February 2000 • Volume 6 • Number 2
Protect young athletes:
Discuss supplements during sports exams
BY SHARON DENT
Blue Nitro. Remforce. Firewater. Thunder Nectar. As young athletes feel pressure to win at any cost, they may experiment with these or similar supplements in hopes of improving performance or "bulking up." Family physicians can educate these patients and help prevent serious health problems by discussing the issue of performance-enhancing drugs during preparticipation physical exams, according to AAFP's Commission on Public Health.
"The commission recently reviewed information from the FDA, and we feel that family physicians are in an ideal position to warn their patients about these dangerous supplements," says commission chair Lily Ning, M.D., of Honolulu, Hawaii.
The FDA is specifically urging physicians to be on the lookout for patients taking supplements that contain gamma butyrolactone (GBL), gamma hydroxybutyric acid (GHB), and 1,4 butanediol (BD). Although labeled dietary supplements, these products are illegally marketed, unapproved new drugs and are associated with reports of at least 122 serious illnesses and three deaths, the FDA warns. Items containing these drugs include Longevity, Revivarant, G.H. Revitalizer, Gamma G, Blue Nitro, Insom-X, Remforce, Firewater, Invigorate, Revitalize Plus, Serenity, Enliven, GHRE, SomatoPro, NRG3, Thunder Nectar and Weight Belt Cleaner.
In 1990, the FDA banned the use of GHB. Some companies switched to GBL -- and after warnings about GBL, switched to BD. These are all similar chemicals that the body converts to GHB with the same dangerous effects, the FDA reports.
Patrick Harr, M.D., of Maryville, Mo., AAFP past president and team physician for local high school and university athletic teams, says raising the issue of supplement use is essential during a preparticipation physical. "Almost all kids have taken some sort of supplement," he says. "Some are taking multivitamins, and that's probably OK. But some are feeling peer pressure to try these performance drugs."
During the exam, Harr says, the FP can tackle three important areas: sending the message that he or she is concerned about dangerous supplements, counseling the patient on the health risks of using them, and making a note to monitor the patient or even talk to the coach or trainer.
However, Harr says physicians should be honest about the supplements' claims. "If you try to tell a kid that none of the supplements are helpful, then you lose credibility because the kids see that the drugs help them bulk up," he says. "Be up front about the fact that the drugs do work, but that there's a heavy price to pay."
Rebecca Jaffe, M.D., has a private family practice including sports medicine in Wilmington, Del. She says she asks about supplement use at every well-patient visit, regardless of the patient's age or athletic prowess.
"With the kids, I always ask, 'What medications are you taking? What vitamins are you taking? What other supplements are you taking, legal or illegal?'" she says. "Whenever someone asks me to comment on a supplement they're taking, I ask them to bring it in. The only way to know what's in these products is to go through them piece by piece."
Jaffe has seen patients who admitted taking Longevity, one of the supplements included in the FDA warning. "Having something from the government is helpful," she says. "Patients can read the details to see how the drugs could affect them."
Jaffe also recommends that FPs pay attention when young patients report hanging out with a new circle of friends or experiencing sudden changes in school perfor- mance or weight. "These should lead you to a heightened awareness, making you keep an eye out for problems or things you can intervene with," she says.
In this day and age, Jaffe says, physicians must stay informed about supplements because so many patients are looking for shortcuts to good health.
"Everyone's looking for that thing that's going to help them win a little faster than the next person," she says.
FDA's warning about GHB, GBL and BD is available at http://www.fda.gov under "What's New" and then "Dietery Supplements." Or request it from AAFP Express; see "Quick Fax" in this issue.
Tool helps physicians break through to resistant patients
BY JANE STOEVER
"We need to learn how to change from a 'fix-it' to a motivational role."How many times have you tried to get Patient X to quit smoking/lose weight/start exercising/reduce stress?
Patients who resist changing their risk behaviors create obstacles to their own health care, leaving their physicians stymied -- and frustrated. However, family physician Richard Botelho, M.D., of Rochester, N.Y., says he's had success working with patient resistance using a tool he calls the "decision balance."
"We need to learn and understand how patients perceive and value the benefits of their unhealthy behaviors," says Botelho, who presented the decision balance concept during a preconference workshop at the recent Conference on Patient Education in Austin, Texas. "We're trained to focus on disease, not the perceived benefits of unhealthy behaviors. Patients and practitioners have differences in values and perceptions about health behavior change. To use our differences to make a difference, we need to learn how to change from a 'fix-it' to a motivational role."
The decision balance tool explores a patient's perceptions about change, asking him or her to list the benefits and concerns of changing, as well as the benefits and concerns of not changing. The patient then ranks his or her resistance to change and motivation to change on a 0-10 scale.
Using individualized interventions (often over several office visits), the physician can help lower the patient's resistance score and raise the motivation score.
Botelho tells of a hospitalized patient who went from smoking one pack of cigarettes a day to two packs when her family nagged her to quit. On the decision balance, she said a benefit of smoking was that it hid her feelings. Upon further questioning, she revealed that smoke created a protective screen around her.
"Probing patients' perceptions and feelings can help you address their reasons for resistance," Botelho says.
But probing for perceptions is not what most doctors do. They tend to "hammer away" at a patient with information and advice, treating risk behavior as a "nail." However, Botelho says, if you think of the risk behavior as a nut rusted to a bolt (the patient), "hammering away at the patient may make the situation worse and even damage the threads of the bolt so the nut never comes off."
Implementing the decision balance involves three steps.
Step One
First, clarify the patient's issues about change without imposing any judgment. Ask the patient whether he or she is thinking about changing the risk behavior. Then, propose filling out the decision balance, using a stage-specific rationale. For example: "You just told me that you're not interested in quitting smoking. Would you mind if we filled out a decision balance form together? It can help me understand better why you don't want to quit." Work with the patient to fill out the form, then obtain and discuss the resistance and motivation scores.Step Two
Review the patient's comments on the form as you try to lower his or her resistance through nondirect interventions, such as:Probing priorities to create general ambivalence. "So what do you like most about smoking? What concerns you most about quitting?"
Using double-sided reflection to summarize ambivalence. "On one hand, you said that smoking helps you relieve stress, but on the other hand, you are concerned about how smoking stresses your heart. What do you think about that?"
Using time-line questions to understand patient perspectives about risk behaviors. "What was your heart like five years ago compared to now? What do you think your heart will be like in five years?"
Wrap up the discussion by asking whether the resistance and motivation scores have changed.
"It takes practice to discuss risk behaviors with patients without nagging or passing judgment."
Step Three
Use direct interventions to enhance the patient's motivation to change. Some options:Back-to-the-future questioning. "Suppose you quit smoking and never had another heart attack, then would it have been worthwhile to quit smoking?"
Benefit substitution. "In what kinds of stressful situations do you smoke? How could you relieve stress instead of smoking? Could you write down ways of relieving stress for each situation and bring the list in next time?"
Clarifying values. "What is more important in your life than smoking? Is smoking more important than your health? If you say that your health is more important than smoking, then you're saying one thing and doing another. What would convince you to do what you say?"
Wrap up by seeing whether the patient's resistance and motivation scores have changed.
It takes practice to discuss risk behaviors with patients without nagging or passing judgment, Botelho says.
Feel free to e-mail Botelho at rick_botelho@urmc.rochester.edu for more information.
Take note of key AAFP deadlines
The Academy's Public Health Award honors members who have made extraordinary contributions to public health. Nomination deadline: March 1. For information or application forms, call (800) 274-2237, Ext. 5542, or e-mail ncrossfi@aafp.org.
The planning committee for the 22nd Annual Conference on Patient Education invites proposals for presentations at this national CME meeting Nov. 16-19 in Albuquerque, N.M. Conference sponsors: AAFP and Society of Teachers of Family Medicine. Submission deadline: March 15. For information, call (800) 274-2237, Ext. 5534; e-mail prodrig@aafp.org; or visit http://www.aafp.org/pec.
The Academy is seeking scientific exhibits and family practice research proposals for the Sept. 20-24 Scientific Assembly in Dallas. For information, call (800) 274-2237, Ext. 6568 (about research presentations) and Ext. 6564 (about the exhibits), or see "Quick Fax."
If you'd like to increase your research skills and knowledge base and tackle questions of importance to family medicine, you may qualify for an Advanced Research Training Grant. Sixteen AAFP members have received grants to far, and the third cycle of grant competition just started. Recipients may receive as much as $50,000 a year for one or two years.
To apply, call (800) 274-2237, Ext. 5504, for guidelines. Submit a letter of intent by April 7. After reviewing submitted letters, the Task Force for the Plan to Enhance Family Practice Research will request full proposals from selected applicants in May and announce recipients in September.
The Commission on Clinical Policies and Research is accepting applications for Matching Funds for Constituent Chapter Research. Application deadline: April 15; grants awarded in spring and fall. Applications must be approved by constituent chapter presidents or executives prior to submission to AAFP. Application information is available at http://www.aafp.org/research/matchapp.html, or by calling (800) 274-2237, Ext. 5560.
Family physicians discuss turf battles, call for collaboration
BY JANE STOEVER
Scope-of-practice battles continue to be waged in statehouses and among health professionals, but some family physicians are calling for more collaboration and less combat.
"What would you rather do tomorrow, fight with nurse practitioners or improve preventive services?" asks Larry Green, M.D., of Washington, D.C.
"We should work with NPs to organize systems that take advantage of their competencies and ours to close gaps in preventive care," says Green, who directs the AAFP Center for Policy Studies in Family Practice and Primary Care.
Concerning privileging conflicts, Green asks, "Do we want to fight more battles with obstetricians, or should we pour more energy into giving FPs surgical skills to do rural obstetrics?"
Green warns against spending a lot of calories and emotion trying to address border disputes.
Two states have hit on ways to save legislators from the "down and dirty" of turf wars between physicians and midlevel providers:
Since 1985, the Nebraska health and human services department has appointed multidisciplinary committees to study petitions for licensure or expansion of scope. The committees report to the department's board and director, who makes recommendations to the legislature. The committees have stymied requests, for example, for licensure of naturopaths and lay midwives.
"The committee process usually leads to compromise," says David Hoelting, M.D., of Pender, who chairs the Nebraska AFP legislative committee.
Texas nursing, physician's assistant and physician organizations formed a collaborative practice committee a few years ago, at legislators' request. When NPs wanted a law protecting their right to due process in case their hospital privileges were threatened, the committee backed the request, and the legislature approved due process for all with staff privileges.
In another case, nurses with hospice and cancer patients sought authority to prescribe controlled substances. "I told them the Texas AFP had discussed the possibility of that request, and the family physicians were adamantly opposed," says Stephen Benold, M.D., of Georgetown, the committee's Texas AFP representative. "There was no way the committee would reach a compromise, so the proposal was dropped."
Family physicians in other states are wrestling with scope-of-practice issues dealing with midlevel providers. For example:
Mississippi has many health professional shortage areas and more NPs than FPs. "We have a dilemma," says Tim Alford, M.D., of Kosciusko, vice president of the Mississippi AFP. "The areas that we want our NPs to move to are the hardest to supervise, because they're the most remote. We're so overworked, we can't get out there once or twice a week. And patients have problems the nurses have to address right away. As our state turns out large numbers of nurse practitioners, we aren't taking stock of who's going to supervise them."
AAFP chapters continue to back members in privilege battles. For example:
The Georgia AFP is raising funds for members who may need legal assistance to gain or defend their hospital privileges. According to GAFP Past Presi-dent George Shannon, M.D., of Columbus, the chapter asks three questions about privilege problems: How well qualified is the candidate? How dedicated is the candidate to pursuing privileges? How strong is the opposition?
"Hospitals don't like legal fights and don't like to alienate their medical staffs, so you can often negotiate," says Shannon. "You don't really want to call in the lawyers. All they do is lick their chops."
Privileges down, office procedures up
BY JANE STOEVERSurveys of family physicians show a shift away from certain hospital privileges and toward office procedures (see chart).
The transition mirrors the overall change to more outpatient care as cost-cutting efforts grind on and office-friendly technology booms.
Physicians and administrators still ask the AAFP Socioeconomics Division for background papers on various procedures as part of family practice. Requests about ambulatory care are on the rise.
However, statements on OB privileges continue to top the list of back-up information family physicians seek.
"It always comes down to economics," says Jane Krieger, R.N., J.D., assistant director of the division. "Whether or not a family doctor has difficulty getting OB privileges depends on how many OB-Gyns are in competition with family physicians in a given area."
The percentage of AAFP active members doing routine OB deliveries plummeted from 37 percent in 1980 to 28 percent in 1990 and slipped to 24 percent by 1999.
Studies suggest family physicians drop OB care mainly because of its lifestyle constraints. According to a 1999 AAFP survey, 77 percent of members without routine OB privileges didn't want them, 6 percent found liability coverage too high and only 0.7 percent had been denied privileges.
Note: If you need help in obtaining any hospital privileges, call the Socioeconomics Division at (800) 274-2237, Ext. 4162.
Percentages of AAFP active members who have hospital privileges/offer office procedures
Hospital privileges 1990 1999 OB -- routine delivery 28% 24% Caesarean section 10% 7% Surgery assisting 45% 33% ICU 75% 67% Flexible sigmoidoscopy 39% 33% Colposcopy 9% 18%
Office procedures 1990 1999 OB ultrasound 8% 11% Cardiac stress test, treadmill 12% 11% Flexible sigmoidoscopy 40% 46% Colposcopy 12% 35% Source: AAFP Practice Profile Surveys
Editorial, AAFP critique study of NPs, primary care physicians
Don't read too much into study findings that compare care by nurse practitioners and primary care physicians, warns an editorial accompanying the study report in the Jan. 5 Journal of the American Medical Association.
The study, "Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians -- A Randomized Trial," suggests that outcomes are similar for patients with asthma, diabetes or high blood pressure, whether they're seeing a primary care physician or a nurse practitioner. The editorial raises concerns about the study's external validity -- whether the findings are likely to apply to other study sites and other patient populations.
The study's lead author is Mary Mundinger, Dr.P.H., dean of the Columbia University School of Nursing in New York.
The population for the six-month study consisted of 1,316 younger, mostly female, Spanish-speaking immigrants who were on Medicaid.
"Although the study purports to show equal efficacy of doctors and nurses, we believe its substantial methodology weaknesses limit the applicability to that setting and population," said Academy EVP Robert Graham, M.D.
The Academy released a statement noting, "This study provides further evidence that primary care works. Patients were moved into clinical settings, away from ERs and urgent care centers, and their health improved.
"We caution that the conclusions of this study cannot be generalized. They are highly limited as to patient population, clinical structure, and the relatively short time period of this particular study. The authors also chose not to discuss the training and preparation of the nurses and physicians."
Medical students or residents with questions about the study's implications should speak with family practice faculty members or other family physicians, or call the AAFP at (800) 274-2237, Ext. 6710, says Deborah McPherson, M.D., assistant director of the AAFP Medical Education Division.
Order from AAFP at (800) 944-0000 unless otherwise noted.A clinical guideline, "The Management of Minor Closed Head Injury in Children" (#R944, free), gives state-of-the-art recommendations; it's online at http://www.aafp.org/policy/camp/22.html.
Advanced Life Support in Obstetrics -- ALSO -- products include four colorful new posters ($10 each), T-shirt ($12), bumper sticker ($2) and course listing (free). To order, call (800) 274-2237, Ext. 6556.
Discover the alternative treatments your patients most likely are using. Take the March 23-25 CME course Complementary/Alternative Practices. See "Quick Fax" for a registration form.
Proven value: The Annual Leadership Forum offers CME credit, April 28-29 in Kansas City, Mo., in conjunction with the National Conference of Special Constituencies. Access http://www.aafp.org/leader/ or call (800) 274-2237 about registration (Ext. 5316) or the program (Ext. 6872).
Proven value: Stand Up and Speak Out to Teens! brochures discuss alcohol, stress, eating disorders, tobacco, sex and STDs (#R090-095 respectively; package of 100 costs $25).
FP Report is published by the AAFP News Department.
Copyright © 2000 by American Academy of Family Physicians.
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