Conference reaches out to area civil surgeons
Nationwide, an opportunity for referrals
In San Diego, TB controllers have tapped into a ready-made referral source of foreign-born candidates for preventive therapy by reaching out to civil surgeons, physicians who are appointed by the U.S. Immigration and Naturalization Service (INS) to screen residents seeking to adjust their immigration status.
"We’re always looking for opportunities to do preventive therapy," says Kathleen Moser, MD, MPH, TB control officer for the San Diego County Department of Health Services. "And here’s this great population." Last summer, Moser, in cooperation with the Centers for Disease Control and Prevention (CDC), held a conference for San Diego County civil surgeons.
Those in attendance had many questions about TB infection, skin testing, and how and when to refer patients to the health department, she says. Since then, Moser has gotten lots of telephone calls seeking advice and says she feels as if she’s successfully made contact.
More health departments should consider doing the same kind of outreach work, says Nancy Binkin, MD, MPH, associate director for international activities at the CDC’s Division of TB Elimination, given that every year civil surgeons screen some 200,000 foreign-born residents for TB. Plus, since it’s a simple process, some health departments might want to have the TB controller — or another physician on board — become a civil surgeon, adds Binkin.
In Denver, the city’s TB control officer, Randall Reeves, MD, is a civil surgeon; he likes the way the process gives his division the chance to review patients’ chest radiographs and evaluate them for preventive therapy.
Throughout the United States, about 3,000 people have been approved by the INS as civil surgeons, says Binkin. The requirements are straightforward: the applicant must be a medical graduate licensed to practice in this country and must have four years’ practice. The INS provides no special training.
Newly appointed civil surgeons receive a booklet that describes the exam they must perform. Along with screening for sexually transmitted diseases, including HIV, and a check to make sure immunizations are in order and up to date, the physician must place a TB skin test, says Binkin.
For reactions equal to or greater than 5 mm, the procedure requires a chest radiograph. In the event that the X-ray is compatible with TB, the physician must refer the patient to a health department. However — and here, say Binkin and Moser, is the interesting part — for those with reactions equal to or greater than 10 mm, physicians are encouraged to refer patients for evaluation for preventive therapy.
Experts review TB component of exam
To see whether that kind of referral was taking place, the CDC conducted a four-site study — in San Diego County, San Francisco County, and the states of Massachusetts and New York — in which TB experts reviewed the TB component of the exam, says Moser. It didn’t look as if civil surgeons were missing any cases, she adds; but when TB experts cross-matched likely candidates for referral with health department records, it was clear that the yield was skimpy.
"It’s hard to say whether the civil surgeons were referring people to us or not," adds Moser. "It’s easier to say that if they did, not many showed up."
She decided to hold a conference, partly to provide education and training and partly to make contact. A call to the district INS office produced a list of the 125 designated civil surgeons in the county. Since the INS permits physicians to charge a set fee for the exam, it’s possible to "make a pretty good living" doing just the exams, says Binkin. Moser discovered that of the 125 civil surgeons in the county, about 50 did many exams; she targeted that group specifically for the conference, making sure dates were convenient for them.
In the letter that went out, Moser asked what kind of information the civil surgeons already had, what type of information they’d like to have, and whether they would come for training and continuing medical education credits.
The response was "pretty good." About 70 civil surgeons and staff assistants (who usually do the actual placement of the skin tests) showed up. Speakers were recruited from the CDC’s Divisions of Quarantine and Immunization and from the district INS office. For a presentation on the basics of TB, there was Moser herself.
The question-and-answer session was lively, she says. Participants wanted information about cutoff points for skin-test readings since INS exam instructions specify a chest X-ray when skin-test reactions are greater than or equal to 5 mm, not the conventional 10. They had many queries about bacille Calmette-Guerin vaccinations. "As elsewhere, that was probably the area of greatest confusion," notes Moser. Finally, participants asked questions about how and when to refer patients to the health department.
"We began to get the sense that they weren’t referring patients because they didn’t know how," she adds. "They asked stuff like, Who do you accept? How do you refer for disease, vs. infection?’"
By the end of the day, Moser says the lines of communication had been established. "There’s only so much training you can do at one session that people can retain," she says. "So it helps a lot if they learn who you are and that they can call you."
And call they did. Many calls, she says, have concerned proper procedure: "Do I do an X-ray now? A sputum?" The phones at the division of immunization are ringing, too. At one time, Moser says, she had considered becoming a civil surgeon herself. "What’s complicated about it is that most big health departments are categorical," she says.
"I have TB staff here, but not immunization staff, and I don’t know much about mental health." It would take some work to figure out how to put together the requisite structure to do the exams, she adds.
Plus, she’s decided that simply meeting the civil surgeons in the area has gone a long way to accomplish her goal. "Once I got to know the civil surgeons, I saw that they just needed some education," she says. "They needed to know our phone number and that we were here to answer their questions." Plus, since many civil surgeons are foreign-born or foreign-trained, their patients may feel more comfortable with them, says Moser.
In Denver, TB controller Randall Reeves, MD, is a civil surgeon and likes the way his position affords him oversight and access he might not otherwise have. He’s been signing off on civil service exams since he first assumed his post in 1990, he says.
This is the way the system works, explains Reeves: Physicians within the city’s system of neighborhood-based, primary-care clinics begin the examination process by applying the skin test and ordering a chest radiograph if indicated. (In some cases, the patient starts out with a private practitioner.) Then, instead of having the chest X-ray sent to a radiologist to be read, Reeves asks for doctors to send the films to the health department for interpretation, and he completes the paperwork process.
"That way, we get a chance to sort out whether they have active TB or inactive TB, or [if they] might be a candidate for preventive therapy," Reeves says. "Most of these X-rays are normal, of course. But that’s fine with me. I’d rather they come here with a film than have a radiologist read it who might not be thinking that much about TB."
Moser and other TB experts at the CDC are working on training materials for other health departments that might want to hold a conference for civil surgeons, says Moser. The material should be ready in about a year.
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