Vol. XXXII, No. 4 October 2005

In this issueIn this issue• • StrategicStrategic

PlanningPlanning

• • New Model of New Model of Care StratCare Strategiesegies

• The Hum• The Human an Face of Face of MedicineMedicine

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November 15, 2005: Health Policy & Legislation February 15, 2006: The Joy of Family Medicine May 15, 2006: To Be Announced August 15, 2006: To Be Announced

Editorial Deadlines On the Cover

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The Washington Family Physician (WFP) Journal is the offi cial quarterly publication of the Washington Academy of Family Physicians (WAFP). It serves as the primary communication vehicle to WAFP members. Its purpose is to provide timely and relevant information re-garding the practice of Family Medicine, and report results of the policies determined by the Board of Directors and activities of members and committees.In addition to regularly published articles from selected offi cers, trustees, and committee chairs, WFP welcomes sub-mission of articles on a wide variety of subjects related to the practice of Family Medicine.WFP also welcomes articles written in a respectful and col-

legial manner that refl ect opinion and editorials, if in our opinion, publishing such articles is timely, relevant, and will be of interest to the general membership of the Academy. Such articles will be clearly identifi ed as an individual writer’s opinion or point of view.The views and opinions expressed by all authors in this publication are their own and do not necessarily refl ect those of the Academy. Publication should not be consid-ered an endorsement, expressed or implied, by WAFP.

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Washington

Family

Physician

President’s Message ............................................................................................................ 2

Editorial ............................................................................................................................ 3

Do Computers & Reimbursement Changes Mean Better Times Ahead for Primary Care Physicians? ...... 4

WAFP Votes to Oppose Direct-to-Consumer Advertising ................................................. 6

The Human Face of Medicine ........................................................................................... 8

Mid Level Practitioners and the Future of Family Medicine ............................................ 10

Medical Malpractice Tort Reform: Who Cares? .............................................................. 11

2006 WAFP Family Physician of the Year ........................................................................ 12

Six Strategic Issues ........................................................................................................... 13

I-901, Healthy Indoor Air initiative ................................................................................ 14

OB Medicaid Reimbursement ......................................................................................... 15

Now Is the Time for All Kids to Have Health Care ......................................................... 16

Strategies for New Models of Care ................................................................................... 17

The Malpractice Insurance Crisis: An Impending Public Health Disaster ........................ 18

Meet Melissa Molsee ....................................................................................................... 22

Students & Residents “Summer Vacation” in Kansas City ............................................... 23

Health Care at the Crossroads ......................................................................................... 24

Executive Director’s View ................................................................................................ 25

You must be the change you wish to see in the world.

~Gandhi

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PRESIDENT’S MESSAGEDon A. Solberg, MD, WAFP President, Ellensburg

Ahhhh, summer - the time of youth and youthful memories! I have just returned from my 40th high school reunion, a reconnection with events and people half-forgotten

yet somehow unchanged despite the passage of considerable time. Somehow we seemed more connected by where we are now than by where we were 40 years ago. Some relationships have not only remained strong, but have continued to grow while others seem to have remained static, and in some cases become stale.

This also applies to the relationship of the WAFP to its members. Unless we work to maintain the relationships, and unless the organization continues to grow in meaning and relevance to its members, this relationship too can slide from familiar, to stale, to half-forgotten. As in lifelong relationships, only organizations that remain relevant, vital, and capable of change can survive. This is the reason why we have put our efforts into planning and thinking about our direction for the future.

At our recent board retreat, we spent time not only on defi ning the strategic goals for the upcoming year, but also on how we go about the work of the Academy. Our primary objectives were identifi ed as:• Strengthen WAFP’s legislative

infl uence.• Support the adoption of the new

model of family medicine in core clerkships sites in partnership with UW.

• Improve WAFP’s capacity to inform, engage and mobilize members.

• Redesign WAFP’s structure and processes to improve organizational performance.

At the same time, it is critical that we continue to focus on what is of value to our members, and strive

to maintain a relevant and vibrant Academy that continues to be meaningful for you, our hard-working members. This must include the willingness to explore any structural change to our organization that furthers our mission, without damaging our existing relationships.

Leadership has begun the process with planning and now we move on to the implementation phase. We have developed action plans, and begun the distribution of the workload to our committees. In reviewing the existing structure it is readily apparent that there are opportunities to revise and refocus the work effort of the Academy in closer alignment with our strategic objectives. Consequently, several committees have been placed on “inactive status”, with the advice and consent of the most recent chairs: Stu Farber, Aging Committee Chair, Barbara Bates, Rural Health Chair, Luke Megna, Research Chair and Luke Olson, Volunteer Medicine Chair. These committees are not disbanded, but will not have a formal project assigned to them. Instead, they would be activated to answer specifi c questions or do specifi c work as it may become necessary, or if new issues or interest arises from within these committees. Accordingly, I would encourage any members who might otherwise feel “left out” to re-channel their interest and involvement to one or more of the active committees, or to bring us your own ideas for activities that would help to achieve our strategic objectives. WAFP’s active committees and commissions along with current membership information is up on the web site and include: Annual Meeting, Bylaws, Child & School Health, Diverse Constituencies, Education, Health Care Services, Information Services, Legislation & Governmental Affairs (CLGA), Membership, Mental Health & Substance Abuse, and Public

Health & Scientifi c Affairs.Strengthening communication

was an important theme in the member feedback we received before the strategic planning retreat. This is why we are looking to upgrade the WAFP web site into a useful tool that enhances communication with members and provides more options for interactivity. Our information services committee has issued a Request for Proposal, and we are currently reviewing the responses. I hope that we have progressed far enough to invite you all to participate in new methods of membership interaction by the time of our next journal issue is published.

If you feel that your Academy has become less relevant to your professional life, less responsive to your needs, or a less appropriate vehicle for your volunteer energy, then we need your help right away. We can’t reach out if we don’t know who you are and how you want us to talk to you. We can’t increase our relevance if we don’t know what you value. The rapidly changing face of our profession calls on each of us to reinvigorate our relationship with the WAFP right now, or risk stagnation, increasing distance, and irrelevancy.

Robert Kennedy said, “It is not enough to understand, or see clearly. The future will be shaped in the arena of human activity, by those willing to commit their minds and bodies to the task.”

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The focus of this issue of the Washington Family Physician is strategic planning for the New Practice

Model. Every two years the WAFP Board of Directors reviews the mission and goals of the organization, examines the current situation and creates a new strategic plan for the next two years. At the Strategic Planning Session this June, the mission of the organization was reaffi rmed:

“The WAFP is a member-driven organization committed to supporting Washington state family physicians in their efforts to provide optimal care to the people of Washington State through education, advocacy, research and political activism.”

The important developments and issues currently impacting family physicians were identifi ed as:• The AAFP Future of Family

Medicine and new family medicine model.

• Increased attention to quality, safety and outcomes.

• Continued decline of students pursuing family medicine.

• Growing attention to tort reform.• Members are struggling with

practice viability and fi nancial pressures.

Four objectives, with work plans, were developed to guide the efforts and use of resources for the WAFP for the next 2 years. These are:• Strengthen the WAFP legislative

infl uence.• Promote the adoption of the new

model of family medicine.• Improve the WAFP’s capacity

to inform, engage and mobilize members.

• Redesign WAFP’s structure and process to improve organizational performance.

The articles in this issue focus on these topics. There are articles on legislative issues – tort reform, OB malpractice, access to care, and smoking. The article on the DOQ-IT program promotes the new model of family medicine with a funding opportunity for family physicians implementing EHR. The resident article shares the energy and enthusiasm for the future from the National Conference of Students and Residents. Steve Krieble, MD, and Malcolm Butler, MD, speak of their views on future family medicine practices. Bob Crittenden, MD, brings us back to our mission statement of promoting optimal health care for the people of Washington by advocating for all children to have health care.

These articles are informative, but also raise questions. Stan Garlick MD, in his article on the new model

of care, asks if the new model is the answer to the declining interest in family medicine. Are International Medical Graduates (IMG) going to be the family physicians of the future? There are questions for other articles. Should the future for mid-levels in family medicine be in a supportive role for family physicians, who are better trained than they are, or can they be independent providers of primary care, like family physicians when there is none available? Is the investment in the EHR going to provide the quality and value that is promised? Will tort reform make family physician practices more fi nancially sound and viable? Should family physicians be the ones challenging the status quo and leading the changes in health care delivery, “making the wave?”

I invite you to voice your views and opinions on these questions and any others through this journal, the Washington Family Physician. I would like to have Letters to the Editor as a regular feature of the Journal. It will provide a format for exchange of ideas, opinions, disagreements and open discussion to better engage all of our members with our organization. The WAFP is “member-driven” but only if members participate. What do you think about the current declining interest and the increase in foreign medical graduates in family medicine? Are the EHR and tort reform the saviors for family physicians? Should family physicians continue to provide OB care, or is it too expensive? Does OB care require too much sacrifi ce for family physicians to continue? Is the Future of Family Medicine project the way of the future or something that will hasten family medicine’s decline as a fi nancially viable medical specialty?

You can respond by writing to: WFP Journal Editor1050 140th Ave NE, Suite CBellevue, WA 98005or vie e-mail to admin@wafp.net.

YOUR ACADEMY; THE NEXT TWO YEARSJean Marshall, MD, WAFP Past President, Guest Editor, Bellevue

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It seems like for years things have only gotten harder for primary care physicians. Those of us who treat the whole patient rather than an organ system have seen cost containment efforts aimed almost entirely at primary care providers. Recently, there have been straws in the wind that signal a changing weather system about to blow through the U.S. healthcare system. Whether we benefi t from those changes will depend on how we respond.

One of those straws was an article in Health Affairs in early 2004 by Baicker and Chandra,1 showing that quality of care (using widely accepted metrics) is lower for Medicare patients in states where the per capita healthcare costs are highest. The reason for this is that states with highest quality and lowest costs are those in which primary care physicians provide the majority of healthcare for Medicare enrollees. On the other hand, states with the highest costs and lowest quality have few primary care physicians, and

specialists provide the majority of care.

This pattern has not gone unnoticed at the Centers for Medicare & Medicaid Services (CMS), already under pressure to respond to the now famous Institute of Medicine report called Crossing the Quality Chasm,2 that is among recent revelations documenting serious quality problems in the U.S. healthcare system.

There is a growing consensus within the federal government, articulated by leaders of both parties, that this situation will not improve until electronic health records (EHRs) have become the standard for managing clinical data in medical offi ce practices. For this reason CMS recently kicked off the Doctors Offi ce Quality – Information Technology initiative, or DOQ-IT as it is known in the CMS world of acronyms. The awakening appreciation of the importance of primary care is refl ected in the fact that the focus of the DOQ-IT initiative is small-to-

medium sized primary care practices, where more than 70% of Washingtonians receive their care.

DOQ-IT is administered through a national network of Quality Improvement Organizations (QIOs). The QIO in Washington State is Qualis Health. Qualis Health has put together a team of healthcare professionals with experience in using EHRs, to provide free consulting to eligible primary care practices on a range of topics that

constitute a laundry list of barriers to implementing an EHR in small primary care practices. That list starts with understanding the economics of EHRs, which are expensive. For that reason Qualis Health is assembling resources to help small provider groups understand the economics of EHRs and how to maximize their own return on investment.

For practices ready to make the leap there are a lot of important steps before choosing a vendor, including a careful analysis of what exactly the providers want to accomplish, their values and priorities. Part of this involves a detailed analysis of current offi ce workfl ow, so that key work-processes are understood and the unique needs of the practice can be prioritized. Then, it is essential to objectively evaluate the strengths and weaknesses (as well as the cost) of the many EHR products on the market for primary care physicians. Once the list of potential vendors has been narrowed to a handful, many physicians can use assistance in negotiating the best possible contract, not only for purchase and installation, but for maintenance as well.

EHR installation is a challenge for the most organized of practices and the pitfalls are many. Qualis has lined up practice groups around the state that have gone through this experience to serve as coaches for the DOQ-IT program to help shorten the inevitable period of reduced productivity that accompanies EHR installation. Much of the success depends on the confi dence, commitment, and planning of the leaders in the practice. There are many essential tasks including careful attention to where workstations, printers, and scanners are to be located in the clinic, preparation of charting templates, and gaining valuable experience in the new electronic environment by

DO COMPUTERS AND REIMBURSEMENT CHANGES

MEAN BETTER TIMES AHEAD FOR PRIMARY CARE PHYSICIANS? by Jeffrey Hummel, MD, MPH, Seattle

5

abstracting paper charts into the new EHR before “go-live.” These many things are part of the consulting that CMS is paying the QIOs across the country to provide to small primary care practices for free.

Other payors realize that it is in their interest as well to support this new effort. First Choice has recently announced that it will provide $20,000 grants to 10 small primary care practices that enroll in the DOQ-IT program in Washington State. Given the average cost of installation of about $13,000 per provider, that is a signifi cant reduction in cost for a three- or four-physician practice.

The rationale for encouraging investment in EHRs is founded on the growing realization that reimbursement based solely on offi ce visits has been one of the dynamics that has contributed to the current cost and quality crisis. Through benign neglect, fee-for-service reimbursement discourages

chronic illness care by not paying for telephone visits, self-management support, and the cost of maintaining patient registries. At its most perverse, fee-for-service actually rewards poor care by paying higher reimbursement for hospitalizations with medical complications, including those caused by medical errors.

Early experiments in pay-for-performance have had mixed results. P4P, as it is known, may not be a panacea for physicians, but it is fairly clear that the next big effort to reform healthcare in this country will include some form of reimbursement that rewards clinical outcomes. Physicians will have the greatest opportunity for infl uencing what clinical performance measures are used and how those outcomes are rewarded if we play leadership roles in this transition and embrace the explosion of practice innovations that follow implementation of an electronic medical record. We are well into the early years of

a revolution in healthcare in this country, and there are plenty of reasons to think that it will be possible for primary care physicians to thrive in the future. That has not exactly been the case for quite a few years.

1. Baicker K, Chandra A. Medicare spending, the physician workforce, and benefi ciaries’ quality of care. Health Aff (Millwood). 2004 Jan-Jun;Suppl Web Exclusives:W4-184-97.

2. Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academies Press.

For information about participating in DOQ-IT, please contact Ellen Pearlman at Qualis Health (1-800-949-7536, ext. 2606 or ellenp@qualishealth.org).

Jeffrey Hummel, MD, MPH is a consultant for Qualis Health and serves as the physician lead on the DOQ-IT program. He is a board certifi ed primary care internist and the Associate Medical Director for Medical In-formatics and Clinical Improvement for the UW Medicine Neighborhood Clinics at the University of Washington.

6

WAFP VOTES TO OPPOSEDIRECT-TO-CONSUMER ADVERTISINGKevin B. Martin, MD, WAFP Child and School Health Chair, Auburn

There was a time when drug marketing was limited to retailers offering trips, books, conferences, and meals to prescribing physicians. As professionals, many doctors responded

by simply refusing to talk to the representatives, preferring to let data inform their prescribing practices. But now pressure is coming from a new direction, the patient. We have all had conversations, usually late in the visit, that start with, “I saw an ad for this drug, and I was wondering if I might do better on it than what you’ve got me taking” or “I saw this blue pill that Bob Dole was talking about, Niagra or something?” These questions are the predictable and intended result of the ever-swelling number of direct to consumer advertisements for prescription medications.

In 1985, the FDA lifted its ban on Direct-to-Consumer adverting (DTCA) of drugs. Pharmaceuticals were allowed to run mass-market ads, but only if they included essentially all of the prescribing information for the product. This

limited these ads to print media simply because the required information would not fi t in a broadcast ad. Most people really had their fi rst exposure to DTCA in 1997, when the FDA relaxed standards suffi ciently that all the required content could fi t into a 30- or 60-second broadcast ad. Since that time, the practice has grown dramatically, with over $2.5 billion spent in 2001I.

Gilbody, et. al., note that while Merck spent $160 million promoting rofecoxib (Vioxx) in 2000, Pepsico spent roughly $35 million less on their fl agship cola2. The pharmaceutical industry feels it is worth investing in these expensive ads. They show a good return on investment: they profi t. They argue that this practice informs consumers, and engenders open conversation between patient and physician. Others cite value in informing patients about their condition and their options, empowering the patient and moving away from paternalistic practices in medicine3. Farrell argues that, since physicians have to inform and teach, some paternalism is inevitable, acceptable and even benefi cial4.

Today only two countries in the world allow pharmaceutical companies to advertise their products directly to consumers, the United States and New Zealand. A rich literature has grown up in both medical and marketing journals over the last 10 years debating the benefi ts and risks of direct-to-consumer advertising (DTCA) and its impact on patient care and physician practice.

Many surveys exist which look at the perceived impact of DTCA on different aspects of health care. In 2002, the FDA surveyed 500 physicians, including 250 primary care doctors, about

the manifestation of DTCA in the exam room . While most physicians surveyed felt that DTCA made their patients more aware of possible treatments and led to more thoughtful questions, 75% felt that the ads made the drugs seem better than they are. Overall, while most doctors (59%) felt that DTCA added no benefi t to the encounter, few saw any deleterious impact5. However, in a press release dated 19 November 2003, the American Society of Health-System Pharmacists blasted the FDA’s interpretation of its own data, pointing out among other things that less than 5% of the physicians in the study felt that their patients understood the risks of the advertised drug6.

In 2005, Gilbody’s group undertook what they believe to be the fi rst systematic, rigorous review of the literature looking for studies which examined the impact of any form of DTCA (broadcast, print, or web-based) on health seeking behaviors of patients at the point of care, requests for prescriptions, patient-doctor communication and satisfaction, prescribing patterns, or direct and indirect cost7. Of 2853 publications identifi ed in their literature search, they identifi ed 6, based on 4 studies, which met their inclusion criteria. One study which met their criteria found that, for drugs in DTCA campaigns such as Claritin and Zocor, the number of prescriptions positively correlated with advertising expense of the drug and the class of drugs, while other brand drugs such as Zantac and Hismanal showed a fall relative to the volume of prescriptions in the class . Moreover, this study found that the number of diagnoses analyzed month-to-month correlated with the money spent advertising drugs in a class. Gilbody concludes: “The main fi nding of this review is

7

the identifi cation of a void in terms of the evidence of the wider impact of DTCA – over and above increased prescriptions and market share. Policy making must therefore proceed in the absence of a defi nitive answer as to the specifi c consequences of DTCA on individual patient care and healthcare systems. The onus is on those who might support DTCA to produce evidence of benefi t and, in the absence of this evidence, we must assume that the likely expenditure (clinical and economic) outweigh the as yet unproven benefi ts.” This opinion was refl ected by Mintzes and colleagues when they examined this issue for the benefi t of the Canadian healthcare system. They concluded that: “We could fi nd no evidence of improved drug utilization, improved doctor/patient relations, or reductions in hospitalization rates, serious morbidity or mortality attributable to DTCA. The aim of the prohibition of prescription drug advertising in Canada is health protection. Any legislative change that would weaken the current restrictions on such advertising should be based on strong evidence that concerns about potential harm are unfounded, and—ideally—evidence of health benefi ts. On the contrary, we found a considerable body of evidence suggesting that such concerns are warranted, and no evidence that DTCA is likely to improve the health.”8

The AAFP has policy in place which supports DTCA only under certain stringent conditions including “Information should be accurate, balanced, objective, and complete, not false or misleading, and should not promote unhealthy or unsafe practices. If specifi c properties or indications are mentioned, then negative or adverse reactions and effects should likewise be mentioned, in a manner that is easily accessible and understood by the consumer.” The 2005 WAFP House of Delegates debated and voted for a simpler policy: The WAFP is opposed to DTCA without reservation or qualifi cation. The arguments which

carried the day echoed Mintzes. The industry has failed to produce ads which educate about a condition rather that promote a treatment. They have spent incredible amounts of money and are buoyed in doing so by data showing changes in our prescribing habits based on their expenditures. The same data that they fi nd encouraging, we should fi nd terrifying. We cannot refute the data. We then have to ask whether this serves patients. The industry has failed to meet its burden of proof. Lacking demonstrable benefi t, and reason to believe that current policy allows advertising practices which increase costs and potentially expose patients to toxicities they might otherwise be spared, the WAFP HOD voted to oppose this practice.

REFERENCES1. National Institute of Health Care

Management. Prescription drugs and mass media advertising 2000. Washington, DC: NIHCM Foundation, 2001.

2. S. Gilbody, P. Wilson, I. Watt. “Benefi ts and harms of direct to consumer advertising: a systematic review”; Quality & Safety in Health Care 2005; 14:246-250

3. P. Kelly. “DTC advertising’s benefi ts far outweigh its imperfections”; Health Affairs 28 April 2004, content.healthaffairs.org/cgi/content/abstract/hlthaff.w4.246.

4. J.M. Farrell. “The ethical implications of direct to consumer pharmaceutical advertising”; Philosophy & Public Policy Quarterly; 23 (3) Summer 2003: 20-23.

5. C. Lewis. “The impact of direct to consumer advertising”; FDA Consumer; 37(2) March-April 2003:

6. ASHP Press Release 19 November 2003, downloaded 3 September 2005 from http://www.ashp.org/news/ShowArticle.cfm?id=3639.

7. W.M. Zachry, M.D. Sheperd, M.J. Hinich, J.P. Wilson, C.M. Brown, K.A. Lawson. “Relationship between direct-toconsumer advertising and physician diagnosing and spending”; American Journal of Healh-System Pharmacisits; 59 1 Jan 2002: 42-49.

8. B. Mintzes, M.L. Barer, K. Bassett, et al. An assessment of the health system impacts of direct-to-consumer advertising of prescription medicines (DTCA). Volume III: Patient information on medicines comparative patient/doctor survey in Vancouver and Sacramento. Vancouver: University of British Columbia Health Policy Research Unit, 2001. Cited in Gilbody.

9. AAFP Policy, downloaded from www.aafp.org 1 September 2005.

8

Roberto is a friend of mine. He is 45, in a body that is 70. Though fi nally sober, too much drinking has left him with heart failure, a fused neck, no teeth, and no job. While working up his disabling cough, a sinus CT revealed a meningioma in his right frontal lobe. A follow up MRI revealed a large AVM in his left parietal lobe. Roberto has bad luck.

Roberto is going to Harborview for brain surgery. He knows that I cannot attend to him there. Yet despite the dangers of surgery, the scariest part of his decision making process was letting go of my care to travel across the state. Why?

What value do family physicians add for patients? Why does Roberto cling so tightly to my care? Roberto knows that his neurosurgeons wield the knife. He knows that the critical care docs will care for him in the ICU. So what do I add? What value do we, as primary care providers, bring to the care of our patients?

Clearly we bring something important, as evidenced by our patients’ allegiance, and by data showing that counties without adequate PCPs have higher costs of care, and poorer outcomes. But patients don’t believe that we as “generalists” can possibly be as good as the “partialists” (who refer to themselves as “specialists”). Patients know that you can have BREADTH of knowledge, or DEPTH of knowledge, but not both. So why do they come? The answer is the future of Family Medicine.

As we consider our real value, and as we strategically focus on leveraging that value into the future, we must fi rst remember that our primary product is NOT just healthcare, but a healthcare RELATIONSHIP. We do relationships. We do them in sickness and in health, for richer and for poorer. In many important ways it is this relationship

that our patients value, possibly more than our knowledge base. Relationships are based upon trust, acceptance, access, and reliability.

Secondly, we must recognize and embrace the concept of THE MEDICAL HOME. We as family physicians provide a medical home for our patients. Consider your image of “home:” Home for me, growing up, was a place where I felt accepted, could let my hair down and be myself. I was known, and always remembered. I felt safe, the door was always open, everyone there cared about me and wanted the best for me. I felt empowered being part of a family, of something larger than myself of which I was an integral part. There was always a strong, caring, guiding force, urging me to improve.

The medical home should have these same characteristics. It should be a place where:1. People feel known, accepted, and

understood – we speak their language, we understand their culture, and we have systems to remember them.

2. People feel safe and well cared for – we are there for them when they need us.

3. People feel empowered and feel that they are a part of something larger than themselves – we are “their clinic.”

4. People feel a strong, caring, guiding force urging them to improve.

Thirdly, family physicians are the HUMAN FACE of medicine. We bring compassion and empathy to our patients’ concerns and problems. We interpret the information in ways they can understand; be that information from consultants, diagnostic studies, or the internet. We manage the complexities of their care, keeping their personhood intact throughout the process. We offer our judgment in recommending the best course of action.

A relationship, a sense of medical home and a human face of medicine are things that family physicians can provide for their patients that the internet and “partialists” can not. Providing these though will require change in the old model of care and using new tools. Our practice must be “patient centric,” with ACCESS as “job one,” with EMR’s central to everything and never hiding our humanity.

“Patient centric” care revolves around the needs and desires of the patient. It assumes that patient safety is more important than physician autonomy. It assumes that the patient is a critical element of the care team. It assumes that patient convenience is more important than physician convenience. It means that the patients park close to the clinic, and staff park in the “back forty.” It means that we interact with patients by phone, by email, or in person, at their discretion. Patient centric care strengthens the relationship and the sense of medical home.

Access as “job one” means moving toward Advanced Access. It means that patients can interact with their care team at the time of their choice, in the manner of their choice. It means extended hours, internet access, group visits, matching provider capacity to patient demand, while providing all of the care and only the care that our patients need.

Finally the Electronic Medical Record: The EMR must be viewed as much, much more than a charting tool. A powerful EMR populates a relational database. It allows us to provide care that is complete and effective. We can track A1C’s, beta-blockers after MI, and mammogram rates on every patient, every day, if we so choose. This allows us to reduce variation and reveals how close we are to best practice. It allows for population based disease

THE HUMAN FACE OF MEDICINEby Malcom Butler, MD, WAFP 2005 Family Physician of the Year, Wenatchee

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management. No longer do we need to maintain a separate database of our diabetic patients to assure complete care. We can run a report against any parameter of diabetic care at any time, and recall any patient who is late on an intervention. It allows us to provide the quality care that our patients expect.

The EMR is the corporate memory of our patient. Every time they visit, or call, or email, we have immediate access to what we have done for them, where they have been, and their issues. From the patient’s perspective we know them, and never forget them.

The EMR allows us to build

evidence based care into every visit. It prompts us to provide all of the preventative care that is recommended. It allows us to track labs and referrals to closure. It keeps patients safe by eliminating bad hand-writing, checking every prescription against their known allergies, known medical problems, and against their other medications. It does all of those things that you would want for yourself or one of your family members in a MEDICAL HOME.

Nothing, however, can improve upon the humanity we bring to our patients. The HUMAN FACE OF MEDICINE is the compassion, the wisdom, the judgment, and the caring

that each of us brings to the process. Rather than hiding behind our knowledge of the science, we must share the tears and smiles that reveal our humanity. While our systems can help us to practice the science of medicine, only we as individuals can practice the art of medicine.

So why all of these changes? Why are we, the physicians, no longer the center of the medical universe? Why group visits? Why the EMR? Why Advanced Access?

The answers are the future of Family Medicine. They are the value that we add to healthcare. The answers will bridge the quality chasm and assure the future of our

craft. They are our primary products:1. A RELATIONSHIP2. A SENSE OF MEDICAL

HOME3. A HUMAN FACE OF

MEDICINE

Malcom Butler, MD, is Medical Director at Columbia Valley Com-munity Health, a medium sized community health center in the center of Washington State. They have, over the past fi ve years, created a patient centric, evidence based practice. They have implemented an EMR and have implemented Ed Wagner’s Chronic Disease Model of Care. They have made patient safety an ethical responsibility. Teamwork is now valued over physician autonomy as the highest corporate value. Their tagline reads “practicing the science of medicine as a team, and the art of medicine as individuals.” They are working toward Advanced Access, and their care is, to quote the IOM Chasm report: safe, effective, patient centered, timely, effi cient, and equitable (and they can prove it). They are blessed with an unbelievably committed, mission driven staff, who have created a practice of the future.

w w w. p e a c e h e a l t h . o r g

PeaceHealth is an AA/Equal Opportunity Employer.

Family Practice w/Med-PedsPacific NorthwestHealing and Compassionate Care is the cornerstone of the PeaceHealthsystem. Located in the Pacific Northwest, St. John Medical Center, a 150-bed (operating beds) JCAHO “Gold Seal” accredited hospital, serves acommunity of 50,000. We are seeking a Family Practice Physician withMed-Peds experience to compliment three Family Medicine teams ofphysicians within PeaceHealth Medical Group (PHMG), a multi-specialtymedical group of approximately 50 clinicians, sponsored by PeaceHealth,St. John Medical Center. Family Medicine is complimented by InternalMedicine primary care. A successful Med-Peds candidate will join twoestablished Med-Peds physicians within a primary care team. Call 1:13weekdays; 1:6 weekends.

St. John Medical Center is located 45 minutes from Portland, OR inLongview-Kelso, Washington. Enjoy the pace and natural beauty of atraffic-free, family-friendly community with urban amenities nearby.You’ll find many beautiful parks, a lively Performing Arts Theatre, well-supported schools, and an excellent city library here. Enjoy lower cost ofliving than our near neighbors in Portland, OR. This is simply a superbplace to live, work and play!

If you would like to learn more, please visit our Web site at:www.peacehealth.org, or contact Debbie Troyer, PhysicianRecruitment, Phone: (360) 636-4106, Fax: (360) 636-7243 or E-mail: dtroyer@peacehealth.org.

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The Family Practice movement co-evolved with the nurse practitioner and physician’s assistant movements. And now 35 years later, the three are all mature professions with

established identities, philosophies and range of practice, and facing the future of healthcare. This article will review a brief history, look at current problems and expound on what the future may be for mid level practitioners and family physicians.

All three movements were aimed at the severe and worsening primary care shortage, especially in rural areas. The events leading up to all three developments occurred during the social upheaval of the 60’s, which added a revolutionary zeal to the beginnings of each. I have seen all of this fi rst hand, because I graduated from the fi rst three-year group of residents from the University of Washington Family Practice residency in 1975. Back then, Medex Northwest was taking Vietnam veteran medics and turning them into physician assistants.

The times were indeed revolutionary, because WWAMI and the National Health Service Corps were conceived concurrently with the three new professions. (Don’t forget, Medicare and Medicaid started in 1965). I did my WWAMI rural residency rotation in 1973 in Omak, WA. That year the American Academy of Physician Assistants began a certifying process. I became Joann Willard’s preceptor in Clallam Bay WA in 1975. She was one of the fi rst nurse practitioners in Washington and the USA. Nurse practitioners and physician assistants were used extensively in early National Health Service Corps sites to aid lone physicians until other physicians could be recruited. Mid levels also took the burden off physician groups for call and for time off. The severity of post WWII physician losses in outlying areas, which led to these developments, cannot be overstated. Forks, as a typical example, had zero

full time physicians from 1971 to 1975. And now with only a slightly larger population it supports 6 full time physicians and 7 mid level practitioners.

In the 70’s, mid level practitioners were exclusively in primary care in rural areas. In the last 25 years mid levels have expanded into every specialty and indeed only 20% of mid levels now practice in rural areas. There was initial strong opposition to the mid level concept among physicians because of fear of mid level practice expansion. This fear was assuaged by the reassurance that mid levels would only practice rural primary care. Strangely, urban specialists, who were initially most vociferously opposed, now seem to be the strongest allies of mid levels. They now practice every specialty and have full prescribing privileges including schedule II narcotics. Nurse practitioners can practice independently, but physician assistants must have a physician preceptor tied to their license.

Mid levels got a big boost when the Rural Health Clinic law passed in 1977. The law was intended to aid rural clinics by paying on a cost basis for Medicare and Medicaid patients (I get $66 a visit as an “independent” Rural Health Clinic and many “hospital based” Rural Health Clinics get $110 a visit). The law has succeeded. It was not widely embraced initially because it paid a fl at per visit amount even for expensive procedures. There are now 110 Rural Health Clinics in WA. (Visit http://www.doh.wa.gov/hsqa/ocrh/RHC/rhcMminpg.htm to learn more about Rural Health Clinics.) Most remote sites depend on Rural Health Clinic cost-based payment; because of the very high numbers of Medicaid and Medicare patients (I have 57% in my solo practice).

In the law, a Rural Health Clinic is required to have a mid level practitioner in the offi ce 50% of the time the clinic is open and yet a mid level may have a Rural Health Clinic practice with only ½ day a week of

physician supervision. This regulation was originally intended to give strong encouragement to use these new practitioners, who were poorly understood. The feeling was that mid levels would save physicians from rapid burnout in remote areas. The law has worked, but now the majority of rural underserved sites are fairly stable and do not need this rigid staffi ng rule. In fact, the regulation is putting pressure on clinics to close or consolidate inappropriately. (I am threatened with closure by Medicare, based on the regulation, even though I employed full time mid levels for 23 of my 30 years in Forks.) Mid levels and physicians in these rural areas are used in many diverse ways that simply do not fi t this simple model. 80% of mid levels practice in urban areas, where they do not need the support of this regulation.

Whither the future of Family Medicine and the mid level practitioner? The Future of Family Medicine report has a whole section devoted to the Team Approach. So much of the Future of Family Medicine report is really reaffi rmation of philosophies and actions we have already mastered. The team approach is one of these. We have teamed with mid levels for 35 years, and Family Physicians literally gave mid levels their start.

Some fear that mid levels will take over the Family Physician role. This could happen, but it would be a disaster. Research and my experience have been that mid levels can not do all that family physicians can do . Mid levels don’t have the synthesizing, procedural and diagnostic skills of well-trained Family Physicians. Most mid levels agree with this and don’t want to challenge the Family Physician role. If Family Medicine disappears, it will be due to lack of rational public understanding. We now have solid research numbers proving the unique value of Family Physicians. We just have to convince the public to take their Family MEDICINE, like a good patient.

MID LEVEL PRACTITIONERS AND THE FUTURE OF FAMILY MEDICINEBy Steve Kriebel MD, WAFP 2004 Family Physician of the Year, Forks

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As some of you know, I have been an ardent supporter of the WSMA campaign, Yes on I330/No on

I336. Of late, however, I have been wondering, where are all the docs who should care about this issue? After the rallies in Tacoma, Seattle and Olympia in 2004 I was impressed that every day docs like me were really getting it, coming out and supporting efforts to move forward on tort reform, and gathering petition signatures to get our initiative onto the ballot. I made a few trips to Olympia and found 80-100 docs at a time signing in to testify at committee hearings in support of tort reform. I heard insightful commentary, gritty stories and specifi c data rolling off the eloquent tongues of many of my colleagues. I admit I’m pretty excitable when there is a cause I believe in and a reason to stir to action. So, where is the action now?

Many physicians have anted up their $1000 campaign donation as requested by the WSMA (shame on you, if you have not.) and gone back to work assuming that the WSMA will “take care of it.” Well, certainly they will try and I feel they have a sound plan, an excellent, well developed campaign with slogans, banners, brochures, posters, radio and TV ads. Hey, they have got it covered, right? Hmm, not quite. What’s missing is those same passionate physicians, many of them Family Physicians, who attended the rallies and testifi ed at the hearings. So, where is the action now? The actions we need are the stories we share with our patients, the advice we give about the initiatives, and the opportunities we have as individuals to share the stories we have heard, the facts we have gleaned, and the passion we

feel for healthcare with our patients, neighbors, friends, fellow Rotarians, Kiwanas, Lions, Republicans and Democrats, especially Democrats.

You see, the personal injury lawyers know who their friends are and the monthly district democratic meetings across the state are being targeted by the Washington State Trial Lawyers Association (WSTLA). They are making presentations and rolling out sympathetic injured patients and their families to speak at these meetings, seeking district level endorsements from nearly every district. In my own district, the 25th, I was narrowly able to avoid such an endorsement because I was in attendance and spoke to the misinformation being presented by the WSTLA and their presenters and by focusing on the issues of access to care, physician manpower shortages in OB care, rural OB care, Orthopedics, and Neurosurgery and emphasizing that I330 is our bill, not the insurance companies,’ and pointing out that all but a small percentage of the money the other side has raised comes from personal injury lawyers. My friends in my district know me and trust me to speak the truth. Now, many of you are Republicans, Democrats, Rotarians, Kiwanas, Lions, etc. Your fellow members know and trust you too. Your voice of reason must be heard. Please, do not shy away from this opportunity. Speak out, speak often, and speak from your heart. People want to hear what you have to say on this. The electorate knows this is an important debate, an important vote. We must not be complacent or allow the new mantra “both sides have it wrong, so I will vote them both down” to rule the day.

For those who are shy about speaking the WSMA has made it easy. They have prepared a brief,

but concise speech that you can use. Memorize it, read it, or just use it as an outline. You can get this from Jennifer Hanscom at jen@wsma.org. She will be glad to provide you with the speech, bumper stickers, brochures, and pins to hand out, delivered the next day by UPS. Join us in this effort.

I just heard today (8/16) that John Edwards, America’s top personal injury lawyer, is in Seattle this week to help the WSTLA raise funds for their campaign ($1000 a head at the Edgewater Inn with over 400 seats sold) In addition, many law fi rms have already donated $10,000 per fi rm for this campaign. We are likely to be out-spent, but we have the ears of far more listeners, let us speak out!!

Finally, how is the malpractice crisis affecting my practice in Puyallup? We have absorbed doubling of our malpractice rates each of the past three years. As a result our average incomes have dropped well below the mean for FP’s while the national trend has also been downward. Just last month, near the end of a recruitment interview, I was asked about my annual income. When I gave the honest answer the prospective future partner immediately lost all interest in joining our group. Since that interview I have stopped my recruiting efforts after coming to the realization that no family medicine physician in their right mind would work for the declining income that I am presently making. With new graduates in Family Medicine fi nding jobs paying many thousand more dollars per year than I am earning, I have had to ask myself why I should not leave the practice I have worked endless hours over 19 years to build and maintain, the second greatest passion of my life, chuck it all and go to work for the highest bidder.

MEDICAL MALPRACTICE TORT REFORM: WHO CARES?by Ron Morris, MD, WAFP CLGA Co-Chair, WSMA Executive Board, Puyallup

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The Washington Academy of Family Physicians is requesting nominations for FAMILY PHYSICIAN OF THE YEAR. The purpose is to honor a physician who exemplifi es, in the tradition of family medicine, a compassionate commitment to improving the health and well-being of people and communities throughout Washington. The candidate must be a member in good standing of WAFP and spend at least fi fty-percent of his/her time in direct patient care. Nominees should exemplify the ideals of family medicine, including providing comprehensive, compassionate services on a continuing

basis to his/her community, and possessing personal qualities that make him/her a role model to professional colleagues. Any member of the WAFP may submit a nomination. Eligibility will be verifi ed by the Family Physician of the Year Committee. Qualifi ed nominees may be nominated more than once, however, a member may receive the award only once. Current members of the WAFP Board and Family Physician of the Year Committee are not eligible for nomination. The award presentation will be made in May 2006 during the WAFP Annual Meeting Banquet and Foundation

Auction on May 12, 2006. The physician chosen as the 2006 WAFP Family Physician of the Year may be nominated as Washington’s Nominee for the 2007 AAFP Family Physician of the Year award.Nomination requirements and forms are available on the WAFP website at www.wafp.net or by calling the offi ce at 425-747-3100. Please send a detailed letter of nomination and any supporting letters from colleagues or patients (8 pages maximum) to the WAFP offi ce no later than January 31, 2006.

2006 WAFP FA M I LYPHYS I C I A N O F T H E YE A R

2005 Malcolm A. Butler, MD, Wenatchee

2004 Stephen H. Kriebel, MD, Forks

2003 Bertha Safford, MD, Ferndale

2002 Joseph Shamseldin, MD, Seattle

2001 Amos P. Bratrude, MD, Omak

2000 John C. Anderson, MD, Cle Elum

1999 William R. Phillips, MD, MPH, Seattle

1998 Joseph N. Scardapane, MD, Seattle

1997 Douglas O. Corpron, MD, Yakima

1996 Timothy R. Teusink, MD, Kent

1995 Walter A. Henze, MD, Tonasket

1994 Ramoncita R. Maestas, MD, Seattle

1993 Richard P. Bunch, MD, Othello

1992 Roy H. Virak, MD, Tacoma

1991 Nancy L. Foote, MD, Yakima

1990 Harold P. Clure, MD, Anacortes

1989 Anna H. Chavelle, MD, Seattle

1988 Norman A. Erie, MD, Oak Harbor

1987 Leeon F. Aller, Jr., MD, Snohomish

1986 Richard H. Layton, MD, Seattle

1985 Charles C. Strong, MD, Vancouver

1984 Kenneth D. Graham, MD, Tacoma

1983 William F. Mead, MD, Port Angeles

1982 Wayne B Zook, MD, Wenatchee

1981 Thomas H. Clark, MD Sumner

1980 Donald M. Keith, MD, Seattle

PR EV I OU S HO NO R E E SWAFP FA M I LY PHYS I C I A N O F T H E YE A R

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Who would have thought 10 years ago that a medical practice unable to submit an electronic billing in 2005

could not bill Medicare at all? Medicine is in a constant, relentless state of fl ux. Unfortunately, we have often been surfi ng behind the wave, rather than at the front. In order for the Washington Academy of Family Physicians to be relevant in the next few years, the six strategic issues below have been identifi ed by our leadership: 1. Practice Enhancement2. Legislative Issues3. Pipeline implementation of the “New

Model”4. FP public relations5. Member Communications6. Information and Knowledge Based

decisionsTo varying degrees each of these

topics demands optimal engagement by ALL family physicians.

The AAFP New Model, which was launched this year in Washington State and New Jersey as the PEP (Practice Enhancement Project), is an opportunity to pro-actively defi ne the way that quality, outcome data driven care will be delivered, evaluated, and compensated. It is anticipated that within 5 years most medical records will be electronic and paperless, but that is only a part of the quality aspect of a future family practice. Many physicians already use a PDA to assist in giving patients up-to-date information or access web sites to print out patient information hand outs. To understand more about the details of this concept, see the AAFP Monograph #295, “Offi ce of the Future,” which when completed provides 5 Prescribed CME credit hours. homestudy@aafp.org or 1-800-274-2237 x 913-906-6285.

In the past, the mode of action for physicians was reactive resistance to adverse legislation. The majority of our energy response was to comply and adjust to the imposed “sea of changes” of Medicare, Medicaid, OSHA, HIPAA,

or the Medicare Modernization Act. Pay for Performance is a current issue which is being shaped in the corporate boardrooms of insurance plans and may be unfolded as mandated legislation for Medicare. Patient registries which track chronic disease treatment are part of the AAFP New Model. These may also serve as a public grading system for Pay for Performance initiatives. Whether it is a bonus award, or the entire basis of eligibility for payment is the “devil in the details” that requires vigilance by every physician who continues to accept payment from third parties. Now is an opportune moment for the WAFP to take a constructive leadership role in shaping the future of family medicine for our state.

The Pipeline concern for new family physicians has always been high in our priorities, but the link to the New Model has been identifi ed as critical for the future. In order for the concept to gain momentum, there needs to be showcase practices in the community who have implemented the New Model, and appropriate learning objectives, focusing on skills for the New Model, need to be built into Family Medicine residency programs.

One of the concepts embedded in the New Model is the Group Visit. Rather than a didactic presentation in a group to avoid repetition, this type of visit uses group interactive dynamics to achieve more effective learning and health behavior change. The one-on-one model of the doctor-patient visit shifts to that of different ratios and employs different and more effective learning methods. This requires a change of expectation on the part of both the provider as well as the patient, a change we need to communicate to our patients, i.e. a public relations opportunity to provide better care for our patients.

In all the meandering about the shifting employment confi gurations and insurance mechanisms, the doctor-patient relationship, and the physician-family bond remains a constant compass point. The fundamental defi nition of a family physician has not

changed, but there may be shifts in our contemporary public image that need to be recognized. Because of this, the average family physician who is engaged in patient care must maintain active, contributing citizenship in the background of inevitable changes that will affect every day interactions between the doctor and patient in the modern world. Communication between family physicians can help inspire and keep us engaged with our patients and communities in promoting better health for all.

About six or seven years ago there was a landmark crossover in the declining number of solo and smaller private practices which were surpassed by increasing number of large employer based practices. The stated advantage was that the physician could now practice the medicine that they were trained to do and not worry their heads about fi nancial matters. Physicians who had such interests could go into administrative work, and fi nancial details could be left to their expertise. The disadvantage of this trend was to disengage the individual physician from overarching concerns and issues that are fundamental to the day to day operations of a family medicine practice. This strategy of leaving everything to a “specialist” runs contrary to the nature of family practice itself. We all need to do our part and remain involved in the future of family medicine. Only with good knowledge can family physicians make the best decisions for their patients and their practice.

We have taken on the challenge of the AAFP New Model and are following their lead for the future of Family Medicine. The main issue may not be where to be on the wave in our surfi ng analogy, but accepting the challenge to generate the wave itself. Change is always a threat to the comfort of static stability, but in contrast, adventure necessitates change, and there is greater fulfi llment in life when we accomplish constructive creativity.

SIX STRATEGIC ISSUESGerald N. Yorioka, MD, WAFP President-Elect, Mill Creek

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Great news: I-901, the Healthy Indoor Air for All Washington initiative, has qualifi ed for the November 8 ballot! This measure enjoys strong support from Washingtonians across the political spectrum. If passed, I-901 will protect us from the cancer, lung disease, and heart attack risks of secondhand smoke in all non-tribal public indoor places, including all restaurants, bars, bowling alleys, bingo halls, casinos, 25 feet around entrances, workplace vehicles open to the public like taxis, and 75% of motel and hotel rooms. As you may know, the CDC recommends smoke-free indoor air laws as a “Best Practice” to reduce secondhand smoke exposure. Such policies also are among the most effective in reducing smoking, as a secondary effect.

Don’t adults have a right to smoke where they want to?

A famous Supreme Court decision said that your right to swing your fi st ends at the tip of the next guy’s nose. Everyone should have the right to be protected in any public place from exposure to secondhand smoke. People who work in smoke-fi lled environments deserve the same protections as the rest of working Washington. Proven scientifi cally, there is no safe level of exposure and

no ventilation system is equipped to remove cancer-causing toxins from the air.

Will I-901 hurt businesses that currently allow smoking?

By expanding statewide smoking regulations for all public places, businesses will be on equal footing and every worker covered by Washington State law and the public will be protected. One year after the City of New York implemented their indoor smoking regulations, tax revenues from bars and restaurants increased by 8.7%, tourism boomed and hotel revenues increased, 10,000 new jobs were added in city bars and restaurants, and 23% of diners ate out more often. Numerous studies of clean indoor air laws have shown retail sales and employment were not affected and in many cases revenues actually increased. Only tobacco companies stand to lose, since with clean indoor air laws, people smoke less, buying fewer cigarettes.

Why does the initiative include a reasonable distance provision?

Like more than 300 communities across the country, I-901 includes a reasonable distance provision of 25 feet or less to ensure secondhand smoke does not fi lter back into

ventilation systems, entrances and exits, and open windows. I-901 is unique because it builds in a fl exibility measure that allows prohibitions at lesser distances where appropriate. Reasonable distance provisions are important especially in light of a July 2005 report by the American Society of Heating, Refrigeration and Air Conditioning Engineers (ASHRAE), which concluded that no ventilation equipment or systems can adequately protect workers and patrons from carcinogens and other toxic agents present in secondhand smoke. ASHRAE encourages clean indoor air laws “as the optimal way to minimize ETS [environmental tobacco smoke] exposure.”

Which states have already enacted clean indoor air laws? California, Connecticut, New York, Delaware, Massachusetts, Florida, Utah, Maine, Montana and Rhode Island. Scotland, England, Ireland, Italy, Uganda, India, Sweden, Norway, and New Zealand too!

Who supports I-901?The Healthy Indoor Air campaign

is led by the American Cancer Society, as well as the American Lung Association of Washington, the American Heart Association, Breathe Easy Washington, Swedish Medical Center, the WAFP, WSMA, Campaign for Tobacco-Free Kids, the PTA, Washington Children’s Alliance, AARP, State Labor Council, Washington Association of Churches and others. Many of you supported the initiative with signature gathering and thank you very much. You can help now by placing a sign about I-901 in your offi ce waiting room, help arrange a public presentation or write a letter to the editor. Visit www.HealthyIndoorAirWA.org for a complete list, or call 206-522-2233, info@healthyindoorairwa.org. Thanks to Washington doctors for helping!

I-901, HEALTHY INDOOR AIR INITIATIVEBy Chris Covert-Bowlds, MD, Ferndale

15

OB MEDICAID REIMBURSEMENTby John McCarthy, MD, WAFP Alternate AAFP Delegate, Tonasket

I fi nd obstetrical care to be a phenomenally rewarding component of family practice. It is an honor

and a privilege to be involved in bringing new life into this world. With this in mind, I have recently had to question my continued commitment to obstetrical care. Due to a variety of reasons, over the last eight years, three of my colleagues have discontinued their obstetrical privileges and one left the community altogether. This inevitably led to an increase in call which created signifi cant challenges for maintaining quality family time, enjoying my practice, and not becoming burnt out. In my mind, things were out of balance and not sustainable.

Obstetrical care in rural Washington State is delivered in large part by family physicians. However, this care has become more limited with fewer physicians available to deliver this care. There have been many factors that have contributed to the current tenuous position of rural obstetrical care including aging of rural physicians, closing of rural hospitals to obstetrical services, and rising malpractice premiums. Malpractice rates rose because of coalescing market forces, but reimbursement rates for obstetrical care did not keep up with overhead increases, in particular, with the cost of the increased malpractice premium. It now costs between $10,000 and $25,000 to pay the insurance premium for doing obstetrics as a family physician. If one takes into account a stable offi ce overhead, it takes approximately 10 deliveries to simply meet this differential in liability while one is doing low risk obstetrics.

When a family physician stops providing OB care, it not only decreases access to OB services but also strains the rest of the providers in the community. It impacts the family physicians who have chosen to continue delivering babies. The

call is more frequent. There is less collegial availability for diffi cult cases or in an emergency. The loss of one practitioner from an already small obstetrical call schedule becomes quite diffi cult to handle. This could also cause a cascading effect because one provider in a small community plays an integral role in the stability of that community. Most family physicians in small communities play multiple roles including hospitalists, ER physicians, urgent care centers, and psychiatric service centers. The addition of increased call responsibilities has the potential to decrease quality of life thereby creating less desire for providing continued obstetrical care. Those physicians wanting to continue to deliver in rural Washington have had to make some diffi cult choices. Some of my colleagues have been in the unenviable position of literally losing money and working harder in order to continue providing obstetrical coverage, a decision they made because of their commitment to their patients, community and colleagues. Their personal sacrifi ce has to be commended however it is not healthy nor is it sustainable.

In Tonasket within the last 5 years, the two closest hospitals have altered how they deal with obstetrical services. A neighboring hospital at a distance of 60 miles, Ferry County Hospital discontinued obstetrical services altogether. Mid-Valley Hospital at a distance of 30 miles has initiated a stipend to obstetrical providers who maintain C-section privileges. Ferry County Hospital’s cessation of services has resulted in the migration of nursing staff and patients. This has the potential to be problematic due to a mountain pass between our two hospitals. In good weather, travel time between hospital districts can easily be one and a half hours. In the winter, of course, this can be considerably longer, if not signifi cantly hazardous or impossible.

Another factor to consider is the impact of Family Physicians stopping OB care on local rural hospitals. If hospitals

do not have a minimum number of deliveries, they cannot continue to provide obstetrical services for fi nancial and quality reasons. This can lead to an erosion of other services including pediatrics and surgery. When a local hospital closes, it decreases access not just to OB hospital care but all hospital care for their community.

Fortunately, there is some recent good news in the rural obstetric picture. DSHS recently increased the reimbursement for Family Physicians in rural counties by $194 for 2005-6 and by $410 for 2006-7. This increase in funding was lobbied for aggressively by the WAFP at the legislative level and in the spring of this year the WAFP’s work on this issue was rewarded. The legislative action supported by the WAFP regarding reimbursement for rural obstetrical care by Family Physicians has helped to stabilize the delivery of OB care in rural Washington State. While this amount of money is far from a windfall and its addition into the reimbursement picture doesn’t solve the root of the obstetrical care crisis, it is a viable temporary fi x. The legislature has farther to go in order to create a long-term solution that is equitable for all obstetrical providers in all areas of the state. Perhaps Initiative 330 will be of some assistance in moving us forward on this issue.

The situation in Tonasket has also stabilized. Two new excellent Family Physicians with surgical skills have joined our practice. Our hospital board has remained committed to the full scope of rural health care including obstetrical services. My local group and the larger multi-specialty group of which I am a member have acknowledged the need for obstetrical care in the Okanogan Valley. It is supporting our decision to continue to provide operative obstetrics in this generally underserved area. My colleagues and I continue to share with our patients that special relationship that develops as new life is brought into this world.

16

Almost all people agree that all children should have needed health care. It is not the kids’ fault that we adults haven’t fi gured out how to make this happen, but they pay the price. In the long run,

we all pay.This is not just a coverage issue.

Yes, all kids should have access to affordable health insurance, but they also need a system of care to ensure that this coverage results in needed care. The majority of kids with coverage do not get all the services they should have as prescribed by our own standards. We know that kids should have developmental, oral health and mental health screening. We know they should be attached to a medical home – a clinic or doctor’s offi ce - where their care can be managed from education, to prevention, to acute and chronic care. They do get these services when we decrease barriers and improve our systems of care. Like chronic conditions, good care for children requires good information, education and effective teams.

The WAFP and its members have helped set up a number of programs around the state that are addressing the issues mentioned above. We have been key to establishing the Kids Get Care program in King, Snohomish and Pierce Counties that reaches into communities, attaches kids to medical homes and ensures these kids get the full range of needed well child care. We have established programs in most of our residency sites for training residents in oral health including screening, education and fl uoride varnishes. We have assisted in updating the age appropriate developmental screening needed for all children. We have worked with the State to identify and decrease some of the barriers faced by low income children and their families. We have the pieces, now is the time to put them together.

We have the opportunity over the next few years to make real and

effective changes in our care for all kids. Some of our state policy makers are asking what can be done differently and better. We (public health professionals, family doctors and pediatricians) have piloted a number of changes that together have shown to nearly double the proportion of kids who get appropriate and needed care. These are the changes that can make a difference.

CHANGE THE CULTUREWe need to ask how we can make sure all kids are healthy and prepared for school – not how we can keep ‘undeserving’ kids out of care (is there an undeserving child?)

REMOVE BUREAUCRATIC BARRIERSThere are easy changes at the state and health plan level that can make a difference. Make applications easier to complete on paper and on-line. Standardize and simplify the forms and documentation. Enable enrollment in clinics and other settings so parents don’t have to leave work just to fi ll out papers.

REACH OUT TO COMMUNITIESHard-to-reach kids are often close to care, but because of a host of reasons – parental work requirements, cost concerns, language barriers, and many other reasons – they don’t get into care. We have examples of how we can work with community organizations like day-care facilities, churches, and schools to contact these families, and initiate screening and referral to medical homes.

ENSURE THAT ALL KIDS HAVE MEDICAL HOMESKids with medical homes in clinics and private offi ces get more of needed care and have better health outcomes. We can get these children in if we work with our community partners in a systematic way. And, we can also improve the systems of care in our own clinics so children who do present to us get all of the

services they need – ranging from developmental screening to oral health care. We need to look at our outcomes to see if we are doing as well as we can.

ALL KIDS SHOULD BE ELIGIBLE FOR HEALTH INSURANCEWe know now that almost all kids are eligible for needed health insurance. Most of the uninsured are eligible for state or private plans. The few that are not eligible should have an affordable health insurance option available. Most importantly, we should not use insurance as a barrier to getting care. If we set up affordable health insurance for the few kids who are not eligible now, we can treat health insurance as a secondary issue. Our public health message can be ‘your child needs care’ not ‘you need insurance.’ Now screening for eligibility is a way to make sure those kids who are not eligible do not get in. We need to use insurance screening as a way to sort out the payer source and not act as a barrier. When all kids are eligible for affordable care, we can focus on the health message for parents.

AVAILABILITY OF SERVICESWe do need to ensure that the services we provide are available and that will include reasonable payments for the services we provide. When we work to solve the problems in our system, we have a better chance of successfully making the case for reasonable payments. This happened with First steps (OB care) and Second Steps (pediatric care) expansions a decade ago.

We have piloted and refi ned all of the steps needed. We have physicians, educators, public health practitioners, and social services interested and supportive. Now we have policy makers who are willing to start working on this goal. We need to encourage them and nurture this change. Now is the time.

NOW IS THE TIME FOR ALL KIDS TO HAVE HEALTH CAREby Robert Crittindon, MD, WAFP Past President

17

This year promises new challenges and opportunities to the House of Family Medicine. Three

years have passed since the introduction of our landmark Future of Family Medicine (FFM) report. Implementation is ongoing; surging ahead in some places, cautiously creeping in others .The foundation of the FFM is the New Model of care for family physicians which includes: • Personal medical home • Commitment to provide a defi ned

basket of services • Advanced information systems,

including electronic health records • Patient-centered care • Elimination of barriers to access;

open access by patients • Team approach to care • Whole-person orientation • Focus on quality and safety • Enhanced practice fi nance • Redesigned, more functional offi ces • Care provided in a community

contextAt our recent WAFP retreat we

reviewed with alarm the continuing decrease in UWSOM student interest in Family Medicine careers. Will implementing the New Model for Family Medicine help reverse this trend? There is also an interesting trend among FP residents in the Northwest to gravitate toward Community Heath Clinic (CHC) employment and a defi nite increase in residency positions fi lled by foreign medical grads. Are New Models of practice more visible in CHC’s? Are foreign medical students more in tune with the value of Family Medicine than their US counterparts?

Pay for Performance (P4P) continues to be a highly visible prospect for the future as the Center for Medicare and Medicaid Services

(CMS) and other purchasers of healthcare look for ways to assure value. Physicians in the US are obviously leery of these concepts. FP’S see potential to enhance New Model practice viability with P4P but justifi ably worry about the risk of more uncompensated management responsibilities. Will the New Model work with P4P efforts and improve care for patients and support Family Medicine?

The federal government continues to promise support for Information Technology (IT), particularly Electronic Health Records (EHR). Several active bills before Congress include various economic incentives. New Models require good IT systems and many FP’s need help with the up front expenses. Can FP’s tap into government support for IT development?

Sometimes new ideas can best be expressed as questions, like the above. At the WAFP Board Retreat in Spokane two new strategies were identifi ed to address these questions: 1. Planning has begun to highlight

New Models of care for our medical students. Curriculum changes around the Ed Wagner “Planned Care Model” and a workshop to enhance New Model implementation by UW Clerkship sites and other WAFP members are in the works.

2. A New Model Task Force has been appointed to advise the WAFP BOD and serve as a resource for the New Model information.

Some new ideas come from unexpected sources. The Lean Enterprise Institute (LEI), a non profi t research institute, has for several years advised the manufacturing industry on methods for improving quality and effi ciency. Recently efforts to apply their concepts to outpatient health care delivery have revealed interesting results. Care

delivery in physician offi ces is often ineffi cient and prone to errors not to mention stress for the physician and staff. “Lean solutions” to these problems have been proposed to avoid waste and improve quality. Visit LEI’s website1 or look for these breakthrough ideas at the Institute for Healthcare Improvement (IHI) website2 to get more information.

The appreciation of Family Medicine’s critical role in planned care delivery raises more questions. How can we redesign our offi ce system to provide the core basket of services smoothly and effi ciently without excessive chaos and stress? Should FP’s be called away from their critical work to see patients in the ER? Should they work hard all day only to have their nights interrupted with ER and hospital care, or worse, uncompensated, often unimportant telephone calls? What are primary care physicians doing in England and Scandinavia that we might learn from? Dr Larry Green of the Robert Graham Center recently posted an article, Notes from Visit to National Primary Care Research and Development Centre, University of Manchester, England, on the Robert Graham website examining the interesting British experiment in primary care redesign.3

And so we have some new ideas and new strategies to help us move ahead. Change is good and the sign of a healthy specialty. We all must continue to transform our practices to meet the needs of our communities and revitalize our profession. The changes of the New Model make me proud to be a Family Physician.

REFERENCE: 1. http://www.leanconcepts.com/healthcare.htm2. http://ihi.org/IHI/Topics/Offi cePractices/3. http://www.graham-center.org/PreBuilt/

Manchester_Visit_Notes_0719.pdf

STRATEGIES FOR NEW MODELS OF CAREby Stan Garlick, MD, WAFP Immediate Past President, Port Angeles

18

INTRODUCTION

In response to a recent dramatic increase in malpractice insurance for physicians who provide obstetrical care, many family medicine physicians have simply stopped caring for OB patients. Between 1984 and 1989 alone, there was a 20% drop in the number of physicians providing OB care in rural United States.1 This trend is continuing with a further decline in maternity care by rural family doctors from 26.1% in 1993 to 22.4% in 2000.2 This situation is particularly devastating for rural communities because the majority of obstetrical care in these areas is provided by family practice physicians.3 Although the fi nancial hardship of rising malpractice premiums is realized by all obstetrical providers, a study done by the Institute of Medicine in 1988 showed that the fi nancial problems are more diffi cult for family physicians than for obstetricians.4

A decrease in access to maternity care has many deleterious effects to the health of the entire community. Studies have shown that women with limited access to OB care are more likely to experience complications during childbirth and give birth to babies with more problems than women with better access to OB care regardless of their fi nancial or social status. These maternal and newborn complications lead to longer hospital stays and subsequently, higher costs.1,5,6

This study investigates this issue for rural family physicians in Washington State. Are Washington’s rural family physicians still delivering babies and if so, how has their enthusiasm for medicine changed in the current malpractice climate? This study endeavors to answer the question of how this crisis has impacted rural women’s access to obstetrical care and how physicians

feel about their options and those of their patients. The study also seeks to determine if city and hospital leaders have seen a change in local medical services and if they are aware of the situation doctors are facing and its severity.

METHODOLOGY

One rural county in Washington State was chosen to represent rural Washington for this study. Kittitas County is located near the geographic center of the state, with a population of 33,362 people. Much of the county is unincorporated, but of the fi ve major towns or cities in Kittitas County, Ellensburg is the most populated. Men and women are equally represented with the largest proportion of the population falling in the 25-44 year-old age range.7 Kittitas Valley Community Hospital, located in Ellensburg, is a 38-bed facility and is the only hospital in the county. In addition to the hospital, there is a Free Clinic in Ellensburg and an Urgent Care Clinic in Cle Elum.8 Compared to 2001 Washington state averages, Kittitas County had lower teen pregnancy rates and abortion rates between the years 1997 and 2001, a higher initiation and 6-month maintenance of breastfeeding, a higher percentage of women receiving prenatal care in the fi rst trimester, and a slightly higher percentage of Medicaid-funded births.8,9

Prospective subjects were identifi ed for interviews within Kittitas County in Washington State. This included family practice physicians, obstetricians, certifi ed nurse midwives, mayors of the fi ve major cities and towns, and the administrator of Kittitas Valley Community Hospital. The investigator traveled to their locations and interviews were conducted at the subjects’ convenience. The interviews

were then analyzed using descriptive, qualitative, structured interview methodology. Simple percentages are reported using no statistical manipulation or evaluation.

RESULTS

Interviews were conducted with twelve of the fourteen family physicians, the only obstetrician, and the only certifi ed nurse midwife in the county. The hospital administrator of Kittitas Valley Community Hospital and four of the fi ve mayors were also interviewed. The physicians and nurse midwife practice in one of six clinics or practices, all of which handle the payment of malpractice premiums in different ways, split evenly, split according to risk, paid for individually, and paid for by the provider’s employer.

All of the physicians included in this study purchase their professional liability insurance from physician-owned Washington State Physician’s Insurance (WSPI). WSPI assigns premiums based on risk level, which is determined by specialty, and if that is family practice, whether or not OB is performed. Risk level is further broken down for FPs who deliver babies based on the number of deliveries per year and whether or not high risk OB (including cesarean sections) is done. In addition, new physicians pay a lower premium which increases stepwise until it equals that of their senior peers after fi ve years in practice. Family practice physicians who deliver babies (who were not in their fi rst fi ve years of practice) saw the greatest increase in their malpractice premiums over the last two years at 53-55% as shown in Table and Figure 1. The obstetrician’s premiums increased 18% in the past year from $60,000 to $71,000, and the nurse midwife’s premiums increased 86% in the

THE MALPRACTICE INSURANCE CRISIS AND OBSTETRICAL PROVIDER SHORTAGES IN RURAL WA: AN IMPENDING PUBLIC HEALTH DISASTERA University of Washington School of Medicine Research Paper by: Drs. Tom Norris and John C. Anderson, and Amy Rodriguez

19

past year from $7,000 to $13,000. Liability insurance for Kittitas Valley Community Hospital through Washington Casualty has also expanded dramatically from $102,000 to over $500,000 per year in the past three to four years, forcing a cut in its level of coverage.

Family physicians deliver approximately 2/3 of the roughly 350 babies born in Kittitas County each year, with the number of deliveries performed by each family physician varying considerably from 5 - 80 per year. Of the twelve obstetrical care providers interviewed, six (50%) said they did not deliver enough babies to cover the recent increase in their malpractice premiums. Five (42%) said they did and one (8%) said they thought they neither lost nor made money delivering babies. Many said they provided OB care as a service to their patients or because they enjoyed it and not for the money.

The thirteen physicians were asked where they felt the most impact of the recent increase in premiums, their fi nances, their

practices, or both. Two (15%) said it has had the most impact on their practices. One of these was a physician whose malpractice premiums were paid for by the hospital and who had recently given up all OB. The other was a physician whose premiums had actually not changed much from the previous year due to discontinuing high-risk OB and c-sections. Six (46%) said they had felt the most impact of the increase on their fi nances. Four (31%) said they had felt the recent increase has had an effect on both their fi nances and their practice. Various impacts on practice are presented in Table 2. One (8%) physician felt no impact, fi nancial or clinical, due to being an employed physician whose premiums were covered by the medical director of the clinic.

Ten physicians who provide

OB care were asked if they had felt any impact from others physician’s decisions to eliminate OB from their practice or limit the type of OB practiced. Three (30%) said yes, they had felt the impact in the form of fewer providers to share in call coverage, six (60%) reported no impact, and one (10%) reported being unsure of the effect. All twelve obstetrical providers thought that if they stopped delivering babies, patients in the area would still have adequate access to OB care. However, eight (67%) of them indicated that discontinuance of their OB care might cause diffi culty for

patients or their peers. Two said it would create a travel hardship for patients, two reported that it would cause a call schedule hardship for the remaining doctors providing OB care, specifi cally for high risk and c-sections, two said that it would be a clinic decision, so that they

would not be the only one to stop, and three said that they provide unique OB care, so that quitting would limit patient options.

Nine subjects (64%) reported that the rising cost of malpractice insurance had adversely impacted their enthusiasm for medicine. Some said that they practiced more defensive medicine, “doctoring charts” and leaving less time for patients. Some said they resented the fact that they have the capability to care for someone, but are not able to do so due to malpractice limitations. One said that it “dampens the whole tenor” of the medical community and has made recruitment of new physicians more diffi cult. Four of thirteen subjects (31%) reported considering leaving Washington State so that they could continue to

Figure 1: Malpractice Premiums for Washington State Physicians

$0$5,000

$10,000$15,000$20,000$25,000$30,000$35,000

High risk OBwith C-Sections

Low Risk OBOnly

No OB

WSPI OB Risk Level

Ann

ual M

alpr

actic

e Pr

emiu

m 200220032004

Table 1: Malpractice Premiums for Washington State Family Physicians 2002 2003 2004 Total Increase High risk OB with C-Sections $20,199 $25,936 $30,892 53% Low Risk OB Only $13,060 $16,958 $20,211 55% No OB $11,496 $13,444 $16,031 39%

Table 2: Effects of Malpractice Premium Increases on Practice � Having to reduce number of babies delivered in a year in order to be able to

qualify for lower stepwise coverage according to WSPI guidelines � Having to lay off a specialist physician employee, forcing family doctors to

provide specialist care (pediatrics) � Stopping or limiting OB care � Fewer doctors providing OB with or without c-sections causes strain on call

schedule

20

provide OB care in another location. Four (31%) said they had considered a change of careers, retiring early, or stopping OB care.

When the eleven physicians who provide OB care were asked if they would continue to provide OB care, or if they would consider stopping all or some of the obstetric services they provide if premiums were to increase another $10,000, none were certain about that specifi c fi gure, and most hadn’t given it enough thought to answer defi nitively. However, six (55%) said they would probably discontinue all OB care, or at least give it serious consideration, two being high risk OB providers. One of these six had actually already made plans to stop high risk OB, but was persuaded by the other partners in the clinic to continue for one more year to ease the call schedule. Another of the fi ve current high risk and c-section providers said he would “look real seriously at cutting back on the high risk”, and still another of the high risk providers was unsure what changes would happen, stating that if the same question were asked “$10,000 ago”, she probably would have said she would quit and yet has not. Those that would continue, would do so even though it might not be fi nancially feasible, in order to keep the call schedule manageable and to provide a necessary service to their patients.

Eight of the nine (89%) subjects who had been in practice long enough to remember the previous malpractice crises in the 1970’s and 1980’s said that this crisis is different. All said that the difference was the magnitude of the premium increases and jury awards, making it not just a loss in salary, but also a loss of jobs and specialists resulting in a situation “reaching the breaking point”. One physician pointed out that some of the changes made in response to previous crises are not available this

time, such as the creation of WSPI. Both of the family physicians who do no OB now had stopped in response to increasing malpractice premiums, and now miss providing OB care and the children it infuses into a practice.

Fifteen subjects, including all of the physicians, the nurse midwife and the hospital administrator were asked to share their ideas about how this problem might be resolved. Fourteen (93%) thought that some sort of tort reform would help. Figure 2 shows that of the many ideas, capping non-economical damages in malpractice lawsuits was the most popular response at 50%.

Several of the subjects felt that physicians should be able to “police their own” and thought that

implementing a system in which potential malpractice lawsuits were sent before a medical review board made up of healthcare professionals before going to court would weed out many frivolous law suits. Other tort reform ideas included setting malpractice insurance premiums on the basis of risk and not punishing experience, having a “loser-pays” mentality to cut down on frivolous law suits, revoking the licenses of negligent providers rather than punishing them fi nancially, having a tax-supported state fund to help with premiums in the short term, allowing juries to be informed if a plaintiff has other resources available to them to collect damages (collateral

source rule), and giving sovereign immunity to all OB providers. Nine of the fourteen subjects (64%) who thought tort reform would help this situation also had other ideas aimed at solving the malpractice crisis. Five (36%) thought that there needed to be a societal change to accept more responsibility and have appropriate responses to bad outcomes. One physician’s idea to “lovingly get radical” was to get the public involved by organizing a modifi ed strike to bring media attention to the issue and to intensify the public’s understanding of the crisis, while it can still be reversed. Another physician thought it was up to the medical community to market physicians and educate patients better

so that patients knew doctors’ limits, and to “deemphasize some of the high tech stuff so that people don’t think that they can go in and get an all body scan and have their physical for the year.” Two subjects (14%) suggested that implementing universal healthcare coverage would help solve many problems with healthcare in general, including but not limited to, the malpractice issue. Other ideas included improving the quality of healthcare to decrease the number of medical errors and freeing the Democratic Party from the fi nancial infl uence of trial attorneys.

Four of the fi ve mayors of the larger communities in Kittitas County agreed to be interviewed.

Figure 2: Tort Reform Ideas

50%

36%

29% 29%

14%

0%

10%

20%

30%

40%

50%

60%

Perc

enta

ge o

f Sub

ject

s

Limit Settlements/Caps onDamages (50%)Limit Attorneys' Fees(36%)Arbitration (29%)

Medical Review Board(29%)End Joint and SeveralLiability (14%)

21

All were somewhat familiar with the recent increase in malpractice insurance premiums for obstetrical providers. Two were aware that Washington State had been given the AMA designation of a state “in crisis” in regards to this issue. Three had not noticed any recent changes in the services provided to their citizens or any negative impact caused by this situation. One reported noticing more diffi culty in keeping people, particularly children, in the community insured and recognized that this meant more people going to free clinics, the cost of which is passed on to the citizens. One reported Republican affi liation, one reported Democratic affi liation, and two reported having no offi cial party affi liation. There was no apparent correlation between awareness and thoughts about the situation and political party affi liation.

DISCUSSION

Family medicine physicians in this rural county in Washington State all recognize that the increase in malpractice premiums is a serious problem that threatens to decrease access to obstetrical care in their communities. Most city leaders are not aware of the severity of this crisis, but do recognize how this issue affects the bigger picture in healthcare, and how their citizens will ultimately be the ones who suffer if access to basic services like obstetrics continues to dwindle. At this time, only a small portion of Kittitas County’s family physicians have stopped providing OB care, but for both of them this decision was strongly infl uenced by rising malpractice costs.

The bottom line is that if clinic overhead increases faster than clinic income, someone loses. Clinic staff are still getting annual cost of living increases in salary and medical insurance companies are not matching the phenomenal increases in malpractice premiums, so overhead skyrockets while reimbursements increase minimally, if at all. Physicians are losing income and family practice

is already one of the lowest paying medical specialties there is. Doctors in Kittitas County are concerned about having enough money to send their own children to college one day and being able to retire. Most do not deliver enough babies to cover the recent increases in malpractice premiums, which means they are losing money delivering babies. So why do they continue to provide obstetrical care? They do it as a service to the community and “for the love of it.” The cost of malpractice insurance for some of these well-meaning physicians has risen over $10,000 in the past two years alone, and over half of the providers say they’ll probably or defi nitely give up all OB if it goes up another $10,000. One family physician who still provides OB services was particularly distressed at that prospect, but had to admit being “only one major malpractice increase again away from... I can’t bankroll it for the community any more.” Another of the county’s doctors said “there’s a certain shake out there that occurs every time there’s an increase. People who are on the fence are going to go one way or the other. They’re probably going to quit doing OB.”

If most of the doctors are not delivering enough babies to make it fi nancially feasible, one might logically conclude that it would make sense for fewer physicians to deliver babies, so that the ones left doing it do enough to make it economically worthwhile. This theory is fl awed in many respects. First, many family physicians love providing maternity care. Taking away this part of their practice may compromise their interest in medicine enough for them to decide they would rather practice somewhere where it is still an option for them or change careers entirely. Second, narrowing the fi eld of obstetrical providers also limits patients’ choices at a time in their life when they ought to be able to bond with their provider and pick exactly the right one. Finally, another quality of life issue that this option

would exacerbate is having enough providers to allow for a reasonable call schedule. This was one reason heard repeatedly for continuing to provide OB services, despite the malpractice increases. If only one physician in each clinic is left doing OB, they would defi nitely make more money doing it, but would also be on call at all times, making planning vacations, family events, and all other aspects of life extremely diffi cult. This “solution” would rapidly turn a fi nancial issue into a quality of life issue.

When issues like increased malpractice insurance rates come up, people are usually quick to blame the insurance company. It is easy to believe that someone must be getting rich off these astronomical increases, but none of the physicians interviewed thought that their insurance carrier, Washington State Physician Insurance, was to blame for the problem. Most had confi dence in this physician-owned company, which was created in response to a previous malpractice crisis. Most believed that the malpractice crisis is a societal problem generated by “jackpot mentality” and lawyers who are willing to represent any claim regardless of its merit. Since even unfounded, frivolous claims have to be defended, even if a physician does nothing wrong, if he or she is sued, insurance companies will spend tens of thousands of dollars in litigation and/or settlement fees.

Recent polls show that a large majority of Washington residents are aware of this problem and support reform.10 If this is the case, why have reform efforts been repeatedly struck down by the U.S. Senate and Washington State legislature? This is not just a doctor’s problem. The public and government need to get involved. The public recognizes that there are problems with healthcare, but given the response from the mayors interviewed it is not clear that people know how urgent this problem has become and how it threatens to undermine all of healthcare and not just physician

22

income. When overhead rises, patients will have to share some of those costs to keep doctors in business. One family physician addressed the public’s involvement by saying “when the American people wake up and realize what’s happening in healthcare, the Boston Tea Party’s going to be a blip in history, because I think at the way we’re going, it’s going to be such a disaster. When the American people fi nally wake up, they’re going to be mad.”

CONCLUSION This study shows that

access to OB care in Kittitas County, Washington is not yet a severe problem, but that there is considerable unrest among the doctors of this rural county surrounding this issue. If something is not done to curb and correct their

rapidly increasing premiums, many of them plan to quit providing OB care or quit medicine entirely. Their attitudes toward continuing increases makes this problem a threat to fragile rural healthcare systems, leaving no doubt that if current trends continue, there will be obstetrical provider shortages in rural Washington and an obstetrical access problem for many of our citizens in the very near future.

REFERENCES1. Nesbitt TS, Larson EH, Rosenblatt RA,

Hart LG. Access to maternity care in rural Washington: Its effect on neonatal outcomes and resource use; Am J Public Health. 1997 Jan, 87(1); 85-91

2. Nesbitt TS. Obstetrics in family medicine: Can it Survive?: J Am Board Fam Pract. 2002 Jan-Feb; 15:77-9.

3. Baldwin LM, Hart LG, Rosenblatt RA. Differences in the obstetric practice of obstetricians and family physicians in Washington State: J Fam Pract. 1991 Mar;

32(3): 295-9.4. Institute of Medicine. The effect of

professional liability of the delivery of obstetrical care. Washington DC: National Academy Press, 1989.

5. Nesbitt TS, Connell FA, Hart LG, Rosenblatt RA. Access to obstetric care in rural areas; effect on birth outcomes; Am J Public Health. 1990 Jul; 80(7): 814-8.

6. Nesbitt TS, Scherger JE, Tanji JL. The impact of obstetrical liability on access to perinatal care in the rural United States: J Rural Health. 1989 Oct; 5(4): 321-35.

7. US Census, 2000.8. Kittitas County Health Department, 2003.9. Washington Women, Infants & Children

Nutrition Program, 2001.10. Mason-Dixon Polling and Research. Health

Coalition of Liability and Access: September 2004.

I would like to introduce myself. I am Melissa Molsee, your WAFP student trustee for the year. I grew up on a farm near a small town in rural western

Washington and completed my nurses’ training at a satellite school nearby. My clinical training at the school was conducted with local physicians in their clinics and at the small community hospital, where I enjoyed the close-knit community. As a result of these experiences, I plan to return to a similar area and serve as a family physician.

In college, I designed and completed a bachelor’s degree in Public Health as the UW didn’t offer a similar degree at the time. I felt that this background would serve me well as a family physician. While in medical school, I got involved with

family medicine activities such as co-leading the Family Medicine Interest Group, serving as a delegate to the WAFP House of Delegates meeting and volunteering as an FMIG regional coordinator for the AAFP.

As the student trustee I would like to increase the involvement of students in family medicine related activities at both the state and national levels. I feel that there is defi nitely an interest in involvement among students and yet some are still uncertain as to how or where to begin.

My leadership experiences have shown me that not only can I make a difference among patients at an individual level but that as part of a group of dedicated physicians (and physicians-to-be) I am able to contribute to an even bigger difference. I want to convey this message to my classmates and

convince them that they, as physicians of the future, are an integral part of this difference.

I am honored to serve as the new WAFP student trustee. Please feel free to contact me at mmlofgren@juno.com.

I am also pleased to introduce the new 2005-2006 Family Medicine Interest Group leaders:

Jake DonaldsonMallorie EvensonKristen GarciaHeather Angell HunzikerJohn LemosPaula McPolandHolly SatoSadie West

MEET MELISSA MOLSEE, THE NEW STUDENT TRUSTEE

23

“Your Voice Counts – Who Do You Speak For?” was the theme for the 2005 AAFP National

Conference of Family Medicine Residents and Medical Students where 637 medical students, 485 residents, and 1,429 exhibitors (many of them residents) came together in Kansas City, MO from July 27-31, 2005. With this theme, residents and students put advocacy for family medicine and our patients at the forefront of this year’s conference.

Incredible leaders in family medicine came to this conference to share their voice with residents and students as guest speakers:• Dr. J. Edward Hill, President of the

American Medical Association, opened the conference with an inspiring speech on how we need to use “our personal compass” to guide the path we take towards advocacy and activism.

• Dr. Michael Fleming, AAFP Board Chair, gave an update on the issues that are facing family medicine today and what the AAFP is doing to address them.

• Dr. Darlene Lawrence, Stephen J. Jackson, MD Memorial Lecturer, discussed how she transformed from a physician to a physician and an activist.

• Dr. Richard Roberts, Past President of the AAFP, talked about how we can take a practical approach to the

Future of Family Medicine Project.• Dr. Richard F. Paris, 2005 AAFP

Family Physician of the Year, demonstrated his commitment to the rural underserved and described how he fl ies his own small plane around central Idaho to provide care for his patients.

Residents and students heard from many other family physicians who presented workshops, clinics and procedural skills courses on topics that are not taught in the classroom or during lecture. Many of the key concepts behind the Future of Family Medicine Project were demonstrated through these sessions, including:• “Future of Family Medicine from a

Medical Student’s Perspective”• “Developing Your Political Advocacy

Skills”• “Finding Your Future Practice: An

Organized Approach”• “I’m a Doctor, Not an Activist

– Why and How Should I Get Involved in Legislative Issues”

• “Show Me the Money: Offi ce Coding for the Family Physician”

• “Behavioral Modifi cation Group Intervention in a Chronic Pain Population”

• “Maternal Care and Childbirth in Family Medicine”

• Procedural workshops teaching the full scope of practice for family medicine – suturing techniques, casting/splinting, gynecologic procedures, nail procedures, joint injections, no-scalpel vasectomy, and treadmill testing.

Family Medicine Interest Group (FMIG) leaders learned by sharing ideas with each other how to make their own FMIG better. Topics that were discussed included: effective FMIG leadership, sharing programming ideas and creative fundraising ideas.

The voices of residents and students were heard loud and clear during the business sessions.

Discussion groups that focused on education, political advocacy, research, minority issues, women issues, GLBT issues, rural underserved and urban underserved were well attended. Multiple resolutions stemmed from these discussions and addressed a variety of topics such as: • subspecialty care for underserved

patients• confi dentiality in adolescent health

care• dental care for patients• communication with patients who

have a language barrierMany people shared their

opinions during the reference committees and gave testimony during the Student and Resident Congress sessions. During all of this exciting activity, WWAMI residents and students were able to caucus together and discuss these issues in detail. It was a lot of fun!

The AAFP National Conference is a wonderful opportunity and the WAFP is very generous in providing scholarships to help residents and students attend this conference.

Congratulations to the 2005 Student Scholarship Recipients!! John Lemos – MS II Jessica Kennedy – MS IV Brian Johnson – MS IV Erin Kallock – MS IV

Congratulations to the 2005 Resident Scholarship Recipients!! Dr. Monika Schlamminger Second year resident Tacoma Family Medicine

Dr. Allison Devers Third year resident Swedish Family Medicine – First Hill

Dr. Stacy Merrifi eld Second year resident Tacoma Family Medicine

Dr. Oana Marcu Third year resident Swedish Family Medicine – First Hill

STUDENTS & RESIDENTS “SUMMER VACATION” IN KANSAS CITYChristina Kelly, MD, WAFP Resident Trustee, and Melissa Molsee, WAFP Student Trustee

24

We truly are at a crossroads in medicine. • Our ability to provide

more innovative care is being challenged by harsh economic realities.

• The need to incorporate state of the art informatics into our medical practices is running up against shrinking practice income and declining margins.

• Publicly funded programs such as Medicaid face a growing gap between their explosive growth in enrollment over the past few years and the funding realities at the state and federal levels.

Overall, it is a challenging moment in our professional lives – and for the patients and communities we serve.

At the state level we are about to see tension between access, costs and the viability of our medical practices played out.

A major focus of the 2006 legislative session will be on controlling the state’s health care expenditures (and not just for Medicaid benefi ciaries). It is projected that our state will pay $500 million more in the 2006-07 biennium for health care than it did in the 2003-05 biennium. The state is spending $4 billion in state funds and another $4 billion in federal funds for health care over the biennium. Health care now represents 28% of the state budget.

Regardless of how you parse the numbers, health care costs will be under the microscope next year.

In recent meetings with the WSMA and others in the health care fi nancing and delivery leadership, Steve Hill, the newly appointed administrator of the Health Care Authority, outlined Governor Gregorie’s administration’s goals and strategies for tackling health care costs.

BROAD GOALS:• Reduce the state’s health care cost

trend to equal or less than the state’s revenue trend.

• Improve the quality and cost effi ciency of health care services.

• Improve the health of Washington residents, starting with state employees.

• Increase the number of insured Washington residents by improving the affordability of health insurances.

STRATEGIES TO GET THERE:• Promote the purchase by state

agencies of the highest quality, safest and most effective care.

• Use education, active decision support and incentives to change the choices and behavior of persons insured by state programs.

• Improve the health of Washington state employees so that “lessons learned” can be applied to improving the health of state residents.

• Focus on the “high opportunity” population insured by state programs with predictive modeling, disease management programs and incentives.

• Create an improved market for both buying and selling health care.

• Create a workable framework for addressing the uninsured state population.

What does all this mean for physicians in Washington state? We will be faced with demands for evidence-based medicine, pay for performance and other measures that impact our day-to-day practice and relationships with their patients. Sorting these issues out (we can all support “evidence-based medicine” but what does it cost to defi ne and who pays for that?) will vex all of us, regardless of specialty. But if we work together, we can successfully meet these challenges.

In the coming year the WSMA

will focus on organizational priorities that include:1. Making Washington a better place

to practice medicine and to receive care.

2. Supporting and promoting physicians’ professionalism and educating the public about the unique strengths and skills we bring to patient care.

3. Strengthening the ability of the WSMA to support and advocate on behalf of our members

These priorities will guide the association on where to focus our energies and activities.

The WSMA will continue to fi ght for better access to care for all Washingtonians and appropriate funding for physicians’ services. We will promote patient safety and error reduction initiatives, and promote best practices and evidence-based medicine. We will fi ght for administrative simplifi cation

The WSMA will continue to build on the good and productive working relationship it has with the WAFP. Our respective leadership groups and staff will continue to work together to meet our common objectives.

The challenges we face as individual physicians and as the WSMA and WAFP can be met. The AMA actually “got it right” when it launched its branding campaign --- “Together We ARE Stronger.”

I urge every family physician to support the WAFP and the WSMA as we work together this year.

Peter Dunbar, MD, was inaugurated as the WSMA President at the Association’s annual meeting in Tacoma in September. He is an anesthesiologist practicing in Seattle.

HEALTH CARE AT THE CROSSROADSby Peter J. Dunbar, MD, WSMA President

25

EXECUTIVE DIRECTOR’S VIEW: PLANNING FOR SUCCESSby Karla Graue Pratt, WAFP Executive Director, Bellevue

The theme of this issue is the New Practice Model, which is certainly appropriate, because it

is one of the primary strategic objectives defi ned by WAFP leadership in the planning retreat that was held earlier this summer. I am personally grateful for the time and effort put in by WAFP leadership to develop the priorities that will guide our work in the coming year, but also for the focus on improving the structure and the processes that will enable the Academy staff and the volunteer committees to achieve the goals.

The leadership gathered to defi ne the Academy’s strategic priorities for the next few years. The process was a rigorous one, starting with the WAFP Mission Statement, incorporating a thorough scan of the environment in which family medicine is practiced, and concluding with an extensive analysis of the capabilities we need to successfully serve our membership. The session was very productive, resulting in reaffi rmation of our objectives and adjustments of some priorities, to better refl ect the current needs and opportunities.

The fi rst priority for the Academy is to continue strengthening our infl uence in the legislative arena. We have achieved some notable successes in the last year, but it is important that we continue the efforts to build a system that enhances our credibility and effectiveness.

There are three initiatives that we will undertake to further this goal. The fi rst is the WAFP Political Leadership Institute (PLI), which will be held November 4-5 at the Marriot Hotel at SeaTac. The

PLI will provide physicians with health care policy insights from stakeholders and experts as well as hands on training opportunities on how to relate effectively with legislators, regulators, the media and community groups and coalition partners on issues important to the future of family medicine.

A second project will focus on improved utilization of the key contacts program. We are recruiting new members to the program, undertaking to educate both existing and new participants about developing stakeholder relationships and effective grassroots activities and communications.

Thirdly, we have refi ned the policy development process through the joint efforts of Academy staff and leadership; so that there is a clearer understanding of roles and responsibilities and a better ability of each group to focus on what will make our efforts most effective.

The leadership team can also be commended for their focus in defi ning the second strategic objective, which relates directly to the implementation of the new model practice. By targeting the specifi c opportunities to improve those practices where students are exposed to the ‘real world’ of family medicine, it should be possible to maximize the impact and contribute to the improvement of our future ‘pipeline’ of family physicians.

As Dr. Solberg has explained, reform of the committee structure should enable a better channeling of the precious volunteer efforts of committee members on those issues that are of most relevance and greatest signifi cance. I believe that this is an important step in the right direction for the Academy, and feel proud of the dedication and courage of conviction in the leadership team to undertake the task of

implementing change.The success of an organization

like WAFP is critically dependent on the effectiveness of communication—with AAFP, with the UWSOM, with our WWAMI partners, and most of all with our members. Communication, in this sense, is very much a two-way process: not only is it important to inform and educate members; it is likewise important for members to have the opportunity to engage with the Academy on issues of importance and concern to them. It is for this reason that I am looking forward to the development of our new website, and to the capabilities it will offer for interactivity and communication.

Strategic planning can be a chore for any organization, but if it is done well, and if the leadership responsible for planning recognizes the necessity of integrating plans with actions, with the realization that those actions are paving the way for the next set of strategic objectives, the efforts will be very worthwhile. The WAFP leadership team has done well with this planning cycle, and I would like to extend my personal appreciation for their work.

26

Membership Status as of Sept 16, 2005Active .............................................................1949Inactive .............................................................. 60Life ....................................................................194Resident ..........................................................185Student ............................................................153Total .................................2541

MEMBERSHIP INFORMATION

AAFP reports that more than 500 Academy members have contacted the Alabama, Florida, Mississippi, Louisiana, and Texas chapters to offer their medical services to Hurricane Katrina’s victims. Some have loaded rental trucks, packed them with supplies and medicine, and delivered them to the stricken areas. Others have offered clinical equipment, supplies, generators, and even their homes to colleagues whose practices and homes have been damaged or destroyed. So far, family physicians

and Academy staff have donated $147,224 for general and physician assistance! The AAFP Foundation will continue to accept donations to the Emergency Relief Effort’s General Disaster Relief and Physician Assistance funds. When you go to http://aafpfoundation.org/x644.xml to donate, you can select either or both funds, and within the physician assistance fund, you can stipulate which state

should receive your contribution. To get updates on family medicine’s response to this disaster, go towww.aafp.org/x37610.xml.

Hurricane Katrina Relief UpdateF a m i l y M e d i c i n e R e s p o n d s G e n e r o u s l y

CONGRATULATIONS BILLWilliam R. Phillips, MD, MPH, WAFP’s Alternate AAFP Delegate, will receive the 37th annual Max Cheplove Award of the New York Academy of Family Physicians, Erie County Chapter. The Cheplove Medal is the Academy’s highest honor, awarded for “the outstanding contribution to the ideals and principles of family practice on the national and international scene.” The award ceremony will be in Buffalo, NY, October 29, 2005.

Washington Academy of Family Physicians Foundation

Call for Non-Designated Donations

Your donation will support philanthropic efforts of the WAFP and AAFP Foundations to improve the practice of Family Medicine and the quality of care available to patients.

Please send your check today made out to:WAFP Foundation1050 -140th Avenue NE, Suite CBellevue, WA 98005

Your contribution is deductible under Section 501(c)(3) of the Internal Revenue Service Code

27

Swedish FM-Providence Campus in Seattle

A 10-10-10 program, has a 1.0 FTE faculty opening for a Family Physician. The program is a community-based residency affi liated with the University of Washington (faculty appointment available) and supported by a fi nancially healthy medical center. For 25 years, the residency has served an ethnically diverse patient population and is dedicated to the care of underserved populations. The residency clinic is located in downtown Seattle in the heart of the beautiful Pacifi c Northwest. The opening is available at the Providence Site, with 6 residents in each year of training. Full spectrum Family Medicine skills including OB and inpatient medicine is required. Practice &/or teaching experience is a plus. Women and minorities are especially encouraged to apply. Job sharing is an option. For information,

contact Kate Sykes at Kate.Sykes@Swedish.org or 206-320-2233. For more information about our program, please visit our web site at: www.swedishfamilymedicine.org and click on the Providence Campus link. To apply, email or mail a detailed C/V and names/addresses of 3 references. Applicants must be board certifi ed in Family Medicine and eligible for Washington State licensure. Salary commensurate will be with experience.

White Salmon, WAWell-Established Primary Care

Practice is seeking a BC Family Practice Physician to join our group. Located in the heart of the Columbia River Gorge, our compatible group of 8 MD’s and 7 Mid-Levels provides a full spectrum of primary care.

Excellent outdoor and recreational activities including

hiking, fi shing, boardsailing, mountaineering, white water sports and year-round snow skiing. All the advantages of rural practice, and yet excellent specialist backup.

Mail a CV, or for further information, contact Ray FitzSimmons, MD or Earl Russell, Clinic Administrator at 509-493-2133. Mid-Columbia Family Health Center, PO Box 1519, White Salmon, WA 98672.

New Medical-DentalOffi ce Space

Brand new building, modern design, in a superb location along Ambaum Boulevard in Burien. Convenient freeway access. Design your own space. Generous tenant improvement package. Up to 5000 sq. ft. available. One fl oor already leased to a medical practice. Call 206.324.5317.

Your local elementary schools are asking for Tar Wars! Please call Brian Nangle at (800) 621-8424 or (425) 747-3100

or email him at brian@wafp.net. Don’t let any students grow up without the tobacco free message.

Have you signed up to be a

presenter yet?

28

Friday Agenda6:00 – 7:00 pm

Registration & Cocktails

7:00 – 9:45 pm

Dinner PresentationCommunicating to Make a DifferenceMichele Hamilton Lane

WAFP Patient

Advocate of the Year

AwardPresented to Representative Eileen Cody by Dr. Jean Marshall, WAFP Past President

A Panel Discussion

with Legislative Leaders“How to Get My Attention”Moderator:

Kathleen Collins, WAFP Lobbyist Legislators (tentative):

Representative Eileen CodyRepresentative Bill HinkleSenator Karen KeiserSenator Linda Evans Parlette

1:45 – 3:45 pm

Plenary Session“Politics from the Ground Up”

This session will focus on: developing and maintaining good political connec-tions, getting involved in initiatives and coalition efforts, developing informa-tion and support for legislative issues, and working toward success with the WAFP Key Contacts Program

Moderator: Dr. Jeff Huebner, Co-Chair of PLI & CLGA

Speakers (tentative):Dr. Ron MorrisDr. Chris Covert-BowldsDr. Jean Marshall

3:45 – 4:00 pm“Ready, Set, Go? A Lessons Learned Recap”Dr. Gregg VandeKieft, PLI Chair

Dear Member,

The political process—it can seem

confusing, frustrating, and sometimes

inscrutable. Certainly we have the Academy

to watch over the big issues and go to bat

for our interests. But many family physi-

cians wonder whether there is anything

they can do as individuals to infl uence the

political debate. The purpose of the Politi-

cal Leadership Institute Conference is to

answer that question, by providing an over-

view of the process; views from the inside;

and fi nally a practical, hands-on workshop

on how to participate and be effective in

presentations and media opportunities.

This program is partially funded by a lead-

ership grant from the AAFP Foundation

and Schering to expressly help Washington

family physicians learn the skills, and

develop the confi dence to participate in the

political process.

We hope to see you there!

Sincerely,

Dr. Don Solberg, WAFP President

Dr. Gregg VandeKieft,WAFP Vice President & PLI Chair

Saturday Agenda8:00 – 8:15 am

Introductions & WelcomeDr. Don Solberg, WAFP President

8:15 – 9:15 am

Keynote Address “A Funny Thing Happened on the Way to the Offi ce -Getting Involved in Evolving Health Policy Changes”Moderator: Dr. Don Solberg, WAFP President Speaker: Steve Hill, Administrator, Washington Health Care Authority

9:15 – 9:30 am

Policy Process Overview“How the Sausages are Made”

This session will outline the compo-nents in the development of policy, and of legislation, to provide the context for family physicians to participate in the process.

Karla Graue Pratt, WAFP Executive Director

9:30 – 9:45 am Break

9:45 – 11:45 am

Workshop“Politics on the Hill and in Action”

This session will feature hands-on op-portunities to practice testimony before a legislative committee and to respond appropriately to the media. It will also include a discussion of balancing politi-cal goals of an organization in the real world of politics.

Moderator: Dr. Gregg VandeKieft, PLI Chair

Speaker: Patricia Clark, Messaging Expert

11:45 am – Noon Break

Noon – 1:30 pm Lunch

WASHINTGON ACADEMYOF FAMILY PHYSICIANS

2005 Political Leadership InstituteLearn the Skills Necessary to Infl uence the Political Process as a Resource oras an Activist within Our Practices & Communitie

November 4-5, 2005 • Seattle, Washington • Marriott Seatac Airport

Download your registration form today.www.wafp.net

Family Physician Nutrition Resource Center

The Family Physician Nutrition Resource Center provides the following tools:

The National Dairy Council’s online Family Physician Nutrition Resource Center provides family physicians with valuable tools and reproducible education materials to educate patients about the importance of healthy eating habits and the dietary benefits of consuming three daily servings of milk, cheese, and yogurt.

Visit the Family Physician Nutrition Resource Center on the American Academyof Family Physicians Web site: 1. Visit www.aafp.org2. Click on the AIM link under Clinical Care & Research3. Click on the National Dairy Council’s Family Physician Nutrition Resource Center

Find a Nutrition Professional - Find a registered dietitian in your area with the American Dietetic Association's Nutrition Professional locator service.

Nutrition Education Materials - Download valuable tools and reproducible materials to help your patients establish healthy eating habits and learn about the health benefits of dairy.

Dairy Weight Loss Research - Learn more about the body of research supporting dairy's role in adult weight loss.

3-A-Day of Dairy – Learn more about the 3-A-Day of Dairy health and wellness campaign.

Washington Academy of Family Physicians1050 - 140th Avenue NE, Suite CBellevue, WA 98005

PRSRT STDU.S. Postage

PAIDPERMIT NO. 751

SALEM, OR

Retreat to the extraordinary at Semiahmoo Resort. This seaside hotel features a luxurious spa and the number one and number three rated golf

courses in Washington state; Loomis Trail Golf Club and Semiahmoo Golf & Country Club.

Nestled on the north-ern Puget Sound shoreline in Blaine, Washington, and overlooking Semiahmoo Bay and Drayton Harbor, Semiahmoo offers a mul-titude of resort activities in an exceptional setting.Come for the meeting. Stay for the fun.

The Washington Academyof Family Physicians

DON’T MISS IT!

May 12-13, 2006at the

SEMIAHMOO RESORT

57TH ANNUAL MEETING & SCIENTIFIC ASSEMBLY