What to do about the epidemic of obesity?

We are the first generation in the history of mankind that can have what we want to eat, when we want it and in unlimited quantities. In addition, the food we eat is largely the rich and fat-loaded "holiday" food which our family ancestors reserved to special family and religious celebrations that occurred only a few times each year but we now have it weekly or daily.

"Health is influenced by factors in five domains - genetics, social circumstances, environmental exposures, behavioral patterns, and health care. When it comes to reducing early deaths, medical care has a relatively minor role. Even if the entire U.S. population had access to excellent medical care - which it does not - only a small fraction of these deaths could be prevented. The single greatest opportunity to improve health and reduce premature deaths lies in personal behavior. In fact, behavioral causes account for nearly 40% of all deaths in the United States. Although there has been disagreement over the actual number of deaths that can be attributed to obesity and physical inactivity combined, it is clear that this pair of factors and smoking are the top two behavioral causes of premature death."

Steven A. Schroeder, M.D. We Can Do Better - Improving the Health of the American People NEJM Volume 357:1221-1228, September 20,2007.

The domain of genetics is a comfortable one because it implies culpability beyond our control. Time and again we have had families in our care where the children using health lifestyles overcame their "bad genes" as evidenced by their older relatives so we need to be prepared to help them. The AAFP Americans in Motion brings just such assistance to our practices.

Quoting from the AAFP AIM Web site, Ready, Set, FIT! is a school-based educational program that teaches third and fourth graders about the importance of fitness through a partnership between the American Academy of Family Physicians' fitness initiative, Americans In Motion (AIM) and Scholastic. Through a partnership between the American Academy of Family Physicians' fitness initiative, Americans In Motion (AIM) and Scholastic, Ready, Set, FIT! offers in-class lessons and take-home activities aimed at encouraging kids to be active, eat smart and feel good.

The AAFP - AIM has developed materials for improvement in our office practices including the AIM to Change Toolkit which contains resources to help us interact with patients as well as patient education materials including the AIM Fitness Inventory for patients to complete and use it to gauge their current level of fitness and their readiness to change. "Tips for Healthy Children and Families Poster Pack " is free and contains helpful posters for our offices. Finally, to help us in new ways of addressing the AIM goals in our office, the AIM Group Visits Guide is a guide to conducting and getting paid for group visits for patients with chronic conditions affected by overweight and obesity.

Environmental and social circumstances are also important. Studies have shown that the availability of high quality food is limited in areas of lower socioeconomic impact because of the lack of quality grocery stores in those areas. Look at your home communities. In most medium towns and larger, the availability of fresh healthy good for families who want to live healthier lives is made more difficult by the lack of groceries. Convenience stores and fast food outlets that often are the sole providers of food to those neighborhoods replace these.

The evolution of the nuclear family also impacts food choices. Both working parents may lead to latch key kids who are unsupervised in after-school nutrition. When the family reconstitutes for the evening meal, it is often prepared outside the home, brought home and is cased in Styrofoam. These are personal values and perceived family needs that definitely impact the family approach to obesity.

Behavioral influences are known to lead to overeating. After World War II, a plump child was a healthy child. We were the recipients of the "clean up your plate" patterning. We are fortunately seeing changes there due to the efforts of family physicians and pediatricians stressing early childhood nutrition to young moms who hear and heed. There are however consistent uses of food as gratification/environmental control. Crying babies get fed - breast, bottle or pacifier. Good children get candy. Ice cream treats are welcome in later years.

Adult interactions (such as church events, dating and medical staff meetings) are all associated with lots of "good" food. Watch the evening TV and be amazed at the pizza and hamburger ads (usually interspaced with the DTC drug ads and the lawyer ads looking for class action suits against the DTC drugs). We are constantly bombarded by Madison Avenue temptations of oral satiety.

As I was on the treadmill this morning (yes, a frightening image but true) watching the brain numbing TV, there came on two different public service announcements of kids turning down high fat, high calorie snacks at play and at movies with cool music and cartoons in the background. They closed with a young child loudly proclaiming "DON'T SUPERSIZE ME!!" What a wonderful image to put in the minds of our kids and grandkids. Effecting programming and clear cut messaging aimed at kids has helped with tobacco - it's use in obesity can do nothing less than help.

Health care approaches require a consistent, continuous, comprehensive,compassionate (The Values of Family Medicine) approach to identification of the above noted confounding factors. A trusted physician "family member" offers advice, education and encouragement for modification of the above behaviors. We have been successful at least in part in the area of tobacco use. The AAFP Tar Wars program stands out as a campaign of education for children and early intervention. We have not been completely successful. As long as product is available, there will be incomplete success.

Taking the "Tar Wars" model, family physicians may want to start a "Fat Fight" or such similar education campaign. We are seen, known and respected in our community.

Advocacy for physical education in our schools, removal of high caloric, high fat snack and drink machines, healthy diets at school and home may take generations but we must begin somewhere. However, as Schroeder says the success with tobacco doesn't predict easy success with obesity.

Food is necessary to life and is very legally available. Governmental agencies have not been very success at changing individual "freedoms" and until the public health and costs are recognized - just like with motorcycle helmets - these food freedoms and their sellers will be hard to change. Just like politics, these battles need to be fought at the local level. Societal pressures just like with tobacco are our best hope. We need to help.

The AAFP can help with programs like AIM and with legislative testimony supporting a strong family medicine base for a new health care plan with adequate payment for on-going continuity based comprehensive care.

As a scientist, I am excited about the future in this area of weight and wellness. We have developing knowledge of the science of weight gain, obesity and GI physiology. The studies of hormone homeostasis concerning Ghrelin Leptin and GLP-1 continue to excite me that we may be able to help patients with new and exciting (non stimulant) therapies.

I have had the enjoyment of sharing patient successes with exenatide with weight losses of up to 60 pounds now sustained and with excellent diabetic control. I would hope that our academic colleagues and those involved in research networks would be participatory in this work. During these times of Pharma-bashing, we need to remember how the lives of many have been changed with real pharmacological advances.

Who would have thought that ten years ago, a failed antihypertensive named sildenafil would have had such an impact on the intimate lives of our patients? The future can be very exciting and who knows.

One place the AAFP can play a role is in the personal health and well being of family physicians. Too often, we are the worst role models. We treat our patient's stress in highly stressful practices. We counsel dietary wellness just before we gulp down a quick high calorie meal. We encourage time off for vacations and wellness as we haven't taken a vacation in years. We measure our quality of care by the number we see in a day and the length of hours we work without sleep. Things have to change.

Modeling is important and best practices must be recognized. Family medicine needs to be practiced in a setting that provides support for time off and coverage. Teams of providers need to be encouraged that permit the physician to do what they do best - diagnosis and decision making - with pre-evaluation and post-care done by others under supervision. We need to model the lives we prescribe for our patients.

Restructuring of the health care system, active modification of medical liability to a state of reality where the patient is protected and the provider treated fairly, support for physicians in need and provision of a work environment that provides expedited information flow with best practices/evidence support quickly and easily available should be our goals. If not for us, lets do it for those students.

I have probably gone on too long. Remember the adage by H. L. Mencken, (Prejudices: Second Series, 1920)

"There is always a well-known solution to every human problem--neat, plausible, and wrong. "

How do we improve medical student to family medicine resident recruitment?

I have seen class after class come into our medical schools bright and eager to practice the excitement of the specialty of family medicine only to come out four years later entering limited practice specialty residencies.

Individuals in internal medicine training delay their decision to avoid general medicine only by a few years since 80 percent of their pipeline in residency ends up in a sub-specialty.

Why does this happen?

In early August, I ate lunch at the AAFP Resident and Student Conference with two delightful students - one from a southeastern state university medical school and one from a metropolitan mid Atlantic city. - The one from the southeast is considering family medicine, pediatrics and psychiatry as career choices. She had taken a year off between her second and third year to get away from the stress of worrying about the debt - yes the debt - not the curriculum - not the call - the debt. She was at that point $80,000 in debt and wanted to figure out if it was worth going on. Fortunately, for the thousands she will touch and help in the future, she decided it was worth it and she came back.

The other student was more up-front. She goes to a private medical school and her borrowings yearly average $75,000 a year. Her debt for her medical education will equal a house purchase. She is enthusiastic and excited and sees the investment as worth it.

To quote James Carville, "it's the economy, stupid."

Students coming out of medical school see years of debt repayment (the southeastern student figures she will be paying off her educational notes for the rest of her life.) vs. life in a "doughnut specialty" with high procedural payments able to give them a comfortable life and pay off a mountain of debt at the same time.

We used to worry about the academic bigotry and specialty racism endemic in the non-family medicine faculty in our academic centers. I'm not seeing that as much recently. It may still be a factor but the quality of our graduates turned out in difficult times and the excellence of our faculties hopefully have put that to rest. Sure, there are some screamers around but they are recognized for what they are - insecure within their own persona as physicians and people. To again quote James Carville, "it's the economy, stupid!"


We must reform how family physicians are paid for their services. Pay family physicians 2/3 of what an orthopedist, a dermatologist or a radiologist makes and you won't have enough slots out there to train eager smart young medical students who are passionate to be family physicians. There are typically two types of services provided - episodic illness (usually structural problems) and ongoing continuous, comprehensive, coordinating, compassionate, caring for life and wellness for life care (apply these to any other specialty and they will come up wanting).

Unfortunately, we in the US have been boxed into the single type of payment - episodic payment for illness-based care for our services. Take out my appendix and follow me for 6 weeks and get paid a global fee. Deliver me from my mother, protect me by immunization, suture my lacerations, counsel me about sexuality, manage my diabetes, control my hypertension, diagnose my chest pain, counsel me when I find drugs in my kids room, advise me about the risks and benefits of prescription drugs, care for me during my surgeries, find my cancer and hold my hand as I die (The Value of Family Medicine) and get paid a pittance for each episode - having to fight a system that does not recognize the value of comprehensive life long care.

That care needs to be paid as a comprehensive service. Paul Ellwood and the Jackson Hole Group were right with the HMO concept. Call it now the RUC proposal for the Medical Home. Call it concierge medicine. Comprehensive payment on an ongoing basis for comprehensive ongoing care is long overdue. The AAFP needs to have a seat at the table leading up to the changes in the American medical system. If not for us, then for those two young students and their patients. I promised it to them.

Response to AAFP Board Candidate Forum

1. Do you concur with this information, these interpretations, values and views? If not, how do you differ?

Arnold Relman was right. It is interesting to read of the development of our current structure (evidence the excellent treatise by Niko Karvounis and Maggie Mahar on July 15, 2008 “The Managed Care Roller Coaster” http://www.healthbeatblog.org/2008/07/the-managed-car.html which described the evolution of managed care from Ellwood to current chaos. ) The Ellwood HMO model envisioned a long term continuity relationship funded by a monthly retainer with emphasis on preservation of health, prevention of illness and appropriate utilization of other levels of health care. Karvounis and Mahar then go on to describe the “profit-ization” and the “for profit” evolution of these plans with profit replacing care to maximize shareholder dividends rather than reward quality practices.

It has been shown that primary care adds value and quality from Starfield B, Shi L, Macinko J. (Contribution of Primary Care to Health Systems and Health -- Milbank Q 2005;83(3):457-502) to the recently released "Disparities in Health and Health Care Among Medicare Beneficiaries" conducted by the Dartmouth Atlas Project. and funded by the Robert Wood Johnson Foundation. While the former study proves the value of a primary care based health care system, the latter study acknowledged the benefits of using primary care physicians to manage chronic conditions and coordinate high-quality health care. "For conditions such as diabetes and hypertension, primary care physicians have been shown to provide care that is similar to (sub) specialty care in quality and lower in cost," the report said. "Adequate access to primary care can improve care coordination and reduce the frequency of avoidable hospitalizations." The report also said "studies have found that regions with a greater proportion of care provided by primary care physicians have both lower costs and higher quality." Family Medicine works. You are good – you are valuable – you deserve respect – Be proud to be a Family Medicine specialist – What better way to spend your life?

Business and, we hope, government are starting to recognize these facts. An article in the Washington Post http://www.washingtonpost.com/wp-dyn/content/article/2008/06/16/AR2008061602471.html?nav=emailpage outlines the think tanks developing health care plans for change - many with a new found old idea of the primacy of family medicine.

In his book, The Social Transformation of American Medicine (Basic Books; Reprint edition 15 May 1984), Paul Starr’s first line was “The dream of reason did not take power into account.” Later he wrote “But medicine is also , unmistakably, a world of power where some are more likely to receive the rewards of reason than are others.” I have always said that I do not fear government medicine which must, by its political nature, have some responsiveness to those from whom it derives its power. I do fear corporate medicine without ethics or values other than profit and dividend maximization. Relman was right. We have been drawn into the same episodic fee payment system that characterizes the partialists.

We need to support and lobby for ongoing payments that will mirror the values of our specialty – those values like caring, comprehensive, consistent, complete, collaborative, cooperating, competent. The value of family medicine cries for changes in our system - changes that reward comprehensiveness as well a complexity - changes that recognize the family medicine specialists as the true physicians that treat a number of problems in the same time and with better efficiency than one problem specialists - changes that reimburse the family medicine specialist for the coordination, documentation and implementation of comprehensive and continuing plans of management for patients with acute and chronic needs. Maybe Relman wasn’t the only one who was right – Ellwood is looking pretty good now. The recent advances at RUC (not yet finalized) as CMS gets RUC recommendations for Medical Home payment model (see http://modernhealthcare.com/apps/pbcs.dll/article?AID=/20080409/REG/751443597&SearchID=73317054443061 ) Further details of RUC medical home can be found in AMA news. http://www.ama-assn.org/ama/pub/category/18528.html.


2. What should AAFP begin to do differently in these matters? To what goal? Over what time frame? Who will be our partners in this reform?

The reality is that Primary Care emphasis and thus our future relies on Payment Reform http://www.aafp.org/online/en/home/publications/news/news-now/professional-issues/20080227gaoreport.html . This must be done on a national level for federal health programs – Medicare, Tri-Care, and DOD and to a significant extent Medicaid. As I said before, to quote James Carville – “It’s the economy, stupid” (I’m not talking about you, Earl.) We need an Academy that advocates for the value of Family Medicine. We need an Academy that demands a seat at the table in the restructuring of American Health and Illness System. We need an Academy that aggressively pursues change or abolition of an outdated limited practice specialty biased coding and compensation system. We need an Academy that uses the Private Sector Advocacy to promote the keystone specialty that we are back to its primary location. We need an Academy that challenges our academic colleagues to continue to develop new knowledge in our specialty and to teach our students and residents cutting edge medicine expanding the skills they bring to their patients. We need an Academy that fights for a level playing field in contract negotiations so doctors and MCO's are on an equal footing in contract negotiations.

We have begun - steps have been taken by Academy leadership but the journey will be long and the effort intense - the battles will be tough and the losses frustrating - but we need to succeed - for the patients who rely on us over the course of their lives and the families who need us to help them when they need help, guide them when they are unsure and congratulate them when they are successful.

We need to join the upcoming change as a unified body - we need to go forward and be proactive - we need to go back home and bring our brothers and sisters out to join us in a stronger more visible force. We need to support the Board, the PAC, our trainees and our local, state and national political systems as they work through the change.

The American Academy of Family Physicians is the last great shining hope for American patients. They have been deserted by their specialists who are intent on generating new codes and churning the system. They have been deserted by their community hospitals that have become big businesses. They have been deserted by the pharmaceutical industry that requires the American patient to fund discounts provided to other countries and to fund the cost of a bloated sales program. They have been deserted by their government which promised them coverage and which is now trying to dump the bloated entitlement system it created back on American industry. This is the best opportunity ever to advocate for patients. We cannot and will not desert them. The AAFP is the strong medicine that this dysfunctional system needs.

Remember the words of John Kennedy “ Efforts and courage are not enough without purpose and direction.”

Led by the AAFP, we will fight for control of the coding system that discriminates against the value of the specialty of Family Medicine. Led by the AAFP, we will form stronger allegiances with our colleagues in General Pediatrics and those left in General Internal Medicine and with our friends in American industry to advocate for a balanced system where prevention and early intervention save money and lives. Led by the AAFP, we will turn inward to improve our specialty and enhance our skills – skills at wiser prescribing, skills at wiser referrals, skills at wiser contract negotiations and skills at developing new means of meeting the needs of our patients in the 21st century – and getting paid for them. Led by the AAFP we will develop systems where knowledge is discovered, validated as evidence based and disseminated to our family medicine specialists in record time. Led by the AAFP we will demand quality of ourselves so we can demand it of the system.

Evidence the challenge put forth by Pope John XXIII “ Consult not your fears but your hopes and your dreams. Think not about your frustrations, but about your unfulfilled potential. Concern yourself not with what you tried and failed in, but with what it is still possible for you to do. “

3. If you are elected, what will be your role?

My intention is to bring to the board experience in rural medicine, academic medicine, solo private practice, organizational skills of putting a 30 physician group together and keeping it alive when the partialists left, organizational skills putting together a physician, hospital and business collaborative, participation in the Academy at a state (two states in fact) and national level. I have significant experience in negotiation. My role will be as a team player with the other 90,000 + Family Medicine specialists who want the same thing – better patient care and greater personal satisfaction. If we don’t believe in that to which we have devoted out professional lives then where is the value of our time spent on this earth. I know the value of Family Medicine – I am ready to work to change this system to benefit our patients – I am ready to do the heavy lifting, to challenge the myths, to make things uncomfortable as we expose myths and complacency to the light of reality.

The greater danger for most of us lies not in setting our aim too high and falling short; but in setting our aim too low, and achieving our mark.
Michelangelo

4. a. Equally important, what should state chapters’ leaders be doing?

Since so much of our movement is now economic and, since most insurance is regulated at the level of the several states, it is incumbent for the state chapter leaders to take very active roles. These roles involve legislative activities to correct the more grievous components of the insurance industry. It is incumbent for state leaders to lead by example, seeking out issues from members, formulating legislation and then pursuing its successful passage for the benefit of our patients. Each state president/board chair/legislative chair needs to get on a first name basis with their insurance commissioner. Finally, state leadership must organize the ability (PAC’s) to provide financial support to those who are friends of Family Medicine to insure that the needs of the patients are expressed at the state capital. We have many challenges ahead of us. Scope of practice is about to heat up again as evidenced by the Wall Street Journal on the Doctor Nurse programs (http://www.marketwatch.com/news/story/making-room-dr-nurse/story.aspx?guid=%7B2425D486-50B5-4594-86D6-C3A1BC84D6EB%7D&dist=TNMostMailed ) and tort reform. If you thought that tort reform was done, look again. We need to organize now for strong and vigorous alliances with business to strategize for the rationalization and reform of the legal system.

These are not dark days: these are great days - the greatest days our country has ever lived.
Winston Churchill

4. b. Equally important, what should individual members like me be doing?

These above thoughts above are well and good - but remember, the Academy is us. Waiting for the AAFP to win the day means you are waiting on yourself - so it is time to act. Depend on others to do your talking for you and you will get their solutions. Don't depend on our "brother" specialists to speak out for us. They haven't before - they won't now - until their position is comfortable and then it will be too late for us. They may actually fight our solutions while benefiting from our victories.
This is the year when we elect a President, 1/3 of the senate, all the house. Next year - nothing. Now is the time - we need to get change for our patients' sake - now is not the time to settle for a paltry 1 % that bites deeper into our ability to survive. Get to the candidates - ask the tough questions - donate to those who understand and will work to meaningful solutions (GET RID OF SGR, etc.) - work to defeat those with lousy track records. Now is the time - if we complain and moan and don’t get active, we have no one to blame but ourselves. Congress is available and responsive now - they will be in their home communities- - find out their phone numbers and call them. Get active in the Academy. Get your colleagues to join and get active also. If you read one thing, read the Verden Report on Cost vs Profit in Managed Care today http://www.osma.org/files/public/CostvsProfit.in.Managed.Care.Today.pdf

This is no time for ease and comfort. It is time to dare and endure.
Winston Churchill

Earl, thanks for the opportunity to respond to your positions. The sign of a true teacher is that he/she teaches as he/she questions and probes. You have done that. I am pleased to have you as a colleague Family Medicine Specialist.

Open Letter to Senator Isakson

Dear Senator Isakson:

Thank you for the courtesy of an explanation concerning your vote on the upcoming Medicare cut. Let me share with you some thoughts.

The 10 day “reprieve" is necessitated by Congress taking a 4th of July vacation. That vacation is being taken while gas prices are over $4.00, homes are being foreclosed and critical issues like the viability of the Medicare program are at stake.

Medicare is withholding my payments for 10 days during which time my Accounts Receivable will increase. What fee schedule should I submit with my claims during that time?

If I hold my claims for 10 days my cash flow drops. If I pay my taxes late, I get charged interest and penalties. Maybe you'll help me if I tell the IRS that I am on July 4th holiday for a week and that's why the money was late.

If your real estate commissions were held for a month while the buyer decided how much you would be paid - you and your agents would be screaming. We are screaming. Suppose the doctors decided to not see Medicare patients until Congress finished their 10 day vacation and fixed the situation. It won't happen - we feel a moral obligation to do our jobs.

The Medicare bill that generated so much last minute smoke and heat takes the money from the Medicare Advantage Programs (paid to companies like Humana, Aetna, Cigna and others) which merit a 12 percent increase (because they weren't making enough money) in the face of a proposed 11 percent cut for the providers who give the care. The President said he would veto it because it would take money away that had been promised to the insurance companies. Next time you get chest pain, call an insurance salesman.

It is time for Congress to show leadership. We have pointed out for years that the Sustainable Growth Rate (SGR) formula is flawed. Yet, nothing is done. The problem is avoided and temporary patches are applied hoping the next guy will take the heat. We have had to fight to get cuts stopped every year. Instead we get paltry increases (visit the 1 percent this year). Our staffs need to pay for gas to come to work. Georgia Power needs to be paid for our office lights. The rent goes on. In the last 5 years we have experienced 20 percent inflation in our costs of doing business. Congress holds out a 1 percent increase and expects us to lick their hands in gratitude for not having cut us 11 percent this year. I think not.

Some ideas I would like you to consider are;

1.) Abolish the SGR.

2.) Have the GAO do studies on the effectiveness of the cost control efforts of Managed Care and Medicare Advantage plans. Please explain to me why, when the power company wants to raise its rates - they have to justify it to a publicly elected commission - but - when health plans want to raise rates, they don't have to explain it to anybody? They just do it.

3.) Immediately institute the payment recommendations of RUC to CMS for primary care Medical Home services. When a recommended fee change for a surgical procedure is made, it is done that same year - why does a recommendation for the improvement of primary care services to Medicare recipients need pilot studies and bureaucratic proof before it is done?

4.) fully fund medical educational initiatives to increase the number of students and residents going into primary care (your payment program cuts and those of managed care have depleted our ranks and dried up our pipeline). We do not have the workforce in primary care right now to take care of a universal access health care program.

5.) Fix malpractice liability - the cycle is moving - we will have another crisis soon. Institute Worker's compensation policies for medical injury and product liability - institute "loser pays" into the system and cap the tort fees for lawyers and give the money to the injured.

6.) Fix Medicare Part D - We can competitively bid for bullets, bombs and battleships but not for drugs. The VA's costs for drugs are 58 percent of retail while Medicare Part D is over 90 percent of retail. Ask Medicare Part D recipients how painful it is to be in the "donut hole' which is really a "black hole" for their money.

7.) institute a national medical record where all the information on my medical records are available to every physician and hospital in the nation on line improving the documentation and communication and cutting out the $10 billion which Medicare alone spends on unnecessary duplicate testing. England is spending more that the US on a national health record with 1/3 our population. The privacy people will object but I trust the government to protect information now and the insurance companies have much of this information now and no one is crying foul.

Please let me correct one thing - you talk about "reimbursement" - this is not reimbursement. This is payment for services. It is the same type of payment that my dad earned in the coal mines. It is the same type of payment which you receive when one of your agents sells a house. It is the same type of payment I pay at the grocery store or the gas pumps. You are cutting the payment for my taking care of Georgia's elderly and disabled - you are not reimbursing me a thing.

Mr. Isakson, you were sent to Washington to lead not to obstruct. It's time to get on the offense and stop all the defensive party saving and face saving maneuvering. I recognize that you are not running this year - but you will again in the future and the pain which this dysfunctional system is causing my patients and your constituents will not be forgotten.

I am forwarding this to Senator Chambliss who voted like you did and who IS running this year. I am tearing up my campaign contribution checks today. I am going to watch who, between now and October, demonstrates real leadership not party line preservation.
That is where my support and vote will go. I'd like it to be you both. It is up to you both. You wanted the job. We gave it to you. Now do it.

George W. Shannon, M.D.
Family Physician
Columbus, Georgia

Medicare Cuts

Restricting new Medicare patients is water torture - possibly effective but who will notice. While those who can't get in can be allies, our strongest allies are the ones who are in our practices, who know us and who value our relationship.

Handing out talking points is good - it is time we shared with our patients the information we have hesitated to because we didn't want to "politicize" the exam room - the time has come but we are restricting our audience. The messages (talking points) need to hit the local news, the paper, the radio station and the TV. Those not yet on Medicare need to know the upcoming reality. AARP and the baby boomers can be powerful allies if we give then the reality and the future downside.

If you need a resource, here is a video clip on my web site to which you can refer (take a look at it first) http://www.gafp.org/shannon.asp - click on Medicare video.

The AAFP position is http://www.aafp.org/online/en/home/media/releases/2008/senate-failure-to-address-medicare-payment.html

The AMA position is http://www.ama-assn.org/ama/pub/category/6583.html

These are well and good - but remember, the Academy is us. Waiting for the AAFP to win the day means you are waiting on yourself - so it is time to act. Depend on others to do your talking for you and you will get their solutions. Don't depend on our "brother" specialists to speak out for us. They haven't before - they won't now - until their position is comfortable and then it will be too late for us. They may actually fight our solutions while benefiting from our victories.

We have other options - see Family Practice Management for options, a discussion and how- to- do it's
http://www.aafp.org/online/en/home/publications/journals/fpm.html

Not wanting to desert our patients is good and professional ( although we may see massive dumping of Medicare patients anyway) - a massive movement to non-participating status may be a good first step - not denying care - just requiring payment from the ones who request and utilize it. They will get reimbursed (note - did not use the word paid - reimbursed is correct here) much later by a slowly moving bureaucracy that will fight them not to pay (sound familiar) It will require us to collect for services (how novel) and be paid by the users for our services. We also need to announce to our communities that we are doing this because of the lack of Congressional action and that we must do this to stay open to provide care. Information and education makes these moves effective. If we are going to act, we need to let the public know why.

Dropping out of Medicare system by private contracting has a two year front if I understand it correctly (see Family Practice Management) but it may come to that. Completely leaving a huge population of patients in the lurch without warning is not our style, our desire or our intention. We want to be able to care for them - hence the time is here to fight.

Be prepared to see limited practitioners (surgical subs, etc.) not accept Medicare payment. It may put us in a bind when their services are needed but we need to let patients know what and why and get releases signed that show what we recommend and that it was not available. Remember, those that help us out with our problems should benefit by seeing our patients who don't have the problems. It is kind of dumb to send our problems to the nice guys who want to help and then send the OK patients to the guys who turn down our patients but send us hams at Christmas.

This is the year when we elect a President, 1/3 of the senate, all the house. Next year - nothing. Now is the time - we need to get change for our patients' sake - now is not the time to settle for a paltry 1 % that bites deeper into our ability to survive. Get to the candidates - ask the tough questions - donate to those who understand and will work to meaningful solutions (GET RID OF SGR, etc.) - work to defeat those with lousy track records. Now is the time - if we complain and moan and don’t get active, we have no one to blame but ourselves. The Senate is in recess now - they will be in their home communities - find out their phone numbers and call them.

That's all I got to say about that (a.k.a. Forest Gump)….for now


George W. Shannon, M.D.

My View on the Value of Family Medicine

I speak for the Value of Family Medicine, What is it to our patients – to the American health care system - to ourselves? Have we lost value? If so, how and why? How do we put forward the value of Family Medicine?

I see value in family medicine specialists who continue to go above and beyond to make sure that their patients have good outcomes - who take the patient with undifferentiated complaints and make sense of the situation – who take the responsibility over the life of the patient as their problems evolve, resolve and develop into new issues - who are the ones that the family goes to for advice and who are the ones who will be there when all the others are done and have signed off.

The value of family medicine cries for changes in our system - changes that reward comprehensiveness as well as complexity - changes that recognize that family medicine specialists treat problems with better efficiency - changes that pay for the coordination, documentation and implementation of comprehensive and continuing plans of management for patients with acute and chronic needs at their true value.

We have begun - steps have been taken by Academy leadership but the journey will be long and the effort intense - the battles will be tough and the losses frustrating - but we need to succeed - for the patients who rely on us and the families who need us.

We need to join the upcoming change as a unified body - we need to bring our brothers and sisters out in a stronger, more visible force - we need to be proactive. We need to support the Board, the PAC, and our students and residents. We must participate with our local, state and national political systems as they and we work through the change.

I bring experience in Family Medicine education, administration, and practice – in state and national activities as well as skills in negotiation, consensus building, and contract development. Been there - done that - want to do more - willing to do more - able to do more.

Cowardice asks the question, 'Is it safe?' Expediency asks the question, 'Is it politic?' But conscience asks the question, 'Is it right?' And there comes a time when one must take a position that is neither safe, nor politic, nor popular but because conscience tells one it is right.” - Martin Luther King, Jr.

Drug which was designed to help people quit smoking is causing Concern

Drug which was designed to help people quit smoking is causing concern following a number of reports that it induces suicidal feelings and aggressive and erratic behaviour.

The drug Champix, which was licensed in the UK last year, is also known as Varenicline and as Chantix in the U.S. and it is causing concern both in the U.S. and Britain.

There have been it seems almost 50 reports to the Medicines and Healthcare products Regulatory Agency (MHRA) in Britain of depression; these have been mainly in patients with a previous psychiatric history, along with another 16 reports of suicidal thoughts.

Between 15,000 and 20,000 people are using the drug in the UK and of the reactions reported to the MHRA, 183 reports were of nausea, 52 reports of abnormal dreams, 49 of dizziness, 37 of fatigue, 82 of headaches, 21 of drowsiness and 67 of vomiting.

The U.S. regulatory body, the Food and Drug Administration (FDA) has also expressed concerns about the drug which is manufactured by drug company Pfizer and are also investigating the drug after receiving similar reports.

Varenicline is novel in that it both stimulates and blocks specific nicotinic receptors in the brain; it is thought that the stimulation of these receptors mimics the effects of nicotine and reduces cravings.

As it also partially blocks the receptor preventing nicotine from binding to it, a weaker response is produced in people who give in to temptation and have a cigarette.

Trials of the drug suggested that it enabled some 44% of smokers to quit; this was on a regime of a dose taken twice a day for 12 weeks where it compared favorably with a placebo and another major anti-smoking drug, bupropion.

The European Medicines Agency also examined some of these concerns in July, and decided then that no action was needed.

Pfizer says there is no scientific evidence establishing a causal relationship between varenicline and the post-marketing report events.

The drug company says quitting smoking, with or without treatment, is associated with nicotine withdrawal symptoms and has also been associated with exacerbating underlying psychiatric illnesses.

The FDA has asked Pfizer for any additional cases of side-effects that it is aware of and is currently reviewing the data; the agency has advised doctors prescribing the drug to monitor patients for behaviour and mood changes.