In the very early days of Annals of Family Medicine, we hosted an "Annals Forum" for discussion. In 2005 the forum was folded into what is now the eLetters section of the website. These early conversations are archived below.

11 August 2003

AAFP National Conference-Future of Family Medicine

Bruce Bagley,

Family Physician

Albany Medical College

Bagleymd@aol.com

The following list of ideas was gathered at the National conference for family practice residents and students. These are their ideas about what they would like the future to be like. We would like this to be a catalyst for a discussion about what you would like for the future of our discipline and the everyday practice of family medicine.

Students and residents were asked to summarize how they felt when they really made a difference or really connected with a patient. Then they were asked to envision the future. Finally they were asked how we might get from here to there.

I am sure you will enjoy their comments and look forward to your discussion.

Bruce Bagley, MD Past president of AAFP

High Point Experience: Excitement, reassurance, rich, endearing, connecting, engaged, confidence, fulfilling, spiritual, gratifying, inspiring, helpful, competent, belonging, privilege, strong, sacred

Practice of the Future: Treat the entire family / All I want to do is treat my patients without interference / Serve / Do the things I was trained to do / Learn more every day / Give patients the time they need / Empowering patients / Prevention - integrate public health & individual care / Group sessions / Urban, rural / Continuity of care regardless of social situation / Prescriptions provided / Pictures from patients / Community-oriented / Practice as a community and family / Stories / Unencumbered, hands-on / Team practice - multidisciplinary / Modeling health behaviors / Personalized health care / Integrated in the community / Better integrated electronic health record (net, ebm) / Warm, friendly for people and environment / Whole person focus / Medical home / Office as a safe place for building a healthy community / Seat for change and family integration / Team that heals the social and medical aspects / Patient-focused, efficient, networked to other resources / Education, specialty care, etc. / Commons room for all involved in promoting health / Big hug

Getting There: Idea sharing / Shared dream / Personal commitment / Engage communities and patients / Stand for our ideals / Prove the worth of fp and get the word out (FFM, etc) / Gain respect of our colleagues and patients / Pursue Quality / Lead the way in quality, innovation, research / Change reimbursement / Little steps based on important priorities

Competing interests: None declared

17 December 2003

THE BANFF DECLARATION AND THE INFORMATION NEEDS OF PRIMARY CARE AND FAMILY MEDICINE IN THE USA

Inge M Okkes,

Amsterdam, The Netherlands

senior researcher, Academic Medical Center/University of Amsterdam,

Henk Lamberts, Maurice Wood, Larry A. Green

Email Inge M Okkes, et al. i.m.okkes@amc.uva.nl

INTRODUCTION: BACKGROUND OF THE BANFF DECLARATION

The HIPAA Legislation requires the National Committee on Vital and Health Statistics (NCHVS) to make recommendations to the Secretary of Health and Human Services on standards for Patient Medical Record Information (PMRI). In early 2003, NCHVS invited terminology developers to complete a questionnaire stating why their system should become a national standard. HIPAA standards would profoundly limit primary care and family medicine research if they do not take into account their essential information requirements for research and practice.

Accordingly, the Robert Graham Center (RGC) in Washington, D.C., and the Family Practice Department of the University of Amsterdam responded to this questionnaire by documenting the importance of data standards for primary care, and why the International Classification of Primary Care (ICPC) with its mapping to ICD-10(-CM) is the best available tool for capturing, structuring, and retrieving reason for encounter and diagnostic data from primary care and family medicine.

Subsequently, SNOMED(-CT) was adopted as the standard vocabulary for U.S. health information and statistical systems. In the statement announcing this decision, the Institute of Medicine (IOM) was asked to define the requirements for Electronic Health Records (EHRs). This Letter Report, addressed to the Director of the Agency for Healthcare Research and Quality (AHRQ), was recently published (see list of recommended reading below). Since SNOMED's diagnostic categories are mapped to ICD-10( -CM) and ICPC, it should be possible to develop a strategy to enhance primary care and family medicine research, especially if EHRs include an episode of care structure.

The development of such a strategy was the main purpose of a workshop held at the North American Primary Care Working group (NAPCRG) Annual Meeting October 25-28, 2003 in Banff, Canada, with participants or contributions from the Agency for Health Care Research and Quality (AHRQ), the National Center for Health Statistics (NCHS), the National Library of Medicine (NLM), the Subcommittee on Standards and Security of the NCVHS, the AAFP, the NAPCRG Special Interest Group on ICPC, the Wonca International Classification Committee (WICC), the IOM, and SNOMED-CT.

On October 28, 2003, the Board of Directors of NAPCRG, an organization long committed to enabling primary care research and primary care classification, unanimously endorsed the "Banff Declaration" (see below). This Declaration calls for standards and conventions that enable the concerns of patients to be identified and routinely collected in frontline primary care practice and move health services towards patient centered care in a continuous healing relationship. Also, the result of using a coding scheme not primarily aimed at billing, but rather at understanding primary care might result in the availability of more accurate primary care and family medicine data.

The publication of the Declaration in the Open Forum of Annals is designed to increase awareness of the importance of relevant classification and taxonomy in primary care and permit further international dialogue about needs and promising opportunities in primary care.

THE BANFF DECLARATION

At the Special NAPCRG Preconference Meeting Patient Medical Record Information Standards Under HIPAA: How to Deal With a Potential Threat to Family Medicine Research, convened by Okkes IM(1), Lamberts H(1), Wood M(2), and Green LA(3), and held October 25th, in Banff, Alberta, Canada, the participants formulated the following Conclusions and Recommendations

CONCLUSIONS

1. The United States is about to establish standards that will determine information processes that the entire health care enterprise will use for years to come. The data standards needed for primary care have not yet been sufficiently addressed, but now can be, to the benefit of millions of people. Indeed, the single largest setting of health care delivery is the physician's office (not the hospital), and a majority of the visits people make to physicians in the United States are made to primary care physicians, specifically family physicians, general pediatricians, and general internists. Thus, the work of primary care physicians in their offices is a large, dominant portion of health care delivery, and their offices are the place where many people bring their troubles for sorting and response.

2. A classification relevant to primary care is necessary in the United Sates. It should be logically organized to (1) reflect the concerns of patients (not the immediate assumptions or beliefs of their doctors), (2) characterize episodes of care, (3) be easy to routinely use, (4) be inexpensive, (5) be honest (not requiring premature closure or misclassification), (6) be relevant to any primary care setting, (7) be expandable, (8) be connected to existing coding and other classification approaches, (9) be readily deployed in the evolving electronic health record, and (10) be sanctioned by the US government and other insurers. The International Classification of Primary Care (ICPC) with its linkage to ICD-10 to be used as a nomenclature, which is sanctioned by World Health Organization and included in the US National Library of Medicine's Unified Medical Language System (UMLS), is the only existing classification scheme that meets these standards.

3. When primary care data standards are established and fully incorporated into routine, front line practice, important policy objectives will be enabled. These include (a) operationalizing patient centered care and care based on a continuous relationship, (b) enhancing quality of care, (c) controlling costs (or: reducing waste), and (d) responding to the threat of bioterrorism. Examples of how appropriate taxonomy and data standards in primary care will benefit the nation include: (a) new knowledge about the earliest manifestations of diseases as experienced and expressed by people, (b) use of routinely collected data to identify potential threats of bioterrorism, and (c) quantitative estimates of the probabilities that various patient symptoms and concerns transition into particular diseases.

4. Primary care physicians in the United States have an immediate need for a simple and honest way to routinely record and retrieve data reflecting their perspective. The primary care perspective must be incorporated into the nation's data standards and electronic health records. Clinical research and a fully integrated health information system cannot be sustained without practical, easily used primary care data standards.

RECOMMENDATIONS

1. We recommend that the US Secretary of Health and Human Services immediately incorporate data standards for the routine documentation of the essential content of primary care.

2. These standards should include: (a) the simultaneous recording of both the patient's perspective represented by reasons for encounter, and the primary care provider's clinical perspective, and (b) the requirement that primary care data should be ordered in an episode of care structure.

3. The International Classification of Primary Care (ICPC-2-E, with its linkage to ICD-10 as an underlying nomenclature) should be accepted and used as the initial basis for classification in US primary care settings.

4. In order to facilitate linkage between ICPC-2-E and reference terminologies we recommend that primary care representatives be appointed to NCVHS and the SNOMED Editorial Board.

(1) Project leaders, Amsterdam University Transition Project, Amsterdam, The Netherlands (2) Emeritus, Virginia Commonwealth University, Richmond, Virginia, USA (3) Director, The Robert Graham Center, Washington DC, USA

24 December 2003

Congratulations

Jean K Soler,

Attard, Malta

Family Doctor

jksoler@synapse.net.mt

I would like to congratulate the NAPCRG and the AAFP on their acceptance of the recommendation by the Robert Graham Center and the Family Practice Department of the University of Amsterdam, and the latter on their successful promotion of the International Classification of Primary Care (ICPC) with its mapping to ICD-10(-CM) as the best available tool for capturing, structuring, and retrieving reason for encounter and diagnostic data from primary care and family medicine.

As a member of the World Organisation of Family Doctors International Classification Committee (WICC) and the project leader of a research project which was amongst the first worldwide to use ICPC-2 Electronic (ICPC-2-E) in electronic patient records, I cannot but agree with the conclusions and recommendations of the Banff Declaration.

In fact, data collected using ICPC has and will be used in Malta to collect reference data from Family Medicine encounters, and to inform research and educational projects both locally and internationally.

I am confident that our American colleagues will share the positive experiences clinicians and researchers have had with ICPC.

Again, congratulations!

Jean Karl Soler Family Doctor Malta

Competing interests: None declared

26 December 2003

ICPC - not perfect, but our best option for data retrieval

Michael S. Klinkman,

Ann Arbor, Michigan, USA

family physician, University of Michigan Department of Family Medicine

mklinkma@med.umich.edu

As a family physician with dual responsibilities - research and health system design - in our academic health center, I have been working with real-world information systems for several years. I've also been using ICPC in one form or another for roughly a decade, often at additional cost to our clinical practices, often at odds with senior health system leaders. Why have I spent so much effort on this classification? To me, the answer seems clear: the central concepts behind ICPC are sound and offer a more complete look at the routine process (or work) of primary care clinicians than any of our current alternatives. We have demonstrated repeatedly to our local health system leadership that our diagnostic data is more accurate,usable, and retrievable than standard health system data. We have created disease registries that are self-maintaining and used to drive clinician prompts and remiders that improve our performance on recommended disease-specific care. Our success is only now beginning to influence our health system's IT development. The main hurdle we've had to overcome locally is to take what is a simple classification and make it sufficiently granular to be useful in an electronic patient-specific problem list; we have accomplished this using ENCODE, a controlled clinical vocabulary. The Banff Declaration advocates an approach to creating a standard data model for primary care that is similar to what we have done in our center, extending ICPC by linking it to the most granular vocabulary available, SNOMED-CT - which has just become the de facto standard for EPRs/EMRs in the US. This is the right time and the right place to push for the adoption of this data model. It is incredibly important for our discipline to support this effort NOW, and I will do anything I can to help this happen. Where are the leaders in our discipline? When can we expect them to step forward? Mike Klinkman

Competing interests: None declared

29 December 2003

Banff Declaration

Kerr L. White,

Charlottesville, Virginia, USA

klw2j@cms.mail.virginia.edu

First, I wish to congratulate and commend all those who participated in this important conclave. Endorsement, at last, by NAPCRG of the International Classification of Primary Care is long overdue. But this is only the first step. What is required is formal endorsement by bodies such as the AAFP, the Teachers of Family Medicine, the Family Medicine Department Heads, etc., the American College of Physicians and the American Academy of Pediatrics. Many European and other academic and professional organizations have long ago endorsed and adopted ICPC. It has been evolving for over 25 years.

How can we possibly argue the case for the importance of primary care information for everything from bioterrrorism to fundamental healthcare cost control wihout extensive information about the nature of the symptoms, complaints, questions, and problems brought to sources of primary care and their resolution in the course of episodes of care? How can we detect and learn to modify systems, behavior, technology, and knowledge at the primary care level without widespread, if not universal, information about what goes on in what is by the far largest component of all health care enterprises? How can we possibly conduct research into the origins and natural history of illness, disease, care, and resolution without a dedicated information system? And how can we modify performance in the interests of safety, effectiveness, and compliance without an appropriate labelling and classification system?

Competing interests: None declared

30 December 2003

ICPC in the US

Lloyd Michener,

Durham, North Carolina, United States

Chair, Dept of Comm & Family Medicine

miche001@hotmail.com

I've been connected with ICPC for about a decade now, and have been repeatedly struck at how our colleagues in other countries are able to easily track their patients, and their reasons for visit, using ICPC. Even more, they can look at patterns of illness in their community, and investigate and intervene in outbreaks of illness, and with increases in chronic illness, in ways that are beyond the imaginations of those of us who grew up in the US systems. As digital medical records slowly roll out across the US, we have the opportunity - now - to gain these powerful tools to help out patients. But it will take the concerted efforts of the AAFP, with support of NAPCRG and WONCA, to make this happen.

It was Gayle Stephens who said, more than 20 years ago:

"Other clinicians have told us their stories about patient's problems, but we have not told our stories to ourselves. Our perspective is different, our temporal relationships are different, and our means of expression are bound to be different. We will never be able to analyze our experiences until we attempt to record and tell them as completely and honestly as possible."

ICPC is our best tool for recording the stories of our patients. Let's use it.

Competing interests: None declared

30 December 2003

Important step in Primary Health Care

Marc R. Verbeke, MD

marc.verbeke@Ugent.be

The Banff declaration is a very good and important step for primary health care. It has to be applauded by all primary care physicians. As a general practitioner I'm using ICPC in EMR since about 15 years. I can assure you that this classification is a very powerful, user friendly and simple tool in organizing the EMR. It's not only the best classification for reason for encounter (RFE) or diagnosis in primary care (both very important in retrieving data for research in primary care) but it's the only classification that reflects so good the process of everything that has been done and thought by the GP in taking care of the patient.

The use of episode of care (or Health Care Element) structure, with three kinds of data (RFE, Process and Diagnosis / evaluation) is the best way of organizing the data in an EMR system. The use of process codes gives extra power to the individual user by organizing links to (classifications used by) different expert systems, other primary health care providers, specialists, laboratories, imaging, and organizing lots of possibilities in the use of internet. I am convinced it improves the quality of primary health care and the well being of the provider. Congratulations with the declaration.

Competing interests: None declared

14 January 2004

ICPC - a classification for all primary care doctors!

Niels Bentzen,

Trondheim, Norway

Professor, Chair WICC

niels.bentzen@medisin.ntnu.no

The endorsement, by the WHO Collaborating Centres on International Classifications, of ICPC as a member of the WHO Family of International Classifications (WHO-FIC) and the Bannff Declaration are major accomplishments in year 2003.

This should give us a possibility to see that ICPC is used in many primary care settings throughout the World, to the benefit of the practitioner and his/hers patients.

It will also benefit societies at large. With ICPC they can get new knowledge about the health seeking behaviour of their populations and information about the diagnostic "landscape", in which the primary care doctors are working. This is important knowledge in planning health care in any country, and this can only be obtained with a simple health information registration instrument, which is reliable and practical to use. ICPC is such an instrument.

In the comming years, it will be important for us to get in fruitful discussions with colleagues around the world, who want to be able to describe their work in primary care/family practice through data collection by family doctors, retrieval and use of these data nationally and internationally. ICPC will continue to be developed to meet the needs of the future, and this development will take place in close co-operation with other groups, who also try to develop comprehensive health registration systems.

As Chair of Wonca International Classification Committee (WICC), professor of General Practice and general practitioner, who uses ICPC in my clinical work, I welcome this development and look forward to being part of the continuation.

I want to thank all colleagues, who have worked so hard on these achievements, and to say: "Keep on going" - the work has just started!

Competing interests: None declared

7 January 2004

Leading ICPC adoption

Robert W. Hungate,

Wellesley, MA, US

Health-seeker, Physician Patient Partnerships for Health

hungater@comcast.net

This comment is a result of a chain of communication which started with my appointment as a member of NCVHS a little more than a year ago. I have ended up chairing the Quality Workgroup of the NCVHS. Kerr White sent a letter to NCVHS about ICPC. It sounded sensible to me and I responded. He and I have engaged in e-mail dialog around chaos theory, ICPC, health system change. I personally have found the dialog very rewarding. In the process of dialog the discussion was broadened around ICPC and others very involved in it's use and advocacy. In that discussion I penned a short opinion piece which Inge Okkes encouraged me to add to this discussion. I said:

With all your indulgence, perhaps you'll grant to listen to my musings. My guess is I come from different space than each of you - I'm a product of my experience, as each of you, but it is vastly different experience. I will use trite expressions in the interest of brevity, hopefully without too much sacrifice in clarity of thought. My experience has led me to two critical conclusions, which become assumptions underpinning my actions. First we do "manage what we measure", Second, Sir Winston was right " we can be counted on to do the right thing, after we have tried everything else."

How do these apply to this subject? As to the first what our society needs to "manage" is the process of achieving health for health-seekers, which I believe is fundamentally achieved best at the level of interaction with classically, a primary care physician, but is sometimes vested in another place. I use a shorthand of Physician Patient Partnership for bounding this activity which has no measurement system equivalent to that enjoyed in other fields of enterprise.

As to the second our progress, improvement, will come from applying chaos management, not hierarchical management. Enabling the physician/patient dyad to achieve the best health result will be a mixture of learned rules and adaptive experience fed back to new rules far more quickly than happens with current 18th century behavioral rules for physicians, their educational system, publications and societies. It will not be achieved without embracing modern information technology.

With that inflammatory statement let me try to point a path that puts leadership back with the profession, the place where I, a health-seeker, need it to be. I can trust a physician. I will never be able to trust a "plan". I believe in "managing by muddling through" chaotic but if you really do know where you want to get to it enables responding to "targets of opportunity." I am most encouraged by what I hear of the academy's initiative on a personal health record for the public domain. I would point out however that venture capital has more readily available money than most governments, moves faster and creates change.

I would like my personal physician to have a registry of all his patients based upon their personal health records. I would like to have that physician base his management of our dialog on those records. I would like him/her to have the benefit of seeing virtual registries, appropriately privacy protected and blinded, but searchable for outliers to determine exceptions that might apply in specific cases. I don't want much when you think about what Google does...yet it is a huge jump from where we are.

So where I want to get to is to have my personal physician have this measurement system for the "health state" of all those in his/her panel. Beyond that I want that panel compared on appropriately risk-adjusted bases with the panel of all other members of the academy. There are many details to those measurements. They will evolve chaotically as we muddle.

I see the ICPC as a key component of the language of quality comparison. I see the academy as the catalyst for re-energizing the practice of primary care using modern information technology. The system has to be transparent and filled with valid information, not that of clinical trials, but the collective experience of those who achieve results. There is a necessary period for becoming comfortable with new systems especially with our defensively evolved system. The only way I can see to deal with the issues is to start, expecting that initial accountability, ultimately yielding transparency, is confined to publishing total results, not individual results. But those total results would have an underpinning of risk-adjustment that would vastly improve the predictions for individual patients. Quality is meeting or exceeding expectations. We're doomed to failure when they are inappropriately set. Hope has its place. Placebos are sometimes remarkably effective. But...

Change will come from the ground up. It will come from collective understanding of how the tools need to be driven, how the measurement system helps the practitioner, not the insurer. Physicians did start the existing model of insurance. They, and I think they alone, can start the new wave of professionalism in the delivery of health.

While real improvement in health will be from the work level up the design of the structure of an information system can be initiated centrally. The first step is to say it is essential to practice. The second is to begin gaining understanding of how it will affect practice. Nike uses Just Do It. My experience at Hewlett-Packard led me to the conclusion that you can never get something right the first time. It takes at least three iterations. But the strongest truism is you don't ever get there until you start. Therefore muddle through!

The issue as I see it is not limited to the language. It is the issue of what the language does, for whom, why and how. It is a piece of a measurement system. Without a commitment to such a measurement system, by the profession for its members and their health-seekers. It is merely another academic exercise to work only on a language.

If you got this far, thanks for your indulgence. More thanks for comment. I think the subject is very important but perhaps lacks clarity in purpose, at least one that gives it enough power of constituency to make progress in a busy chaotic field, ready for change now, but unsure of what to do, how not to waste effort. Bob Hungate

7 January 2004

The United States (finally) discovers the importance of family medicine in the framework of primary health care.

Jan De Maeseneer,

Ghent, Belgium

Head of Department of Family Medicine and Primary Health Care, Ghent University

jan.demaeseneer@ugent.be

The BANFF declaration means an important step in the development of health services research in the United States. The declaration states clearly that the point of first contact with a health care system should be a comprehensive level of care, looking both at the patient's and the doctor's perspective. The way to reflect this is the use for an adequate classification. The International Classification of Primary Care integrates both the patient's perspective (in the "reason for encounter") and the physician's interventions, leading finally to the diagnosis and therapeutical strategy.

The BANFF declaration is not only a scientific statement, but it also puts the emphasis on the need for a comprehensive and accessible health care system. An important challenge for the United States in the years to come !

Competing interests: none declared

8 April 2004

The campaign to revitalise academic medicine kicks off

Peter Tugwell,

Ottawa, ON, Canada

Professor, Department of Medicine, University of Ottawa, Institute of Population Health

elacasse@uottawa.ca

The campaign to revitalise academic medicine kicks off.

We need a deep and broad international debate to begin.

The BMJ and a range of partners, including other journals published by the BMJ Publishing Group, Lancet, Canadian Medical Association Journal, Dutch Journal of Medicine, Medical Journal of Australia, Croatian Medical Journal, the Academy of Medical Sciences, and many others have initiated a project to bring people together to debate whether the existing structure of academic medicine is still fundamentally sound and, if not, to propose alternatives to it. (1) I have taken on the challenge of coordinating this project, and I extend an invitation to readers all over the world to join me in this exciting enterprise.

To achieve the project’s broad goals (box 1) we begin from the position that “more of the same” is not enough. We need to be free to propose radical changes to the fundamental nature of academic medicine (is the balance between bench and applied research all wrong?); its name (should it become “academic healthcare” or should we drop “academic”?); its home base (are hospitals the wrong place to train doctors?); its relation to service (why are they so often far apart?); its methods of training and certification (should medical education be lecture based and far shorter?); and its responsibilities (should it be held accountable for inequities in health care at the global level?)

Box 1: Goals of the project

Development of strategy on the following issues:

How should academic medicine look in the 21st century

How can we increase the impact of academic medicine on the rest of medicine and on health and healthcare

How should academic medicine be positioned internationally within medicine and also in the wider intellectual arena

How can recruitment to and job satisfaction of those working in academic medicine be increased

Our approach will be inclusive and is designed to ensure a broad input of opinions. Rather than allowing the process to be taken over by a few experts with vested interests, we will build consensus by inviting an exhaustive range of global stakeholders to contribute their views. We are especially interested in the views of the “customers” of academic medicine--patients, politicians, practitioners, the public. Anyone can contribute their views right now, today, as a rapid response to this article at bmj.com. In addition, our new project webpage is under development (www.bmj.com/academicmedicine), and this will contain regular campaign updates, news, and collected resources.

The proposed structure is as follows. The pivotal group will be an international working party whose composition will include knowledge and competency across the dimensions of global health and basic to applied healthcare research, representing the range of constituents (medical students, postgraduates, junior faculty, established academics--especially women). Supported by four advisory groups (box 2) and made up of approximately eight individuals, the working party will begin by answering four questions. Firstly, what are the roles of academic medicine?

Box 2: Four advisory groups

Perspectives forum - patients, health professionals, government representatives, and medical unions

Ad hoc consultants - providing systematic reviews and other factual summaries about the efficacy of different educational, organisational, and administrative approaches, and trends in human resources in academic medicine

Communications consortium - disseminating surveys, drafts, and reports to everybody who is joined up to the campaign or may want to give input

International advisory panels - deans, chairs, and funders whose support could help establish funding, profile, and implementation; also used as an ongoing sounding board

Secondly, how well is academic medicine carrying out these roles? Responses to the earlier BMJ editorial launching this initiative have already nominated a wide array of (but no clear consensus about) perceived failures, including failing to serve the public good, lack of a global perspective, an unnecessary dichotomy between education and research, various shortcomings in medical education, and inadequate numbers of and career paths for well trained medical academics. (2)

Thirdly, why is academic medicine failing to fulfil its roles? Reasons might include inadequate leadership, a failure to translate basic discoveries into benefits for patients, inappropriate incentives to take up or maintain an academic career (especially among women), deficient mentoring for aspiring academics, lack of appreciation of the benefits of academic medicine by elected representatives, and poor integration with other health services. Many of the reasons will be economic--the salaries and resources needed for research and teaching make academic medicine unattractive currently--but we need to examine ethical and moral explanations as well.

Finally, for each failure, what ought to be done about it? Given current economic constraints in countries with high and low income, special attention will go to strategies that call for no additional funding. We will, however, welcome strategies that call for the reallocation of current funding. At the policy level, we welcome strategies for how academic medicine can contribute to national and global health. These strategies will be combined and formulated into concrete proposals for action.

We need your support and input. To nominate a member of the working party, join an advisory group, or register your experiences and views, send a rapid response to bmj.com or contact our project manager, Jocalyn Clark, at jclark@bmj.com.

This editorial is being published simultaneously in the Lancet.

1. Academic medicine: resuscitation in progress. CMAJ 2004;170:309.

2. Clark J, Smith R. BMJ publishing group to launch an international campaign to promote academic medicine BMJ 2003;327:1001-2.

* Competing interests: PT has received travel and research support from pharmaceutical firms for over 30 years. This support has permitted research associates to work on methodological projects of no commercial interest, has supported students and fellows who otherwise wouldn't have been able to get an education, and has provided partial support for the planning and organisation of scientific meetings in which they had no say about subject matter, content, or speakers. His randomised trials of cyclosporine published in the Lancet and New England Journal of Medicine were funded in part but never in whole by pharmaceutical firms, who had no access to the emerging data, no control over whether or when the studies stopped, and no veto power over any publications or presentations.

PT is editor of the Cochrane Musculoskeletal Review Group, which has received unrestricted grants for staff support in carrying out systematic reviews, some of which failed to draw favourable conclusions about donor's drugs.

While PT was Chair of Medicine at the University of Ottawa a policy was introduced to prohibit pharmaceutical firms from solo support of department educational rounds or from any say in content. He also enforced a policy of using generic names. PT has never received awards from pharmaceutical firms. When serving on the US Government National Science Panel examining the relationship between silicone breast implants and connective tissue disorders, PT was certified by a US District Court judge to be free of any industry influence.

Previously published as:

Tugwell P. Campaign to revitalise academic medicine kicks off. BMJ, 2004;328:597. doi:10.1136/bmj.328.7440.597

Tugwell P. The campaign to revitalise academic medicine kicks off. Lancet. 2004 Mar 13;363(9412):836. doi:10.1016/S0140-6736(04)15772-3

Published here with permission from BMJ and Professor Tugwell.

Submitted by William R. Phillips, 8 April 2004.

Competing interests: Details of competing interests are on bmj.com and above*

18 July 2005

Problems in definitions, assumptions and examples

Eric K Pritchard,

Berkeley Springs, WV, USA

President, Metis Research, Inc.

ekpritch@earthlink.net

It seems that medicine, at least in hypothyroidism, has fundamental logical problems in definitions, assumptions that are not always true, and a substantial lack of respect for honest, valid counter examples. I would like to know if this situation adversely affects patients elsewhere in medicine. Please contact me - ekpritch@earthlink.net

Competing interests: Metis Research, Inc., A West Virginia Non-profit dedicated to precision linguistics in medicine

28 August 2005

HIV: perhaps time to change tracks. Dear Editor, HIV incidence is burgeoning rapidly [1-3]. It would soon become unmanageable, especially in developing countries, unless something more is done and thought processes readjusted and realigned. Despit

Dr. Rajesh Chauhan,

Agra. India

Family Medicine Practitioner

drchauhanrajesh@yahoo.com

Competing interests: None declared

26 August 2005

WHAT IS THE THERAPY OR REHABILITATION FOR THE MOST COMMON DISABILITY IN THE WORLD, SHORT TERM MEMORY LOSS?

WILLIAM H NAUEN,

SYRACUSE,UNITED STATES

DISABLED FAMILY PHYSICIAN

WHNAUEN@YAHOO.COM

Competing interests: None declared

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Annals Forum

In the very early days of Annals of Family Medicine, we hosted an "Annals Forum" for discussion. In 2005 the forum was folded into what is now the eLetters section of the website. These early conversations are archived below.

11 August 2003

AAFP National Conference-Future of Family Medicine

17 December 2003

THE BANFF DECLARATION AND THE INFORMATION NEEDS OF PRIMARY CARE AND FAMILY MEDICINE IN THE USA

THE BANFF DECLARATION

24 December 2003

Congratulations

26 December 2003

ICPC - not perfect, but our best option for data retrieval

29 December 2003

Banff Declaration

30 December 2003

ICPC in the US

30 December 2003

Important step in Primary Health Care

14 January 2004

ICPC - a classification for all primary care doctors!

7 January 2004

Leading ICPC adoption

7 January 2004

The United States (finally) discovers the importance of family medicine in the framework of primary health care.

8 April 2004

The campaign to revitalise academic medicine kicks off

18 July 2005

Problems in definitions, assumptions and examples

28 August 2005

HIV: perhaps time to change tracks. Dear Editor, HIV incidence is burgeoning rapidly [1-3]. It would soon become unmanageable, especially in developing countries, unless something more is done and thought processes readjusted and realigned. Despit

26 August 2005

WHAT IS THE THERAPY OR REHABILITATION FOR THE MOST COMMON DISABILITY IN THE WORLD, SHORT TERM MEMORY LOSS?

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