Letters

Family doctor's role in pain management

To the Editor:

While I respect Dr. Sanford Brown's judgment not to do what he's not comfortable doing, I'm sure I'm not the only one rather shocked by his statement in the July/August 2001 issue [page 48], "I don't do pain management except for terminal care patients" on the grounds that, over the long term, opiates "are addictive and can often do more harm than good."

Surely pain management is an essential part of a family physician's work, and it's not something that always needs a subspecialist. There are many tools and techniques family physicians can use to increase confidence that long-term opiates are being used appropriately. Patients with chronic pain can live productive and happier lives with the appropriate use of these medications, and the questionable risk of addiction in such patients is of minimal importance compared to the benefits they can bring. All medications can do more harm than good. We should not shy away from using whole classes of effective medication on the basis of vague fears.

Tony Glaser, MD, PhD
Summerville, S.C.

Author's response:

If my judgment not to do what I don't feel comfortable doing is truly respected, then what is the difference why I beg off the long-term prescribing of opiates, particularly in patients whom I feel are conning me? Besides pain management, it is also within the scope of practice of family physicians to do C-sections, joint injections, herbal medicine, treadmill testing, no-scalpel vasectomies, endometrial biopsies, slit lamp biomicroscopy, breast biopsies, direct nasolaryngoscopy, thoracentesis and chest tube placements. Do all family physicians do all these things as well to help their patients live productive, happier lives, or do they, too, do what they are comfortable doing?

Sanford J. Brown, MD
Mendocino, Calif.

A new direction

To the Editor:

Unfortunately, "Is It Time to Re-examine Family Practice?" [September 2001, page 43] came too late for this 39-year-old former family physician.

After 10 successful years, I left practice because of demoralization due to managed care attitudes and policies, frustration over my patients' changing mindset and genuine fear for my future security.

The PPO reimbursement in my area is atrocious, and our HMO payments are eaten up by the associated overhead expenses. When I left, eight employees in my office were doing work that wouldn't have been necessary were it not for HMO rules.

The changing attitude among my patients was the largest disappointment. They came in less for my expert medical opinion than for referrals for an MRI or to other specialists. They paid less for their services and felt more entitled, and became less accountable for their own health in the process.

Lastly, I feared the marginalization of the family physician. I did 70 percent less than I was trained to do because of lack of time, patient pressures to see a specialist and lack of payment for my service. It became clear to me that I did little more than what a nurse practitioner or physician assistant could do. After coping with an overwhelming sense of loss, I decided to pursue another dream of mine in the pharmaceutical industry.

I admire those family physicians who have stayed to fight. But I believe the action plan is poorly aimed. The public needs to be educated about HMOs. They have enjoyed unopposed propaganda while we wage a time-consuming battle in our offices. The proposed patient bill of rights is grossly inadequate, and will result in a dramatic shift of wealth to the legal profession. The Academy needs to speak to family doctors on the front lines - not the ones quoted in the article with fancy titles who are paid by institutions.

H. Jeffrey Wilkins, MD
Sovderton, Pa.

An alternative financing model

To the Editor:

"Is It Time to Re-examine Family Practice?" notes that "comprehensive, continuing patient care - the hallmark of family practice - is becoming increasingly difficult to provide in a fragmented health care system where productivity pressures, increasing rules and regulations and concern for short-term profits threaten to compromise the physician-patient relationship." In fact, the article goes on to quote others who state that the physician-patient relationship is already compromised.

It is evident that managed care is incompatible with this hallmark of family practice. For our specialty to survive, we must devise a palatable, efficient and safe alternative health care financing and delivery system.

The answer is a primary care retainer plan, in which patients would pay a low single annual fee to their primary care physician of choice. In return, patients would receive comprehensive primary care. The annual fee could variably come from patients, their employers or the government.

Financing of "extra primary" services (i.e., lab, X-ray, specialty referral care, ancillary services, drugs, emergency department and hospitalization) would be handled by various combinations of personal savings, medical savings accounts, defined contribution plans, low-cost, high-deductible insurance and intermediate benefit insurance. A government safety net would remain for those least able to afford coverage. Notably, managed care would have no role.

New market-driven relationships would arise among these extra primary entities and primary care physicians, based on quality as well as cost. We would be free from most, if not all, of the current administrative and bureaucratic hassles impeding the practice of medicine.

A primary care retainer plan would make primary care the cornerstone of health care, offer affordable primary medical care to many more individuals and smaller employers, restore the focus on the doctor-patient relationship and vastly reduce administrative costs and burdens.

A full treatment of this plan is beyond the scope of this letter, but can be found on the Web at www.flashdoc.com.

James Schwartz, MD
East Providence, R.I.

PAs offer help, not hindrance

To the Editor:

Your article "Is It Time to Re-examine Family Practice?" was timely. I am a physician assistant (PA) who was trained with Generation-2 family physicians and am also a preceptor for medical students and masters-level PAs.

PAs are completely dependent on physicians to practice their profession. Therefore, I find comments that portray us as competitors onerous.

In PAs, family physicians have devoted disciples in their desire to provide primary care. Unfortunately, most are unaware of the advantages of this dependent, efficient and cost-effective partnership.

I strongly believe and advocate that medical school curricula and/or resident training of family physicians should include comprehension of how PAs are trained and teach strategies for effective utilization.

By assisting family physicians in their mission, PAs will help provide patients and physicians with a better quality of life.

Ross H. Fichthorn, PA-C
Bernville, Pa.

Raise reimbursement, raise student interest

To the Editor:

I agree with the efforts of the AAFP that are mentioned in "Is It Time to Re-examine Family Practice?" Over the last few years, the number of students in family medicine preceptor programs has steadily declined. Interest in our specialty decreased when the cost of medical school increased to astronomical levels. The $30,000 that medical school costs each year is a much greater burden for a family physician than for an orthopedic surgeon. Increasing our reimbursement by even 30 percent won't help us pay off huge loans. Cut an orthopedic surgeon's reimbursement by 30 percent and he or she will still make $200,000 a year.

What would make a difference is paying family doctors for the care we give instead of calling it "health maintenance" and not covering the service. Pay us for doing colposcopies and skin tag removals. No one will do these things but us, but no one will pay us for them.

J. Goodwin, MD
Washington, N.J.

Practice what they teach?

We want to hear from you. Letters is an open forum for our readers. Write to Letters Editor, Family Practice Management, 11400 Tomahawk Creek Parkway, Leawood, KS 66211-6272. If you prefer, fax your letter to 913-906-6010. You may also contact FPM by e-mail at fpmedit@aafp.org. Include your address, daytime phone number and fax number, if any. Letters may be edited for length and style. All letters sent to the editors of FPM are presumed to be intended for publication unless otherwise specified in the text of the letter. Submission of a letter constitutes transfer of the copyright to the AAFP.

To the Editor:

I am in my third year of family medicine residency, and I too have concerns about the future of family medicine. I have talked with numerous family physicians who have had difficulty obtaining privileges for procedures ranging from deliveries to stress EKGs. I have also seen billboards that say, "Give your baby every chance at life, always see a specialist" posted by an OB/GYN group in a city where family physicians do most of the deliveries.

I chose family practice to learn and do everything family practice has to offer. However, few programs exist that actually train residents to perform the full spectrum of family medicine. Thus, there is a general misconception about family practice - that it's a specialty of doctors overextending themselves beyond their training.

Most of my colleagues who didn't consider family medicine favored internal medicine for the pathways it provides to subspecialization. I have felt for some time that family practice should offer pathways to subspecialization in emergency medicine, cardiology, gastroenterology, obstetrics, etc. By creating such pathways, more medical students will be drawn to family medicine, programs will become stronger, and the specialty as a whole will benefit.

Steven Koerth, MD
Fort Worth, Texas

Correction

The article "Supercharging Your Web Experience" [September 2001, page 31] incorrectly stated that AdsOff! 2.0 is a free software plug-in. AdsOff! 2.0 is available free for a trial period, but costs $19.95 should you decide to keep using it.

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