Monday Mar 31, 2014

Visit to Army Medical Center Provides Insight Into Military Care

Recently, I had the good fortune to tour Brooke Army Medical Center (BAMC) Fort Sam Houston in San Antonio, and I came away extremely impressed by the great job that the Army does in caring for our soldiers on multiple levels: keeping healthy soldiers healthy, treating the acutely injured and helping the injured recover.

I also was impressed by the many opportunities available for family physicians to serve in military medicine. And it would be hard not to be awed by the largest inpatient medical facility run by the Department of Defense.

I recently toured Brooke Army Medical Center Fort Sam Houston in San Antonio with Col. Karrie Fristoe, commander of the U.S. Army's Medical Recruiting Brigade, and Rebecca Hooper, Ph.D., retired Col., and former assistant director of BAMC's Center for the Intrepid.

But to me, even more impressive was the commitment to improving the overall health of our soldiers and our country. One of our hosts, Lt. Gen. Patricia Horoho, U.S. Army surgeon general, stressed the importance of both the patient-centered medical home and efforts to emphasize health, not just treating illness and injuries. The Army Medicine Performance Triad -- eating well, being active and sleeping well -- are guides for soldiers to lead a better life with more engagement, energy and fulfillment.

The 2.1 million-square-foot, 425-bed San Antonio Military Medical Center has a certified Level 1 Trauma Center that handles more than 5,700 ER visits per month, yet it also offers primary care, pediatrics, OB/Gyn, bone marrow transplants, a cardiac catheterization lab and psychiatric care to service members, their families, veterans and civilians.

BAMC is home to the Army Burn Center, part of the Army Institute of Surgical Research. We were able to see how the Burn Center has the ability to project ICU level burn care anywhere in the world, to bring injured soldiers home in a mobile ICU, and treat them all the way through rehab and recovery.

It also is the site of the Center for the Intrepid (CFI), a world class facility for service members recovering from amputation. Here you can really see the benefit of combining the complete range of state-of-the-art amputee treatment in one facility: prosthetists, psychologists, challenging sports equipment and even virtual reality systems with one aim: bringing wounded warriors back to the highest level of functioning possible. The CFI and their athletes are inspiring, and the facility is far beyond anything offered in the civilian world.

Most family physicians likely know that the Armed Forces Health Professionals Scholarships Program (HPSP) offers full scholarships for medical school, but during my visit, I was struck by the wide number of opportunities available to family physicians practicing in the military. Indeed, by the age of 42 one of my hosts, Lt. Col. Tom Hustead, M.D., family physician and AAFP member, has already served as a clinic director, a flight surgeon, and a department chair in family medicine. In addition, he has been deployed in a military service area.

Hustead said many of the more than 550 Army family physicians, like him, initially joined out of a desire to serve our country, but they remain for the camaraderie and opportunity found in the in Army Medical Corps.

There are nearly 2,000 active AAFP members in our Uniformed Services chapter.

My message today is for them: Thank you for your service.

Jeff Cain, M.D., is Board Chair of the AAFP.

Tuesday Mar 25, 2014

The Truth About E-Cigarettes: Unregulated, Unproven and Unhealthy

Here is a burgeoning twist to the tobacco wars and a new public health risk.

In a new television advertisement, electronic cigarettes are being touted as better than traditional cigarettes because the byproduct is "only vapor," not tobacco smoke. Consumers -- including children -- are being told that e-cigarettes are the “smart alternative” to smoking. The implication is that e-cigarettes are safe for the user and the people around them. The truth is the vapor from e-cigarettes contains carcinogens, including arsenic, benzene and formaldehyde. 

Here I am speaking at a news conference to address Chicago's ban on the use of electronic cigarettes in public places. Family physicians can make a difference in public health issues not only in our exam rooms but also through advocacy.

A preliminary study recently presented at the Society for Research on Nicotine and Tobacco found that second-hand exposure to e-cigarettes can cause harm after the user has left the room or turned off an e-cigarette because nicotine released by the products leaves residue on indoor surfaces.

Tobacco companies have long tried to glamorize their deadly products, and now e-cigarette marketers are doing the same thing, including using high-profile celebrity endorsements.

But the marketers' unsavory tactics don't stop there. Although proponents will argue that e-cigarettes are tobacco cessation devices, the fact is that manufacturers are targeting the next generation of smokers by marketing their products to kids.

If you have doubts, ask yourself how many middle-aged men are reaching for the e-cigarettes that come in cotton candy and bubble gum flavors. Those clearly are intended for kids, and the percentage of middle school and high school students who have tried e-cigarettes doubled from 2011 to 2012.

That's a huge problem because the products aren't regulated, so the amount of nicotine and other chemicals can vary from cartridge to cartridge.

And those touting e-cigarettes as the "smart alternative" to tobacco are ignoring the fact that many consumers are doubling up, using both conventional cigarettes and their electronic counterparts. In fact, a CDC survey found that more than three-fourths of middle school and high school students who use e-cigarettes also smoke. A recent study in JAMA Pediatrics concluded that the use of e-cigarettes "does not discourage, and may encourage, conventional cigarette use among U.S. adolescents."

A recent survey of e-cigarette users found that only 12 percent were former smokers who use the electronic products exclusively. A study in JAMA Internal Medicine found that e-cigarette users did not quit with greater frequency than nonusers. In fact, among smokers who called a quitline, e-cigarette users were less likely to quit than nonusers.

It's also worth noting that poisoning incidents related to e-liquids increased 300 percent in the past year.

So what are we, as a society, going to do to counter a billion-dollar industry that is spending more than $20 million a year to promote an unhealthy product?

The FDA was granted the authority to regulate cigarettes and other tobacco products in 2009, and the agency has been trying to gain similar control of e-cigarettes for years. Meanwhile, children are allowed to buy products that could adversely affect their health for the rest of their lives, and targeted advertising is unregulated.

We have a duty to protect those children and our communities, and if a product looks like a cigarette and contains nicotine like a cigarette, it should be regulated like one. So while we wait for the FDA to act nationally, we can advocate locally.

Here in Chicago, the Illinois AFP supported a city ordinance passed earlier this year that will subject e-cigarettes to the same sales restrictions as tobacco, and it also subjects the products to the city's Clean Indoor Air Act.

New York, Los Angeles and several counties across the nation also have implemented similar laws that ban the use of e-cigarettes in public places. Some states, including Illinois, prohibit the sale of e-cigarettes to minors. Legislation regarding sales restrictions and use in public places is pending in several states.

But legislators aren't the only ones who need to hear from family physicians about this health issue. Our patients are hearing about e-cigarettes from paid endorsers of the products on a regular basis, but what are we telling them?

Parents need to know that children are using these products, and there are numerous possible harms. Patients who are ready to quit smoking should be encouraged to use evidence-based methods that have been proven safe and effective.

Smoking rates for adults and teens are at historic lows. We must ensure that trend isn't reversed by misinformation and questionable marketing practices.

You can read the AAFP policy on e-cigarettes here. And to learn more about how to talk to your patients about e-cigarettes, the Illinois AFP, the AMA and the Chicago Department of Public Health recently offered a free webinar that is archived online

Javette Orgain, M.D., M.P.H., is the Vice Speaker of the AAFP.

Wednesday Jan 15, 2014

Food Security: Take a Lesson From Your Patients

A recent study in Health Affairs found that low-income Californians with diagnosed diabetes were more likely than the state's higher-income residents to be admitted to the hospital for hypoglycemia. The results were particularly striking when evaluated on a week-by-week basis because low-income residents had a 27 percent increased risk of being admitted for hypoglycemia during the last week of the month compared with the first week.

The study's authors suggest a correlation between economics and health. As patients' funds become limited, so did their access to healthy food. The results indicate that those most vulnerable to food insecurity -- defined as limited or uncertain availability of nutritionally adequate and safe food -- may also suffer adverse health outcomes when resources are scarce.

The results are not surprising, and other studies have suggested a link between food insecurity and adverse health outcomes. These studies should remind us of the importance of asking patients about their access to food. It rang clear for me through my interactions with one of my patients, who we'll call Dennis.

Dennis was in his mid-40s and obese. He also had diabetes and hypertension. When I took over his care, his conditions were well-controlled, and he was compliant with his medications. After seeing him for about a year, his hemoglobin A1c rose significantly and his blood pressure became uncontrolled.

He told me that he wasn't eating as well as he knew he should. We reviewed carbohydrate and sodium goals, and he promised to try to eat more salad. I suggested adding insulin, but he said he wasn't ready to take that step.

At his next visit, when we hadn't seen much change in his numbers, I finally asked why things changed so dramatically. It was at this point that he admitted he now was homeless, surviving on food stamps and the good will of others.

His diet consisted almost entirely of eating at fast food restaurants and soup kitchens, he told me. He was still reluctant to use insulin because he feared he would be robbed for the needles. With that knowledge, we were able to strategize how to use his limited food dollars to get the nutrients he needed and how to titrate his medications more appropriately to match his food intake.

For me, it was a wake-up call to ask not only what people are eating, but also how often they are eating. It opened my eyes to the need to ask my patients about their eating habits. I'm sure I'm not the only family physician who has encountered mothers who water down their baby's formula to make it stretch, elderly patients getting by on tea and toast, or parents who go hungry so their kids don't have to.

Patients often are reluctant to admit that they are having a hard time putting food on the table. And the impact of food insecurity on health is vast, including both malnutrition (from lack of nutrient-rich food) and obesity (due to eating cheap, calorie-dense and nutrient-poor food) , as well as all of the complications associated with those problems.

According to the U.S. Department of Agriculture, 14.5 percent of households were food insecure at some point during 2012. As family physicians, the most important thing we can do to help our patients regarding this issue is to ask about their food practices, especially when there is a change in their health status. There are federal, state, and local programs to help individuals who may be food insecure, including the Supplemental Nutrition Assistance Program for adults; the Special Supplemental Nutrition Program for Women, Infants, and Children, better known as WIC; and national school breakfast and lunch programs for children and families.

For my patient Dennis, asking the right questions about his food practices was the key to getting his health back on track.

Kisha Davis, M.D., M.P.H., is the new physician member of the AAFP Board of Directors.

Thursday Aug 29, 2013

Adaptive Sports, Peer Support Give Patients New Perspective

You could feel the discouragement just walking in the exam room door.

Roy sat with his head down and shoulders hunched. His cane was propped against the wall. As the preceptor in clinic, I had been asked by our third-year resident to meet Roy, a 50-year-old patient with diabetes who recently had lost his leg and was having a hard time learning to walk on a new prosthesis.

Readers of this blog may know that I wear two prosthetic legs since an accident long ago, but when I walked in the room Roy didn’t know that. With just a glimpse of my carbon fiber ankles, his eyes flew open wide.

“But how can you be an amputee? You’re the doctor!”

It was just a glance, followed by a few words of encouragement and direction to a couple of resources for amputees, but Roy walked out of the room smiling, his back a little straighter, his perception of living well with amputation altered.

Driving home that night, I couldn’t help but ask myself what was it that had brightened Roy’s day, and what had made it possible for me to successfully walk that same path of uncertainty so many years ago?

For me, three reasons came to mind.

The first images to meet my eyes when I woke up in the ICU after my accident were those of amputees engaged in sports. My best friend had gone online, found photos of people wearing prosthetics while doing crazy, fun things, and posted them throughout my room.

Secondly, as a lifelong skier, every ski season has started with a viewing of one of director Warren Miller’s fabulous ski movies. Warren has always included images of adaptive athletes, kicking it on the mountains, in his movies. These images were planted so deeply in my mind that, on my first night out of the ICU, I sat on the edge of my bed visualizing making my first turns on a snowboard while wearing a prosthesis that I had yet to even see.

It was a gift from the filmmaker that I hadn’t even known I had received.

And lastly, but perhaps most importantly, my family physician and friend Tim Dudley, M.D., made me call the National Sports Center for the Disabled (NSCD) from my hospital room before I went home.

The NSCD is one of the nation’s oldest and largest adaptive sports centers and helps people with disabilities discover joy and freedom beyond their perceived limits of disability. It offers skiing in the winter, as well as summer activities such as bike and horseback riding.

 With help from the NSCD, I rediscovered the mountains and the thrill of skiing. And together, we introduced a new device, the ski bike, to the North American adaptive ski community.

The great thing about skiing for people with disabilities is that a physical activity that may have been limited by muscle strength or discomfort can be overcome by adaptive equipment and the power of gravity. With adaptive skis or a ski bike, people with disabilities find freedom through speed and movement and the joy of keeping pace all day with their family and friends.

Whether it's skiing, horseback riding, kayaking or any other activity, with the NSCD, people with physical challenges can find ways to enjoy the outdoors and lead an active lifestyle. And it isn't just about sports. Recreation is for everyone, and the benefits -- physical, mental, social and spiritual -- are transformative for body and soul.

Adaptive sports programs also helped connect me with others facing challenges. I met and saw peers who are active and drew inspiration from their experience. It broadened my perception of what is possible, not only in sports but in life.

Perhaps most importantly, organizations like the NSCD are also "stealth" peer support programs. Lessons are personal, visual and more powerful than any printed words, website or stories -- even those from a physician or therapist. For people with physical challenges, peer support can replace self-images of disability with images of ability.

What had brightened Roy's day and what had helped me so much was the power of peer support, which helps us understand we are not alone by allowing us to learn from those with the same challenges.

Groups like the NSCD and the Amputee Coalition certainly helped me with the nuts and bolts of dealing with amputation, like how to ride a bike, travel and even how to answer the questions of inquisitive children at the pool. ("Who would ever guess that sharks could live in chlorinated water?")

More importantly, these groups provided me with life lessons on how to live in a different body.

My hope for you as family physicians is that the next time you sit across from a patient who is discouraged with a new diagnosis of a disease or disability, you will find a way to offer him or her hope through adaptive sports and peer mentoring programs. Remember, peer mentoring programs are not just for people with disabilities; they have been proven to improve lives and outcomes for patients with diabetes, arthritis and even cancer.

Need a few starters? The NSCD is based in my home state of Colorado, but there are adaptive sports programs in almost every city and state in the country. Disabled Sports USA has dozens of chapters nationwide and is a great resource to connect people of all abilities with recreation and the outdoors. Most chronic diseases have online support groups and resources, as well.

Recreation and peer support help people become more active, confident and independent.

Your short conversation, invitation or encouragement can make a huge difference.

Just ask Roy.

Jeff Cain, M.D., is President of the AAFP.

Friday Jul 26, 2013

Understanding Patients' Literacy Level is Crucial Step in Care

Fewer than half of U.S. patients have the necessary skills to read and follow drug label instructions, respond to insurance forms, provide a patient history or communicate effectively with a physician, according to the National Institutes of Health

If patients don't understand us, how can we possibly expect them to follow our instructions? This massive shortcoming puts patient safety at risk, jeopardizes our patients' quality of life and adds costs to the health care system. According to the NIH, health literacy -- or lack of it -- costs our nation up to $236 billion a year.

The problem isn't new. More than 20 years ago, researchers at the University of Arizona found that the health care costs of Medicare patients with low levels of health literacy were more than four times higher than those who were health literate. In 1993, a national survey found that up to 22 percent of Americans were unable to read a medicine bottle.

The numbers aren't surprising when you consider that more than 40 percent of the U.S. population speaks something other than English as a first language. But this issue is not limited to immigrants or those with low levels of education. It is pervasive, affecting all ethnic, economic and age groups.

The 2003 National Assessment of Adult Literacy ranked subjects into four categories based on their skill levels: proficient, intermediate, basic and below basic. That study found that only 12 percent of Americans (14 percent of whites, 4 percent of Hispanics and 2 percent of blacks) were considered proficient. Meanwhile, 41 percent of Hispanics, 24 percent of blacks and 9 percent of whites were considered below basic.

Although patients with higher levels of education scored better, only 30 percent of subjects with a bachelor's degree or higher were considered proficient.

So where does that leave us? Do we understand the extent to which people are health literate? Do we speak and write instructions at a level our patients understand?

One easy, critical step to gauge the level of health literacy in our practices is to include the following question on patient history forms: "How far did you go in school?" Then include check boxes so patients can indicate the appropriate grade level. It should be a standard question, and we need to teach our medical students and residents to ask it.

Sadly, students and residents receive little formal training on this important issue. If you work with residents and students, listen to how they speak to patients, and challenge them to speak at a level patients understand. And ask patients, "Do you understand what is being said?"

Teaching back is vitally important, not only for students and residents, but for all health care professionals. At least 40 percent of information patients receive is forgotten soon after an appointment, and roughly half of what they do remember is inaccurate. The brief time it takes to ask a patient to repeat the instructions you have given them can make a huge difference in compliance and outcomes.

We also should educate our staff members who have contact with patients to be aware of patients' education levels. Not only that, we need to ask in what language patients prefer information -- both written and spoken  -- be delivered.

Health education material should be written at a fourth- or fifth-grade level, but it often is prepared at an eighth-grade level. The problem can be even worse when materials are translated into other languages. For example, college-level Spanish isn't helpful to Spanish-speaking patients with a lower education level.

I specifically look for educational materials that address health literacy, and I have even taken the step of making my own handouts when necessary. Keep in mind that pictures and symbols say a lot to patients who aren't literate. Reading isn't the only skill in question. Numbers and measurements are barriers for some patients, who may need extra help from you or your staff.

If you know what issue a patient is being seen for and what their literacy level is, you can give them appropriate materials to read while they wait during their appointment. ( has a number of patient education resources available.) Hopefully, this will help them understand their condition and help them ask questions during their visit.

Patients often don't know what they should ask. The NIH initiative has resources for patients to help them prepare for an office visit and suggests questions they should ask related to a wide variety of conditions, including heart disease, diabetes, weight loss and more.

We might have the best training, the right diagnosis and great bed side manner, but if we don't take the time to understand where our patients are coming from, they might not understand us.

Javette Orgain, M.D., M.P.H., is Vice Speaker of the AAFP.

Wednesday Jul 03, 2013

Child Abuse: We Have a Role to Play

Sometimes, child abuse is painfully obvious. Broken bones, suspicious marks and bruises are things we all are trained to identify, treat and question.

Other times, though, the red flags are more subtle. When the patient is being examined during a well-child visit, what is the interaction like between the parent and child? What is the demeanor of the child? How is he or she doing in school?

Physicians in all 50 states are required to report suspected maltreatment of a child. Reporting one such suspicion once cost my practice more than a dozen patients from one family. My suspicion was determined to be "founded," and the child and family got needed help. Although losing a group of patients is never easy, especially when you are fulfilling a difficult job requirement, it is critical to remember that we have a professional obligation to children and their future well-being. 

According to HHS, roughly 680,000 children were confirmed victims of maltreatment in 2011. Note the emphasis on "confirmed." How many abused children went undetected, unreported and untreated? What role should we play?

The AAFP and the U.S. Preventive Services Task Force recently issued final recommendations stating that current evidence is insufficient to assess the balance of benefits and harms of primary care interventions to prevent maltreatment in asymptomatic children.

Unfortunately, the red flags often aren't easy to see. Most children are asymptomatic. Children heal quickly. Those that have been sexually assaulted usually appear normal during exams.

So what do the new recommendations mean?

Well, they don't mean we should stop evaluating children, thinking about abuse in our differential, asking the tough questions when indicated and doing a thorough exam. A child or teen who starts wetting the bed, who is fighting an eating disorder or who is pregnant may be a victim of forms of abuse. We must do our best to prevent and stop abuse. We must educate ourselves about trauma survivorship and its clinical presentations and advocate for healthy homes and communities for our children.

And it means that more research is needed to tell us what interventions make a difference. Can we change the trajectory of an abused child? I know that I have made a difference by asking questions, even when the abuse was long ago but the scars still linger. Letting a patient know that you will believe -- using active listening and referring for effective counseling, when needed -- can go a long way to helping a patient find the path to true health in the fullest sense of the word.

Sadly, many cases of abuse go unnoticed. That makes it so important that family physicians be aware of the long-lasting effects that childhood abuse can have on our adult patients. Abuse and neglect can haunt people for years after they have stopped, and they can have profound effects on an individual's health.

Every day in a typical family medicine practice, I see these patients, You likely see them as well. Do you know who they are? Do you know how to inquire and what to do with a positive response? Is it your coworkers? Is it you? Do you know which community resources are trauma informed and provide effective help?

The Adverse Childhood Experience (ACE) study, an ongoing collaboration between the CDC and Kaiser Permanente, follows more than 17,000 patients who underwent comprehensive physical examinations and provided detailed information about their childhood experiences. The original research was published in 1998, but more than 60 scientific articles have been published based on the research.

Patients derive their ACE scores by assigning one point to each of the 10 following adverse experiences: abuse (emotional, physical or sexual); neglect (emotional or physical); or dysfunctional household (a household member who had mental illness, substance abuse problems and/or was incarnated; parental separation or divorce; and a mother who was treated violently).

Sixty-four percent of patients experienced at least one adverse experience, 16 percent experienced two, 10 percent experienced three and 12.5 percent experienced four or more.

      Researchers found that as ACE scores (and childhood stress) increase, so do patients' risks for a number of health problems, including

  • adolescent pregnancy,
  • alcohol abuse,
  • chronic obstructive pulmonary disease,
  • depression,
  • early initiation of smoking,
  • early initiation of sexual activity,
  • illicit drug use,
  • intimate partner violence,
  • ischemic heart disease,
  • liver disease,
  • sexually transmitted diseases,
  • suicide attempts and
  • unintended pregnancies.

Researchers estimate these long-term health effects can shorten a person's life by nearly 20 years.

The good news is that we can help. If we know what to look for and ask the right questions, we can help our patients unburden themselves from the old secrets they have kept and help them start to heal.

We've all been exasperated by patients who are noncompliant with their medications and others who don't follow up with our referrals. Why don't they take our advice? Maybe they never learned that they are valuable human beings.

Unfortunately, some patients do not realize that they are worthy of care because of the way others, often those who were supposed to love them, mistreated them in the past. And certain exams and procedures -- going to the dentist, colonoscopy, pelvic and rectal exams, etc. -- can cause people who have been violated and traumatized to relive that trauma.

I've presented ACE at medical conferences, and every time, at least one person from the audience has approached me afterwards and told me that they counted their own ACE score, and they don't know how they made it through. Often, they confide that even their own wife or husband doesn't know what they endured.

Too often, victims of abuse never tell anyone.

Will they talk to us? Are you prepared to listen and respond?

Family physicians can make a difference because we treat entire families. We can build relationships with young parents; steer them to parenting classes; and give them good advice about supporting each other, being resilient and providing a nurturing environment.

And because we take care of both the parents and the children, we also are more likely than our subspecialty colleagues to know when something isn't right. It is our obligation to the child to report abuse and neglect.

We also can make a difference for our adult patients who still are dealing with old scars and current health challenges related to the past.

See the big picture. Educate yourself and advocate for children and families in your community.

Take action when it's needed.

We can help. This is family and community medicine at its finest.

Wanda Filer, M.D., M.B.A., is a member of the AAFP Board of Directors.

Wednesday Jun 12, 2013

Hospice Experience Can be Rewarding

It used to be that when I had a patient whose health was declining and he or she was nearing the end of life, I would direct the patient to hospice care.

Hospice would take responsibility for the patient's care, and I would receive updates by phone. I might go by and see the patient once or twice. Ultimately, I would be notified that the patient had died, and I would call the family to offer my condolences.

That was my standard procedure for more than 20 years.

Life goes on.

Then my own mother was diagnosed with cancer. Her health declined, and she went to hospice. There, I was free to be her son and not another doctor in the room. We listened to the old 1950s music that she loved and reminisced. I will always be grateful that we had those 21 days together.

My mother's physician at the hospice was a general internist who had his own practice but who also worked at the hospice on the side. I was intrigued, and, rather than following the old routine of referring my terminal patients to someone else, I started following them through hospice care myself.

It only makes sense. Family physicians help bring new lives into the world. Then we care for those patients throughout their lives and help them make that life as healthy and productive as possible. At the end of life, we can help them be as comfortable as possible.

The hospice in San Antonio is near the hospital to which I refer my patients, so I make rounds at both facilities. I was at hospice often enough checking on my own patients that, after a few years, I was asked if I would take calls a few times a month. So now I work two weekdays and one weekend a month at hospice in addition to my own practice. And after I take on a hospice patient, I follow him or her through the process.

Hospice can be an uncomfortable topic for physicians, but I've found it incredibly rewarding. The opportunity to build relationships with patients is why many of us chose family medicine in the first place. We build connections over years with our patients. In hospice care, similar bonds can form in a much shorter time.

One of the patients I met at hospice was a 42-year-old single mother. She had terminal throat cancer and could no longer talk. During rounds one day, I asked if she had any pain. She did not look up from her notepad and simply wrote, "No." I asked if I could do anything for her. Again, she wrote, "No."

So I went on and completed my rounds. But when I was done, I went back to her room and sat down by her bed. She wrote that she did not want to talk, but I told her that we should talk anyway.

Then I asked her what she was afraid of.

I looked down at her notepad waiting for a response, but what I saw next were not words but tears dropping on the page.

She was afraid that the cancer would eventually erode a major artery in her throat, and she would drown in her own blood. I assured her that if her condition deteriorated to that point, we would give her medication to make her sleep, and she would not suffer. She asked me to promise, which I did.

She then told me about her adult daughter and her 6-year-old son and that she wanted the daughter to have custody of the boy. The paperwork had not been completed, so I arranged for a social worker to meet with them, and it got done.

At one point, she took my arm and told me, in writing, that two oncologists, two surgeons, an otolaryngologist and two radiologists had seen her during her treatment, but I was the first doctor who had sat down and talked with her.

Well, that's what family physicians do, isn't it?

In 72 hours, she was gone. But after those three days, it seemed like I had known her for years.

That's what the hospice experience can be.

If you think you don't have anything to offer to hospice care, you might be wrong.

Lloyd Van Winkle, a member of the AAFP Board of Directors.

Wednesday May 22, 2013

AAFP Joins CDC Campaign Urging Smokers to 'Talk With Your Doctor'

During a busy day in the office, have you ever stopped to ask yourself which of the myriad of services we provide are the most effective in improving our patients' health? Perhaps it is when we screen for cholesterol, perform a Pap smear, or recommend a mammogram.

All of these are important and proven to be effective in improving our patients' health.  But you might be surprised to know that, according to The American Journal of Preventive Medicinewe are at our most effective when we are talking with our patients about tobacco cessation.

How can that be? On the surface, the success rate for getting patients to quit seems frustratingly low.

Yet, asking every patient about tobacco and giving brief cessation counseling has been proven to double the number of successful quit attempts by our patients. And the disease burden from tobacco use is so high that doubling the quit rate for our patients has a profound effect on their health and has been proven to be one of the most effective things we do in our offices, both for improving health outcomes and for cost effectiveness.

And don't be surprised if more patients begin to ask for help with smoking cessation during the next few months.

Today, the AAFP joined CDC Director Thomas Frieden, M.D., M.P.H., (pictured with me here) and U.S. Surgeon General Regina Benjamin, M.D., M.B.A., in Washington to announce a new component of the agency's "Tips from Former Smokers" campaign that will encourage smokers to "Talk With Your Doctor" about quitting.

Last spring, the CDC ran a three-month, national tobacco education campaign featuring former smokers telling their own powerful stories about the horrors smoking inflicted on their bodies: heart attack, stroke, cancer and more. In late March, the CDC rebooted the campaign with new stories from former smokers suffering from a different array of health problems.

No doubt, you've seen or heard the advertisements that have appeared on television, radio, billboards and buses, as well as in magazines and movie theaters. The tales are grim and hard to forget, but so is the reality of tobacco use. Tobacco remains the No. 1 source of preventable death and disease in our country.

This month, the CDC will begin running new televisions ads to encourage smokers to partner with their physicians. The ads feature the tagline, "You Can Quit. Talk With Your Doctor for Help."

So, are you ready to help?

During last year's campaign, call volume to 1-800-QUIT-NOW more than doubled. Imagine how many more people might be helped with a high-profile reminder that physicians are a great resource for smoking cessation.

Seventy percent of smokers say they want to quit, but only one in 10 will manage to stop on his or her own. And they are in our offices every day. Smoking cessation is one of the most simple, cost-effective interventions we can offer. And that brief conversation can save lives.

If you are looking for resources for your office and for your patients, the Academy can help. The AAFP's Ask and Act program offers dozens of free resources, including a practice manual for treating tobacco dependence, coding information for cessation counseling, a pharmacologic product guide and a Stop Smoking Guide for patients.

The CDC's web page related to this initiative also has free resources for physicians

Talking to our patients about tobacco cessation is one of the most important and proven things we can do for their health. Will you be ready when your patients who smoke ask to "Talk With Their Doctor?"

Jeff Cain, President of the AAFP.

Monday Apr 29, 2013

Lessons for Boston: FPs Can Help Amputees Move Forward

 In the aftermath of the terrorist attack on the Boston Marathon, the media has put a focus on a topic that has been part of my life for nearly two decades -- amputation.

More than a dozen people have had amputations since two bombs went off near the finish line of the April 15 race.

On a day that started with celebration, lives were changed forever. In that instant, young and healthy athletes on the road to celebration (and spectators who were cheering them on) were shocked to now face the long and challenging road to recovery.

I can relate.

Just one week before the airplane accident that eventually claimed both my legs, I remember joyfully riding my bicycle up a sunshine-splashed hill, reveling in what my body could do.

A week later, I was on a ventilator in my own ICU.

In the hospital, the questions began. "Who am I now, and what can I do in this world with this radically changed body?"

Fortunately for me, I had a team there to to help me find the answers.

There were a large number of subspecialists. Trauma, ENT, orthopedic and plastic surgeons were able to save my face, hands and one foot. But it was my family physician, Tim Dudley, M.D., who had the insight and ability to take care of the whole of me.

And of all the members of the health care team that helped put me back together, it was Tim who played the most important role in the weeks, months and years that followed.

In the short term in the hospital, Tim asked important questions about nutrition, rehab and insurance. For a full recovery, it was essential to have a family physician who knew me, would listen to me and would advocate for me. When my insurance company tried to limit the number of physical therapy sessions it would cover for multiple traumas to 10 total home visits, Tim threatened them with a different covered benefit -- six months in a nursing home. The payer listened, and I got my physical therapy, at home.

To this day, Tim writes letters when I need new legs.

Tim, you could say, stands by me. Like all patients, amputees need a physician who will help them see the big picture beyond their immediate loss.

Many well-intentioned coaches and doctors focused on what I would be unable to do with prosthetics. My family, friends and Tim helped me focus on what I could do, even when we had to modify prosthetics or sports equipment.

Yes, amputation is painful, physically and emotionally. Learning to walk again is a hassle.

But re-engaging fully in a life you love makes it worth all the pain and hassle, and that was my message to those injured in the Boston bombing during a recent interview with CNN Radio.

Our job as family physicians is to help patients look forward and find things in their lives that are more important than their pain. By knowing them as people, we can better help them take the steps they need to have a full life after amputation, cancer or any loss.

One year after my accident, I rode up that same hill again on my bike, in the sun. And I marveled at the wonder of what my body, now with prosthetics, could do.

My wish for those wounded in Boston, injured veterans returning from Iraq and Afghanistan, and others facing amputation is for them to be as fortunate as I am to have a family physician like Tim who can help them take the necessary steps and guide them on their path.

And thanks to all of you for what you do for your patients every day.

Jeff Cain, M.D., is President of the AAFP.

Tuesday Apr 09, 2013

Fit Physicians Can Lead by Example

Years ago, I attended an event where tennis legend Arthur Ashe spoke about the need for sustainable exercise -- finding something you enjoy that can be done indoors or outdoors and at any age on a regular basis. His words resonated with me. Teaching people -- including my patients and friends -- the tremendous benefits of regular exercise from an early age has always been important to me.

I have tried many sports in my time, but when my children were old enough, I signed them up for what I hoped would be a sustainable activity. When I told my kids I was enrolling them in taekwondo lessons, their response was, "Only if you do it, too." The usual negotiations ensued.

Fair enough. It's important to be a good role model.

Ten years later, I am a black belt in taekwondo and am working on becoming a second-degree black belt. It is a commitment that takes time each week. I share a weekly lesson with my husband and, typically, on the weekends we practice, train or just "play" together. I also make time to exercise -- even if it's a shorter workout, like a walk with my daughter -- on weekdays.

Our children aren't the only ones who can benefit from a good example. It helps me talk with patients about doing the right thing when I am doing the right thing myself. I tell them that if I can do it, so can they. And sometimes, you have to show them.

About 20 years ago -- before I had children -- I made a standing offer for my patients to walk with me before office hours. I said, "I'm going to be at the office at 6:30 a.m., and whoever wants to join me can. If nobody comes, I'm still doing it."

Some days only a few people came. On others, there were more than a dozen of us. That effort lasted for a few years until my office changed locations.

This wasn't targeted only at patients with diabetes or other chronic conditions. It was for anybody, because everybody should exercise.

Sadly, we know that only one-third of adult patients are advised by their physicians to exercise. We also know that physicians who lead a healthy lifestyle are more likely than those who do not to counsel patients about issues such as diet and exercise.

It is important to me to try to be a good role model. We all have too many patients who are not making good choices, but we can make a difference in their behaviors.

I have a patient who, at age 58, had slightly elevated blood sugar and elevated blood pressure. We discussed nutrition -- including high fiber and the DASH (Dietary Approaches to Stop Hypertension) diet -- and exercise, especially cardio. When the patient came back a month later, she said she was having a hard time finding low-salt and high-fiber foods. Together, we found a website that sold foods that could not be found locally. She joined the Y, started going at least three times a week and quickly lost five pounds.

At a recheck two months later, she still was following the diet and exercise plan and had lost eight more pounds.

Fast forward three years, and she is down more than 30 pounds. Her blood pressure and blood sugar are normal, and she's been able to stop taking medications for those issues. Diet and exercise were the prescription she needed.

The take-away message: We should be telling our patients about the tremendous benefits of a healthy diet and regular exercise.

There are five keys to succeed at losing weight and keeping it off:

  • Eat a high fiber, low-fat diet.
  • Weigh yourself on a regular basis for feedback.
  • Eat breakfast daily.
  • Exercise regularly.
  •  Document everything you put in your mouth so you are mindful of all the calories you are taking in. 

Eating mindfully is essential. I advise my patients to use a calorie counter. If they have an appropriate app on their phone, they can put their food options into the calorie counter before they put the food in their mouth. Seeing the caloric imbalance of poor choices allows people to have second thoughts before an unhealthy selection passes between their lips. Is that large plate of nachos really worth it? Probably not. You would have to spend four hours running on the treadmill nonstop to burn most of those calories.

We have had good success with calorie counters because they educate people about what they're putting in their bodies and about energy balance.

Another tool that works (and it's free for Academy members) is the food and activity journal available through the Americans In Motion -- Healthy Interventions program, which positions fitness -- physical activity, nutrition and emotional well-being -- as  the treatment of choice for the prevention and management of many chronic conditions.

Of course, some patients need more encouragement, and you have to be creative. I have made bets with patients about how much weight they can lose before a birthday or some other significant date. If they reach their goals, I take them out for a healthy lunch.

Now, I have to admit -- I like to win. I have been fortunate to be a volunteer physician for the U.S. Olympic Committee and Team USA, and I have served as a team physician for a local high school for 30 years. But when it comes to helping a patient push him- or herself to a healthier way of life, that is one instance where I don't mind losing.

Rebecca Jaffe, M.D., a member of the AAFP Board of Directors.

Monday Jan 21, 2013

Asking Tough Questions About Abuse Can Save Lives

It was more than 20 years ago, but some patients you never forget.

I was not the primary care physician for this new baby girl, but I was on call when her mother brought her in for a well visit. I had treated the mother, her husband and their other children before during sick visits. They seemed like an average family.

During our last visit, the mother and I talked about typical new baby topics -- car seats, breastfeeding and immunizations. What I didn't know at the time was that this young woman was desperately looking for a way out of an abusive relationship.

I was a new physician, just three years out of residency. Although I asked important questions about the child's health and safety, I didn't know to ask the mother about her own safety. Back then, we didn't know that homicide -- not bleeding, blood clots or infections -- is one of the leading causes of death in women in the first year after childbirth.

Now we know.

That woman wanted to find a better, safer place for herself and her children, but a short time later she was dead. The baby's father killed the mother, their older children and two other family members before a failed attempt to take his own life. The infant survived.

I remember my practice partner -- who was their primary care physician -- crying while dictating notes from their files. She stopped the recorder and said, "This family could have made a difference."

For me, they did.

I wanted to learn more. What could I have done differently? What was the dynamic in that family that led to this horrible act? Could it have been prevented?

The U.S. Preventive Services Task Force has published new recommendations that call on physicians to screen all women of childbearing age for intimate partner violence and to refer them to intervention services, if needed.

It's good advice. We can save lives with the right information. I have seen an extraordinary number of positive outcomes when a physician understands the dynamic of what his or her patient is living with.

One excellent screening tool is RADAR, which prompts physicians to follow these steps in a private setting:

  • Routinely screen female patients;
  • Ask direct questions; 
  •  Document your findings;
  • Assess patient safety; and
  • Respond, review options and refer.

The recommendation to screen all women of childbearing age is a good one. I have heard disclosures about abuse from politicians, judges and colleagues. It's worth noting that men and children also are at risk. Sadly, abuse happens all the time in every community, and you never know who might need help.

A variety of conditions could raise a red flag. If a patient is experiencing things such as anxiety, chronic pain, depression or eating disorders, go upstream. What is causing those problems? Don't be afraid to ask difficult questions when you are alone with the patient, such as

  • Are you safe?
  • What happens when you argue?
  • Are you afraid to go home?

This is something family physicians can, and should, do. And just a few minutes of our time can make an unbelievable impact in the long term.

So what do you do when a patient is willing to confide in you? Telling him or her to "just leave" an abusive relationship is not the answer. Know the resources and shelters in your community. Often, I've taken a patient to a private place in my practice, dialed a shelter for them, started that important first call and then left the room so that the patient could talk in private.

We can help our patients with a better outcome and better quality of life. But we have to be willing to start the conversation.

Wanda Filer, M.D., M.B.A., is a member of the AAFP Board of Directors.

Tuesday Jan 15, 2013

As Flu Reaches Epidemic Proportions, Protect Yourself and Patients

During the past three months, hospitals in my home state of Illinois have admitted 150 patients to intensive care units with influenza-like illness. Six of those patients died. During the same time last year, Illinois had two hospitalizations and no deaths from the flu.

Closer to home in Chicago, six area hospitals were recently on bypassin part because of the spike in influenza illnesses. And, we're not alone. The CDC said Jan. 11 that 47 states are reporting widespread influenza activity, and 24 states were reporting high influenza activity. In Boston, officials have declared a public health emergency after the number of reported influenza cases in the city jumped 10-fold over last season's total.

CDC officials have said this could be the worst flu season in a decade. We already have reached epidemic levels, and we've still got a long way to go.

So, what are we going to do about it? I got my flu shot. Have you got yours?

The CDC's Advisory Committee on Immunization Practices (ACIP) recommends that all health care workers get vaccinated annually against the flu. The AAFP adopted policy two years ago supporting mandatory influenza vaccinations for health care workers. At least 10 other medical organizations have adopted similar policies, and numerous employers -- including mine -- have taken a similar stance.

Still, the CDC estimates that fewer than 65 percent of health care workers are vaccinated against the flu, leaving our patients, colleagues and families at risk.

A hospital in Indiana recently made news when it fired eight employees who refused the vaccine. That state already has reported 21 deaths from influenza this season. So many health care workers -- from front desk staff to nurses and physicians -- come into contact with patients. Those who refuse immunizations are denying the proven safety and efficacy of the vaccine and jeopardizing the health of our most vulnerable patients. 

Low flu vaccination coverage among health care workers has led to outbreaks in hospitals and long-term care facilities. Conversely, health care workers who are immunized help reduce the transmission of influenza and prevent illness and death as well as lost work days among staff.

According to a 2010 AAFP immunization survey, 94 percent of family physicians said they are immunized against the flu each year. Ninety-seven percent of respondents to the 2011 survey said their staffs were routinely immunized against the flu, so we're well on our way to ensuring our patients don't get the flu in our offices.

For those of you who are not vaccinated, however, flu season typically lasts into March, so it's not too late to be vaccinated. You also can help improve vaccination rates in your patients by encouraging them to get immunized and also by dispelling myths -- such as you can't get the flu from the vaccine.

Some of your patients may refuse the vaccine because they are fearful of needles. But the flu vaccine also is available in a painless nasal spray, as well as an intradermal shot with a needle that is 90 percent shorter than those used for intramuscularly administered vaccines. Patients whose insurance offers them a choice should be made aware of those options.

It's not too late for your practice to increase the rate of vaccinations in your community by decreasing barriers to your patients getting vaccine. You can offer extended nurse visit availability or create campaigns -- alone or in partnership with local public health agencies -- that target your patients as well as the most vulnerable in your area.   

If your practice is not providing vaccinations -- or if you have exhausted your supply of vaccine -- make sure you know where to refer patients and staff in your community. There are vaccine shortages in some areas, according to the CDC.

More than 90 percent of the influenza viruses that the CDC have analyzed match the viruses included in the 2012-2013 influenza vaccine. The agency said people who are immunized are 62 percent less likely to need medical care for the flu than those who are not. Although that level of efficacy is less than what we see in many other vaccines, staff and patients should be reminded that the flu vaccine still is the best way to protect themselves and their families. After spending a day with sick patients, don't take the flu home to your loved ones.

Finally, the CDC has a Web page devoted to flu resources for health care providers, including information about diagnostic tests, antiviral recommendations and surveillance. The AAFP also has a Web page devoted to immunization resources.

Protect yourself, your patients and your family. Get immunized.

Ravi Grivois-Shah, M.D., the new physician member of the AAFP Board of Directors.

Monday Nov 12, 2012

Great American Smokeout Offers Another Opportunity to Help Patients Quit

Smoking is the No. 1 cause of preventable death in this country, contributing to more than 440,000 deaths -- or roughly one in five of all deaths in the United States -- each year. So it's no surprise that 70 percent of the nation's 43 million smokers say they would quit -- if they only could.

Millions of smokers try to quit each year, but those who go it alone are likely to fail. In fact, only 5 percent of smokers who attempt to quit on their own are successful.

But we can make a difference by helping our patients quit smoking. In fact, even simple advice increases their chances of being successful in their attempt to quit by 60 percent.

And, this week is the perfect time to brush up on our tobacco cessation skills and talk to our patients about tobacco. The Great American Smokeout is Nov. 15, and the American Cancer Society has an abundance of patient resources available to help people quit.

The AAFP also has an abundance of resources to integrate tobacco cessation efforts into our practices and to help us be successful in the long run, including tips for coding for tobacco cessation counseling, information about group visits, a pharmacologic product guide, quitline referral cards and more. You can find it all in the Ask and Act toolkit. 

Sure, delivering the same message about smoking to the same patients over and over may at times feel frustrating, but the time that we spend on Ask and Act has been proven to be one of the most clinically effective things we do in our offices. Brief tobacco cessation counseling for every smoker in our practices is more cost effective than screening and treating for hypertension, lipid disorders or breast cancer.

Primary prevention is even more important. We can make a difference by talking to kids about tobacco before they start. Most smokers have their first cigarette by ages 12 to 14, are hooked by 16 and have tried unsuccessfully to quit even before they can legally buy tobacco at age 18.  The Academy's Tar Wars program is a great opportunity to bring the tobacco-free message to kids in school.

Jeff Cain, M.D., is President of the AAFP.

Thursday Sep 27, 2012

Step Up to Help Curb Teen Medication Abuse

Today, more than 2,000 U.S. teens will use prescription drugs to get high for the first time. Sadly, for many, it won't be the last time.

One in six teenagers has abused prescription drugs at least once, and more than one-third of all prescription drug abusers in the United States are between the ages of 12 and 17. Many become addicted, and some die. In fact, drug overdoses are the leading cause of accidental deaths in more than a dozen states.

So what can we do about it?

Some practices use a patient prescription agreement, in which the patient agrees to take medication as directed, not share it and dispose of unused meds properly.

In my practice, we've taken things a step further. Patients receiving prescriptions for controlled substances have to sign a contract, which requires them to use specific pharmacies and to submit to random urinalysis. If a patient doesn't cooperate, they don't get the meds.

It may sound harsh, but with the privilege of prescribing comes the responsibility to assess the needs of each patient, the risks and benefits involved and the need to monitor their use. Physicians who abuse that privilege threaten our ability to prescribe for patients with legitimate needs.

For patients who agree to submit labs, their urine samples tell us whether or not they are taking their medication. If their labs indicate they aren't taking the meds, we want to know why not and what happened to that medication. Labs also tell us if patients are mixing the prescribed medication with any other drugs -- legal or illegal.

This isn't a message about limiting access to pain medication. It is about balancing that need for access with the need to reduce abuse. At the same time we are grappling with abuse issues, under treatment of pain is a real problem for many patients. This summer, the AAFP released a position paper that opposes regulations that limit patients' access to physician-prescribed pharmaceuticals.

This week, the Academy supported The Partnership at in its launch of a weeklong public awareness campaign: "Wake Up to Medicine Abuse." The initiative -- part of a multi-year campaign called the Medicine Abuse Project -- urges parents, law enforcement, teachers and health care professionals to take action.

So, again, what can we do? The Partnership's Medicine Abuse Project has resources written specifically for health care professionals, including fact sheets about teen medicine abuse and painkiller overdoses, an FAQ about prescription monitoring, a National Institute on Drug Abuse report, screening tools and links to best practices and guidelines. The site also offers patient education resources, including posters for our practices and a hotline for parents.

You also can check out the AAFP's webpage dedicated to pain management and opioid abuse.

This is a big problem, but family physicians can be a big part of the solution.

  • We can use well-child visits to talk about keeping medications up and away from children's reach.
  • We can educate parents of teens that this is a real problem of which they may not be aware.
  • We can inform patients -- adults and kids -- with legitimate need for these meds not to broadcast the fact that they're taking them because doing so could make those patients a target of people who would misuse those drugs.
  • Lastly, we can direct parents to unused drug disposal sites in our communities.

When you prescribe prescription pain killers for adult patients with children, what advice do you offer them? Please share your thoughts below.

Wanda Filer, M.D., M.B.A., is a member of the AAFP Board of Directors.

Friday Jul 20, 2012

Tobacco Marketers Lie; Tell Kids in Your Community the Truth about Cigarettes

Nearly 4,000 U.S. children will smoke their first cigarette today. Nearly 4,000 more will join them tomorrow. And the sad tale will continue the day after that and the day after that -- unless someone takes action.

Who can stop them?

We can.

Children look up to physicians, and we can make a difference. Tobacco is the No. 1 cause of preventable death in this country, but if we can prevent children from starting to smoke, we can prevent them from suffering the horrible consequences.

I was a resident when I co-founded Tar Wars in 1988 as a local tobacco education program in Denver. That first year, we reached more than 7,000 children in the city. A year later, our tobacco-free message expanded across Colorado. Today, the program -- which has spread to all 50 states and beyond -- has been heard by roughly 8.5 million American kids. The program was presented by physicians and other health care professionals to an estimated 500,000 U.S children last year alone.

But we can do more, and we should.

According to the CDC, nearly 20 percent of U.S. high school students smoke at least one cigarette a month, and more than 5 percent of middle school students smoke. Clearly, we can do better.

Research has shown that Tar Wars is effective in increasing students’ understanding about the short-term consequences of tobacco use, cost of tobacco use, misleading nature of tobacco advertising and peer norms.

Kids might not understand or appreciate that long-term tobacco use can lead to things like lung cancer or emphysema. But we can frame the conversation in a way that will get their attention. For example, smoking a pack a day will cost a person -- depending on taxes in your city and state -- $1,500 to more than $3,000 a year. Little Suzie could buy a lot of friendship bracelets with that kind of dough.

Kids don't like to be lied to, but that's exactly what tobacco marketers do when they portray cigarettes as fun, sexy or cool. Tell the children in your community the truth about tobacco. Is there anything sexy about yellow teeth? How about bad breath and a hacking cough?

My inspiration for starting Tar Wars came after hearing a speaker at the AAFP's National Conference of Family Medicine Residents and Medical Students talk about the lies that marketers tell children about cigarettes. I had a patient who was dying of lung cancer at the time, and when that speech was over I was angry.

When I think about it, I still am.

How many patients have you seen suffer the effects of tobacco use? How many people have you seen reduced to toting around an oxygen tank?

More than 400,000 Americans will die this year because of tobacco-related illnesses.

Are YOU angry yet?

What are you going to do about it?

For those of you who already present Tar Wars in your local schools, thank you. For those of you who haven't yet been presenters, here's what you need to know: It's easy. A classroom presentation takes about an hour, and Tar Wars provides you with all the resources you'll need. The program will be celebrating its 25th year in the upcoming school year, and updates are being planned that will make Tar Wars even better.

Physicians who have participated tell me that the first time they presented they did it for the kids. The second time, however, they did it because they enjoyed it so much the first time. It reenergizes you.

Tar Wars isn't just for practicing docs. It's a great, ready-made program for residencies and family medicine interest groups, too.

To get involved, contact your state's Tar Wars coordinator or contact the AAFP's Tar Wars staff.

On a lighter note, every year, the Tar Wars poster and video contest concludes at the Tar Wars National Conference in Washington, D.C. This week, 34 state poster and video contest winners attended the conference, and many of them also were able to visit Capitol Hill and meet with their elected officials.

Our first poster contest winner, back in 1988, was impressed by an exhibit we brought to her classroom that showed the difference between healthy lungs and lungs damaged by smoking. That young girl, Kelly McMullen, M.D., went on to become a family physician who now counsels her own patients about smoking.

School will be starting before you know it. Whose life will you influence?

Jeffrey Cain, M.D.of Denver, is president-elect of the AAFP.

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