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John G. Bartlett, MD Well, I'm John Bartlett, and my charge is to discuss mobilizing professional communities. I want to thank the organizing committee for inviting me to participate. I'm a member of that committee.
(Laughter.)
There's 600,000 doctors in the United States. I'm going to talk mostly about doctors because that's the community that I know the most about, but I would not for a moment deny the equal importance of nurses, paramedical personnel, and the other people in the health care team.
But I've talked to a lot of physicians in various parts of medicine, and I would have to say that, to be brief, they all are aware of bioterrorism. The great majority understand that it's an important issue. A limited number think that it's an issue for them, and almost none know about local plans or have participated in local plans for preparedness.
And so my first slide here summarizes this question. Why do physicians reject participation in what everyone here is gathered to talk about?
Managed care is one of the major issues, and we've heard a bit about that already in terms of what it means, but I've talked to a few people that work in managed care groups, which is now a major portion of the physician work force, and what they get is 15 minutes a patient for seven and a half hours a day for five days a week with a schedule that's made three months in advance. That's 30 patients a day, 150 patients a week. If they miss an hour, they have to make it up. Our meeting today is on Tuesday. That's my clinic day. I have to make up nine units at some point.
The second issue is it's a low probability event, and I think everybody knows what that means. So for the physician in Cincinnati, bioterrorism is important because it will probably occur someplace in the United States, but the probability that it will occur in Cincinnati is regarded as very low. I don't mean to pick on Cincinnati. I'm from Baltimore. So you have to be careful.
They tell me they're not trained to do this. They're not paid to do this, and they're not required to do it, and the reason they're not required to do it is because it's not been made a mandate or a high priority by people in authoritative positions within medicine. And Jim Bentley and Ken Bloem have already talked about that issue.
There's also an information avalanche. That's an awful lot for doctors to try to consume. I personally take 40 journals, but I only try to keep up with infectious disease. It just is an awful lot of information.
Physicians in general, at the bottom I've noted two idiosyncracies of physicians. One is they tend to be fiercely independent, and people that deal with physicians probably know exactly what I mean by that. Sometimes they're compared to teenagers. The only way to can get them to do something is to tell them not to do it.
(Laughter.)
And then they would do it, and they tend to prioritize the individual patient because that's what they do. That's how they spend their life. They don't tend to think of patients as populations. They've never done that, and it's unlikely that they would be easily persuaded to think in those terms.
Now, I wanted to go on to say something about where they fit. We've already heard about this. So I don't need to belabor the points,b ut I thought the West Nile virus epidemic was important instruction in a couple of places.
First of all, Dr. Asmis was the alert physician who called attention to this on the basis of two unexplained cases of weakness and cerebral spinal fluid, pleocytosis, and called Marcie Layton who implemented the program for detection that you've all heard about that eventually uncovered an epidemic.
Now, it turns out that this is perhaps an -- I don't mean to imply at all that this had anything to do with bioterrorism, but it's perhaps instructive in terms of the way it played out.
Where do you want the physicians to be participants in this? Well, in this scenario they were critical in the detection, and they would have been critical or were critical for managing the cases. This was aberrant because there was no treatment, no prophylaxis, and no patient-to-patient transmission. So some of the challenges that we know about for the health care system and the management would not apply here. So this is a marriage between public health and the practicing community in which there are distinctive roles, but critical interaction that is absolutely mandatory to make it work.
So what is the role of the physician in practice? First of all would be the recognition of the case, either as a single case or as a cluster, and I'll talk more about that in a minute.
The second is in policy making, but they bring their expertise in the terms of medical management, and then for medical practice, it will be medical care for the patients who are sick and then the distribution of any sort of prophylaxis.
And finally is sort of the issues dealing with the legal and ethical component of this and the credibility of physicians. By and large, I think the American public hates doctors, but they like their own doctor. Well, it's true. The lawyers always tell me medical people hate layers until they need one, and then they like them.
In terms of how to engage physicians to be better participants, I've suggested these things. First of all, they will continue to think that this is an issue for someplace else. It's a low probability event for wherever they are, and most of them will be right.
However, whatever we learn about bioterrorism can also be applied to influenza and the movie we saw as a great example of how that could play out. West Nile virus is an example. E. coli 157, a variety of different type of epidemics in a system that has almost no surge capacity that you've talked about.
Credibility. Physicians, by and large, listen to peers, and they have that attachment to a peer system that is probably unprecedented in professions. So Sid Feingold says this is how you treat an enterobic infection. You just do it. You don't ask questions. If D.A. Henderson says this is how we should respond, we tend to line up and say, "What do we do next?"
There are some people who have that kind of established reputation in medicine, and I'm not sure what gains it. Lily Weinstein had it. I've given you a couple of other examples of it, but by and large it's reputations that have been hard earned, but very deserved.
Physicians tend to listen to their professional societies. They have an attachment to their society. It's viewed as their peers, and they will pay attention, and they will also pay attention to organizations for which they have enormous respect in the CDC and several other organizations would be in that classification.
Physicians don't like to go to committee meetings. They don't like to be on committees. When I took charge of my division I said we would have committee meetings when people wanted them, but they always had to be before six o'clock in the morning or after six at night or on a weekend.
(Laughter.)
And people always found ways that they could get their work done without having meetings. This has to be a group that is dealt with with extraordinary efficiency, and in terms of what is efficient, I think perhaps the development that is most prominent is the point of care decision tools that give physicians information at the bedside. It's information within one or two minutes. It will be with some hand-held device. It will be like a Palm Pilot or a CE or something like that. It's likely to be in general use within a year.
In terms of rewards, you can either reward the physician or you can penalize the physician. To reward the physician, you could put it on the boards. People study for the boards. Whatever is on the boards they're going to learn.
You could pay, and what I mean by pay, I don't necessarily mean monetary. It could be paid in time, pay in job description, but by and large, as we have heard, this is a part of the puzzle that at this moment is unfunded. There is no source or resources that I'm aware of to do this.
And the penalty would be JCAHO and the mandate to do this, which will always get the attention.
Now, if we had a Palm Pilot program, something that's right in the physician's hand at the time that he sees 30 patients a day, what could we put on it that would say, "Think bioterrorism. Call this number"? Well, I worked on this list. I worked from several other lists and came up with what's on the slide. We have a lot of patients who die with pneumonia. It's about 40,000 a year, but I have to say I never, never see a young previously healthy adult die of pneumonia in the year 2000. It doesn't happen. So if that did happen, I would be very worried. Summer flu is self-explanatory.
Critical illness. What could take a member of this audience who's basically health from being healthy to moribund or critically ill in a period of a day or a few days? Toxic shock syndrome, Neisseria meningitides, meningitis or bacteremia, Rocky Mountain spotted fever. The list is short. By and large, healthy people do not get critically ill fast.
The wide media stinum, of course, specifically suggests inhalation anthrax. The rash of smallpox can only be confused with chicken pox. There's no primary dermalogic disease that looks like that. Viral hemorrhagic fever does not occur in this country. Dick Johnson tells me that the only thing that might be mistaken would be a return of dengue if it happened, but the capillary leak syndrome should alert us all.
Or you could have a laboratory diagnosis, not a clinical diagnosis, but inhalation anthrax never occurs; smallpox never occurs; glanders never occurs. It just does not occur. If it ever occurred, then it should call attention to this as a possibility.
The hemorrhagic fever I talk about, and non-endemic tularemia or plague, and I've covered most of the Class A organisms and a chunk of Class B as well, and those are individual cases, and then, of course, is the more obvious, which are the clusters that are unusual, severe or unexplained.
So that's what I would put on the hand-held device in order to have physicians better participants in that early part of the equation.
Now, in terms of the societies, I mentioned that physicians by and large entrust their societies and participate in their activities. The Infectious Disease Society of America has 6,000 members, and about 3,000 of those are practicing physicians, and as an example of what they have done in the area of bioterrorism, there is a committee called the emerging infection committee that's headed by Mike Hauster, whom we all know. The co-chair of that committee and the head of the subcommittee on bioterrorism is D.A. Henderson. They've written a draft of a white paper which expresses outrage to our colleagues in other places who participate in waging war with microbes.
There's an EIN at work that I'll talk about. They're developing educational materials in concert with the CDC, SHEA, state health departments, and so forth.
There is a CID which is clinical infectious disease. The society journal, which has a section devoted to bioterrorism. It's presented at annual meetings. It's included in guidelines when it's appropriate, and they have a major role in this conference.
So in terms of a couple of things that I just mentioned, this is the second here, but I also wanted to mention the fact that there's a couple of other relevant people here. For the section on biologic weapons, it's Dr. Henderson, Dr. Inglesby, and Dr. O'Toole, and then you can see Mike Osterholm and Larry Strausbaugh, as well, who I'll talk about momentarily.
Here's our guidelines on community acquired pneumonia. There are 300,000 copies of this that were sent out by request. So it's gotten a wide distribution, and we think in order to do this right you've got to be in people's face. So in all of our guidelines where it's appropriate, there is something dealing with bioterrorism if it 's relevant to the topic.
And then this is a portion of the program in 1999, a workshop for practicing physicians on bioterrorism, who's headed by David Relman, who is the chairman of the program.
The Infectious Disease Society also has an emerging infection network that's headed by Larry Strausbaugh, which is a field force. It's 900 physicians trained in ID in all parts of the United States who have received information regarding what to look for, who to call, and what to do. They're funded by the CDC in a cooperative agreement. They're in their fourth year, and they exchange information by fax and Internet, and they're wired now to bioterrorism, and it's a field force, if you will, and in some ways it's quite unique.
Now, I should also mention that SHEA also has a bioterrorism plan. They have some of the similar underpinnings, as does the American College of Emergency physicians who have written a paper dealing with specific recommendations for the health care profession relevant to that group.
And finally I should mention the Center for Bioterrorism, which represents a network that communicates extensively with physicians, as well as others, and their activities include a quarterly newsletter, which can be received free by anybody that requests it. They have a Web site. They have a number of publications in good journals, as well as white papers dealing with methods to manage anthrax, smallpox, plague, botulism. Tularemia is about to come, and then they have the reviews that are mentioned in a variety of journals that really reach a wide readership.
There are 250 to 300 lectures a year. They've arranged a number of conferences, including this one.
In terms of their Web site, the activity is shown here. I'm not sure that either the people at the center are aware of these numbers. They get about 1.5 million hits so far this year. That's a very deceptive number because it doesn't mean very much.
The visitors session is 67,000; unique visitors is 23,000. The average is 162 a day, and the average visitor session is incredibly long for a Web site and averages 30 minutes. That's about twice what it is with any of our other Web sites.
And finally, where do we stand with regard to the issue of the test? Well, I call Harry Kimball, who's President of the American Board, and, you know, the American Board of International Medicine exams are like a military secret. I mean they're not going to say anything. So he gave me this statement.
(Laughter.)
The ABIM recognizes the increasing importance of bioterrorism. But actually that may say a lot more than what you think it says.
So those are my ideas about how to reach the physician audience. Let me just mention what I think are the most important summary points. This is an area that as far as I know is almost completely unfunded. We heard before 0.0046 percent of something, and this is probably lower than that in terms of the total allocation at least as far as I know. Most of what I've shown has been stuff that people have done with their own resources and their own energy in time that's fairly precious, and it represents the effort of the American Board, the medical societies, the center that's sponsoring the conference and a lot of volunteer efforts by a lot of different people.
In terms of education, I think we really need to continue to be in the face of physicians so that they are aware of this, even though they may not chew and digest it, and that's probably best done through the medical journals, speeches, and then we probably have to have this now incorporated as some part of a medical school curriculum. Quite frankly, I don't know anybody that's really done that.
There may be the necessity of using a carrot or a stick. The carrot, of course, would be pay or some other reward. The stick would be to have it as part of the JCAHO requirements, but there may be something necessary in order to get the participation that I've talked about.
The societies that I've talked to are doing a pretty good job of making sure their members are hearing about this and have access to the right information. Some are moving faster than others, but all of the relevant societies seem to be doing something.
And finally, in terms of how to recognize and respond to problems, my own view is that trying to teach physicians through journals and speeches and so forth in this area the way it's currently being managed is going to be very difficult without resources to do it, and the only way I can think of to do it that will probably make any sort of impact is to have it in the point of care device where the recommendations are given with quite great clarity, with some specific recommendations about what to do.
That completes my remarks. Thanks.
(Applause.)
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