of health insurance and to help them purchase coverage.

Practice Pearls from here and there

More time in no time

As a physician, you can't afford to waste your time. Instead, you need to maximize it by separating your duties into the following three categories:

1. Work that requires your expertise and training.

2. Duties you could delegate to less expensive staff members.

3. Tasks no one should waste time on.

— Use highest and lowest paid workers more efficiently. The Physician's Advisory. Conshohocken, Pa: Advisory Publications. July 2000:6–7.

Collecting practice data

Think twice before accepting an offer from a health plan, hospital or other entity to collect data on your practice for you. What you receive from them may have been edited, giving you a distorted picture of your practice. Of course your best option is to generate your own data, but if that isn't an option, ask specifically to receive unedited information.

— DeShazo CV. Hold or fold? Phys Exec. 2000;26(4):38–43.

Discussing alternative medicine

Even if you don't endorse alternative medicine, you should be aware of any alternative treatments your patients may be receiving. Here are some tips, developed by David M. Eisenberg, MD, for handling alternative care discussions with your patients:

• Don't discuss alternative care until you've performed a medical evaluation and tried conventional options.

• When you do discuss it, avoid using labels such as “alternative,” “complementary” or “unorthodox.”

• Suggest to your patients that they check the credentials and licensing of any alternative providers they see.

• Follow up with patients who are using alternative care to ensure they're receiving responsible care.

— Greene, J. Alternative talk. Hippocrates. 14(5):22–25.