March 2000 -- FP Report

March 2000 • Volume 6 • Number 3

Deadly risks of antibiotic overuse warrant widespread education

BY SHARON DENT

Green mucus implies a bacterial infection. ... If a cold lasts a week, you should consult a physician. ... Antibiotics might not help you get better, but they can't hurt.

Right?

Wrong! Physicians involved in curbing the excessive and inappropriate use of antibiotics insist misinformation is the main culprit.

Education for physicians, office staff and patients would go a long way in preventing antibiotic resistance, said family physician John Hickner, M.D., who serves on a CDC panel developing principles for the judicious use of antibiotics for respiratory infections in adults.

According to him, green mucus isn't a good indicator that antibiotics are needed. Research shows cold symptoms commonly last longer than a week. And the misuse of antibiotics leads to strains of bacteria developing resistance to drugs. Misinformation, such as these commonly held beliefs, results in many patients prematurely visiting their physicians and expecting a prescription for antibiotics. Too frequently, the physicians comply, Hickner said.

"When you look at well-designed studies of antibiotics for bronchitis or sinusitis, for example, there's no evidence of any clinically significant benefit, just very marginal benefits," said Hickner, professor of family practice at Michigan State University College of Human Medicine in East Lansing. "Nearly all people get better from bronchitis and sinusitis on their own without the use of antibiotics. But doctors are a little uncertain about that."

About 70 percent of patients diagnosed with bronchitis and more than 90 percent of those with sinusitis are prescribed antibiotics, he said. "There is still some belief that antibiotics are effective enough to be used in those cases, but the data just don't bear that out."

And the consequences are serious.

Drugs that once guaranteed eradication of bacterial diseases are suddenly up against strains that don't respond as predictably. These bacteria have developed resistance in part because of overuse and misuse of the drugs, often in ambulatory settings. As a result, patients are getting sicker, and death rates for some communicable diseases, such as tuberculosis and malaria, are on the rise in regions where such diseases had been under control.

"Some doctors think of antibiotics as harmless placebos," said William Hueston, M.D., family medicine department chair at the Medical University of South Carolina in Charleston. "You risk not only harming the patient when you prescribe unnecessary antibiotics, but also harming the community."

Although doctors should refresh their knowledge and get up to speed on issues surrounding antibiotic use, patient education also is key.

The January Family Medicine details research conducted by Hueston with his university colleague Arch Mainous, Ph.D., to assess the use of two interventions aimed at reducing the rate of antibiotic prescribing for pediatric upper respiratory infections. The interventions -- (1) providing feedback about the physicians' antibiotic prescribing habits and (2) providing physicians with patient education materials on antibiotic use -- had little overall effect. However, providing patient education materials to physicians did seem to have a slight positive impact on antibiotic prescribing.

The study notes that "providing them with tools for educating patients may be a good way to help physicians change prescribing practices, and thereby confront the public health problem of antibiotic resistance."

If physicians don't have time to do it, nurses or other staff members could be trained to teach patients the facts about antibiotics, said Hueston. The CDC offers a plethora of resources on the topic, including a handy Q&A sheet for patients (see "A pill that cures every ill?").

"One of the biggest ways we can help patients gets back to why we're family physicians," Hueston said. "Let's talk to our patients. If we take the time to educate patients, we'll save them money and keep them healthier in the long run."

Better telephone triage also helps by teaching patients to know when an office visit is warranted. If patients get good counseling from staff, they won't head to the office for a prescription and therefore won't misuse an antibiotic, said Hueston.

Hickner said that overall, he's optimistic about the situation. "For example, physicians have dramatically decreased antibiotic prescriptions for adults with upper respiratory infections," he said. "For the common cold, antibiotic prescriptions have gone way down. It's now around 20-30 percent, and most of those patients probably have something else, too. I think we're moving in the right direction."

Ask senators to defeat pain relief bill

Relieving patients' pain is one thing, but having the government watchdog the process is another.

The proposed Pain Relief Promotion Act discusses pain management but primarily aims to prevent federally controlled substances from being used for physician-assisted suicide.

The Academy, which opposes physician-assisted suicide, fears the bill could make FPs liable for criminal penalties for prescribing needed pain medicine.

Under the bill, the government would collect and disseminate protocols and evidence-based guidelines about palliative care. Using those materials, federal law enforcement officials could decide -- after a patient's death -- whether the physician provided appropriate care or assisted in a suicide.

The House of Representatives passed the Pain Relief Promotion Act Oct. 27 by a vote of 271-156. The bill, H.R. 2260, is on the Senate Judiciary Committee's priority list for action this month.

Tell your senators why a bill that sounds good for patients may not be good at all; it may stop physicians from prescribing pain control medicine. For more information, access www.aafp.org/gov/keycontacts/20000211/.

AAFP launches Practice Quality Enhancement Program

The pilot phase of the AAFP Practice Quality Enhance-ment Program is under way -- and you can volunteer to participate.

First applicant: AAFP President Bruce Bagley, M.D., of Albany, N.Y., hands his application for the new Practice Quality Enhancement Program to Colleen Lawler, staff executive of AAFP's Task Force on Quality Enhancement. With her are, from left, Norman Kahn Jr., M.D., vice president for education and science, and Stacey Eubanks, quality improvement manager. Bagley presented his application during the Feb. 10-13 meeting of AAFP commissions and committees in San Antonio, Texas.

Most FPs can find ways to enhance the quality of their practice systems, says AAFP President Bruce Bagley, M.D., of Albany, N.Y., who has made quality the key issue of his presidency. And patients appreciate improvements in any system that makes them wait, he says."What we need to do is take a look at our outcomes, look at how we're doing, and then make improvements and measure again."

While it's voluntary, the quality program functions similarly to the present mandatory CME requirements for AAFP membership. Volunteers must accumulate 50 quality points over three years to remain members. For example, participating in a National Committee on Quality Assurance audit would earn a participating FP 10 quality points, and implementing changes recommended by the audit, with later evaluation of performance, would yield another 25 points.

Bagley says information gleaned in this pilot phase will be used to beef up the program -- all with one common goal: "We want Americans to equate family physicians with the delivery of high-quality medical care even more than they do today."

Want to volunteer? Call (800) 274-2237, Ext. 6800.

Visit the Academy's Medical Quality Clearinghouse at www.aafp.org/quality/ for re-sources to promote and improve quality in your practice.

AAFP policy center forum
Gore, Bradley campaigners swap ideas

BY JANE STOEVER
Washington, D.C.

Ideas on changing the health care system took center stage at a breakfast forum in Washington, D.C., Feb. 10.

Representatives of Democratic presidential candidates shared views on what America needs and is willing to work toward. The AAFP Center for Policy Studies in Family Practice and Primary Care hosted the forum.

"Vice President Al Gore has an ambitious program he thinks he can get passed in his first year in office," said Sarah Bianchi, representing the campaign. "He thinks the best way to get everybody covered is a step-by-step approach, building on what works today."

Margy Heldring, representing former Sen. Bill Bradley, D-N.J., characterized his proposal with two words: leadership and universality.

"Bill Bradley sees around the corner," said Heldring. "He wasn't afraid to step onto a landmine, the world of health care."

As the forum opened, Bianchi conveyed Gore's thanks: "The vice president appreciates that Sen. Bradley is taking leadership on this issue."

That set the tone for a laid-back exchange bearing little resemblance to the attacks that have peppered the primary debates.

The two representatives gave details of their candidates' positions:

Al Gore

Gore proposes a $146 billion "coverage initiative" that would be the largest health care program since Medicare began in 1965.

To begin trying to insure all children, Gore would raise the maximum income level for the Children's Health Insurance Program and increase enrollment efforts. Bianchi said about 85 percent of parents whose children are in CHIP or Medicaid have no coverage, and Gore's plan would give them affordable options.

Medicare would cover the fastest-growing group of the uninsured, those 55-65 years old, and would offer prescription drug benefits.

Bill Bradley

Bradley would mandate health insurance for all children. "Children are a national resource. Their coverage should be a federal responsibility," Heldring said.

Bradley also wants to open up the federal system to all adults. Uninsured adults would be able to enter Federal Employees Health Benefits programs. Medicare benefits would expand, including prescription drug coverage.

"For the frail elderly, what does it take to stay healthy?" asked Heldring, saying Bradley proposes a blend of medical and social services. He would beef up community health centers. "They're anchors in the community," she said.

Bradley also wants to create a community-based public health sciences institute in the National Institutes of Health.

The AAFP policy center has asked Republican candidates to present their health system suggestions at a forum this spring.

Academy expresses concerns with POL payment methodology

Twenty years ago, when Paul Fischer, M.D., was wrapping up his textbook, The Office Laboratory, that topic was very different. You could run a quick test, then return with results a few minutes later. Made sense.

"There's nothing like walking into an office with results a few minutes after drawing blood," Fisher said recently from his Evans, Ga., home. "Nothing is quite as efficient as providing 'teachable moments' to a patient."

Now, all FPs know, the situation has changed for physician office laboratories. You want to do a simple blood test? Most likely you can't handle it in-office and might have to send the sample out to a reference laboratory. You'll wait a few days for results, call the patient to give the results and schedule another appointment, if needed.

Paul Fischer, M.D.:
"This used to be simple."

Or you can post the results on a secure Web site, give the patient the URL and abandon hope of that "teachable moment."

"There's no advantage to testing like that," said Fischer, an AAFP nominee to the Health Care Financing Administration's Medicare Coverage Advisory Committee.

The Academy agrees and has voiced its concerns in a statement on the Medicare payment methodology for clinical laboratory services. The statement was sent Jan. 24 to an Institute of Medicine committee that is studying the issue.

The Academy statement said weaknesses include:

The charge-based current payment methodology "reflects the vagaries of how labs have historically set their charges rather than either the actual or relative costs of the services themselves."

Medicare pays on a geographically differentiated basis, even though service costs may not vary. The result: Some payments are below cost.

Payments for tests done manually are often equal to payments for the same tests done with the automated equipment often used in large reference labs, which "favors larger, better-equipped labs at the expense of POLs."

Medicare carrier policies often require physicians to reduce the number of tests or confine tests ordered to specific diagnoses, whether or not it makes sense in individual cases. The policies also add to the documentation requirements of physicians and discourage testing that may be medically appropriate.

Fischer used far fewer words. He called the situation "a nightmare."

"This used to be simple," he said. "Now, you've got to support all diagnoses, and everyone is changing the rules under which diagnoses can be supported. Nobody really knows what kinds of rules they're working with."

The Academy statement said a better payment methodology would meet guidelines spelled out in AAFP's policy on physician reimbursement. One option would be paying for clinical lab services under the resource-based relative value scale that Medicare uses for other physician services. Major reservations were expressed about another option: competitive bidding. It may be acceptable "if quality of care takes precedence and competing bidders are at an equivalent level," the Academy statement said. But it also noted that POLs and large reference labs could not bid on equal terms.

AAFP's statement also addressed the direction POLs might take given the constant introduction of new lab technology.

Fischer suggested national guidelines for reimbursement and a better range of common tests in evaluation and management coding as possible solutions. "Things like urinalysis make FPs jump through plenty of hoops," he said. "If they'd just incorporate that into E/M coding, we wouldn't have to do that anymore."

• Grassroots Advocacy •

Carolyn Shepherd, M.D., testifies to a Colorado committee.

Colorado AFP fights for prenatal coverage for all pregnant women

BY JANE STOEVER

If the Colorado AFP has its way, Colorado may be the first state to fund prenatal care for its undocumented residents. Two FPs made their case for the coverage Jan. 24, testifying before the Colorado House of Representatives Committee on Health, Environment, Welfare and Institutions.

Currently, the state's Medicaid program pays physicians and hospitals for labor and delivery services but does not cover prenatal care. The bill's specifics and the role of FPs supporting it illustrate advocacy in the legislative arena, a hot spot only too familiar to most AAFP chapters.

"The prenatal care problem has two parts," says Carolyn Shepherd, M.D., who testified on behalf of the CAFP. "First, there's the cost of providing a high level of service to all pregnant women. But if that care isn't provided, then there's the cost to the babies who are born premature because their mothers had no prenatal care. The babies might be blind; they might have developmental abnormalities; they may never go to normal schools. For the babies and their mothers, these issues can last a lifetime."

Shepherd, medical director of Clinica Campesina in Lafayette, told committee members the Lafayette and Thornton clinics provide care to pregnant women whether they're insured or not. "Our two clinics together give about $200,000 worth of uncompensated prenatal care each year," she says. "But Clinica can't provide care to everyone."

Virgilio Licona, M.D., right, strategizes with Jesse Thomas of Colorado Access during a committee hearing.

The bill the committee considered would funnel Medicaid funds for prenatal care to a managed care organization. For budget neutrality, physicians now providing free care would be paid; hospital payments for labor and delivery would shrink.

CAFP President-elect Virgilio Licona, M.D., of Denver testified to the committee on behalf of Colorado Access, a not-for-profit, safety-net health plan that will bid for the Medicaid HMO contract if the bill is passed. Colorado Access is owned by the Denver Health Authority (the public health department), Children's Hospital in Denver, the University of Colorado Hospital in Denver, and Colorado Community Health Network, composed of 10 migrant and community health centers.

"The full Medicaid coverage for prenatal care should be provided," Licona says, even though the state's Medicaid department is concerned the HMO would be assuming high financial risks. "Our HMO is prepared to assume the risks," says Licona.

Leaders of the Colorado Health and Hospital Association are not impressed; they oppose the bill.

"If the bill passes, you're going to take a chunk out of Medicaid funds for prenatal care, take a chunk out for managed care administration, and then the MCOs will sit down and negotiate different payment rates with hospitals. All that adds up: The payments to hospitals are going to be less," says Larry Wall, president of the hospital association.

Licona suggests the current Medicaid payment for hospital labor and delivery services for an unauthorized patient is about $1,750 above market rates -- a difference sufficient to cover prenatal services.

The committee passed the bill 10-4, forwarding it to the House Appropriations Committee. The bill is likely to come before the full house this spring and move to the Senate, where the hospital association may fight it full force.

The association will have to tangle with the CAFP, pediatricians, OB-Gyns, social service groups and the Colorado Medical Society.

Shepherd sees defending the bill as part of family practice. "You have to work wherever the decisions are being made," she says. "Sometimes it's in the clinic, sometimes in the health department or legislature. The work is ours to do."

• Grassroots Advocacy •

Who wants to be an activist?

You might be interested in launching a statewide initiative, or you may volunteer once a year at a local health fair. Whatever your involvement, family practice has always had one leg in the community.

Here's a round-up of suggestions from the family physicians whose stories fill this special section.

Start your advocacy with something simple. Don't think of it as a commitment; it's okay if you can't ever do it again.

If you strike out at a local level, go higher. Someone at the top might want exactly what you want.

Listen to your patients. They'll tell you what they need from you.

Live in the community you serve. Be part of it, go to local functions, get involved, or you won't know what's going on.

Get a gimmick to show media photographers. It will increase publicity for your cause.

Work wherever the decisions are being made, whether in the clinic, health department or legislature.

• Grassroots Advocacy •

HAWK-I kids rate -- they get free or low-cost insurance

BY TODD SIMCHUK AND JANE STOEVER
Ames, Iowa

Gary Erbes, M.D., notices the squint and quickly confirms that Michael Oelschlager, 13, is a prime candidate for eyeglasses.

The Oelschlager family of Roland, Iowa, left their previous residence in Des Moines because they were unhappy with the schools there. Sons Michael and Tyler would do better elsewhere, they figured.

But in Roland, a small town between Des Moines and the Minnesota border, Tim and Julie Oelschlager found an incomplete and expensive insurance situation.

Keeping Tyler and Michael covered would be tremendously difficult at best, they figured. Until Julie Oelschlager saw a brochure for the HAWK-I (Healthy and Well Kids in Iowa) program.

"This we could afford," Oelschlager said Feb. 2 at the McFarland Family Medicine Clinic in Ames.

She was there with Tyler, 12, and Michael, 13, who wore matching football jerseys to their visit with family physician Gary Erbes, M.D. Neither boy had been to a doctor for nine months.

Tyler is 4 feet 9 inches tall, and Michael is 5 feet 2 inches tall, they discovered in the moments before Erbes entered the examination room, and Michael is pushing 100 pounds.

Erbes added to those facts. Tyler's got a heart murmur -- which the family knew -- and needs regular doctor's visits. Michael's squint means it's indeed time for glasses.

"Glasses really will help," Erbes encouraged Michael. "You might not believe this now, but there's a good reason people get glasses."

It was the kind of exam thousands of kids in Iowa receive regularly. And thousands don't.

"An estimated 63,000 children in Iowa are uninsured. Farm families often find it hard to get good insurance rates," said Erbes' partner David Carlyle, M.D. "About 33,000 children would qualify for Medicaid, but many of them belong to working families that don't want to be looked on as wards of the state. They'd be embarrassed to use a Medicaid card."

Besides, Medicaid places unrealistic demands on families, said Carlyle, noting the need to reapply for Medicaid each month. "Our mission should be to make Medicaid better," he added. "I don't see us obtaining universal health care until we have a Medicaid that people can take pride in."

Factoring in an earned income credit benefit, Medicaid in Iowa covers families with incomes up to 160 percent of the poverty level, now set at $16,000 for a family of four. HAWK-I covers children in families at 160-220 percent of the poverty level. Only families at more than 180 percent of the poverty level pay premiums -- $10 per child per month, but never more than $20 per month.

HAWK-I uses Children's Health Insurance Program funds (see story below left) and has enrolled almost 4,000 children.

Carlyle, the AAFP Public Health Award winner in 1999, helped establish the HAWK-I program separate from Medicaid.

"For the HAWK-I children, we go out and buy insurance from companies," said Carlyle. "These people have a private insurance card, often from the state's Blue Cross Blue Shield. It gives them confidence."

• Grassroots Advocacy •

CHIP success accents need for more primary care physicians

BY SHERI PORTER

The influx of new enrollees in the Children's Health Insurance Program has created a logjam of patients.

Audrey Boyd, M.D., of Columbia, S.C., a member of the AAFP Commission on Legislation and Governmental Affairs, was an early CHIP advocate. She now says the same children who recently lacked insurance now lack medical "homes."

"These children are being signed up, but they need doctors on the other end to take care of them -- it will do no good to sign up 100,000 children if they have no physicians to go to," she says.

Last April, Boyd introduced a resolution at the AAFP National Conference of Women, Minority and New Physicians asking the Academy to formulate a national program to educate physicians and increase awareness of all facets of CHIP, including the dire need for primary care physicians. The commission is studying the resolution.

Boyd says much work still needs to be done to get children signed up for the program. "It won't be the physician signing up the kids. You need workers out in the communities getting them signed up," she says, adding that South Carolina has a strong outreach program.

"The applications can be anywhere the more diverse the distribution, the more enrollments that will come out of it," Boyd says.

After a slow start two years ago, enrollment in CHIP doubled in 1999, bringing current enrollment to 2 million children. But it's still far short of the federal goal of 5 million.

Physicians and parents can get state-specific information by calling, toll-free, (877) KIDS NOW [543-7669]. The Web site www.insurekidsnow.gov features detailed information about each state's plan.

• Grassroots Advocacy •

Teens hear straight answers from FP at school

BY JANE STOEVER

Melinda Silva, M.D., shares her views about relationships and sexuality as she leads her own high school's first peer group for girls.

Family physician Melinda Silva, M.D., attended Serra High School in San Diego as a carefree kid 20 years ago.

She was in for a surprise when she visited the school recently to find out about a class reunion. "They have a police officer on the campus now," says Silva. "There's a gate around the Coke machine. The kids look older. There's more of an ethnic mix. And there are gangs."

Silva, a new physician who recently returned to San Diego from Los Angeles, touched base with the school administrators. The officials acknowledged the gangs but said they're under control, partly because the school has many counselors and outreach programs.

Silva was intrigued. She remembered volunteering with Social Advocates for Youth when she went to Serra High School. So she offered to work with small groups of students, and she led a girls' peer group Feb. 2.

"We talked about healthy relationships," says Silva. "They asked, 'How do you know if you really like someone, or if you're just lusting for them? How do you know if you're in love? How can you tell someone you're not ready for sex, when they are ready for it?'"

Silva suggested they role-play several situations, and she played the parent to help the girls learn to broach tough topics at home.

She also talked about birth control, something the girls --13-15 years old -- had not discussed with physicians or their mothers. "I always stress abstinence first, in talking with young people," says Silva. She went on to explain the need for condoms whenever people have sex and described Depo-Provera and birth control pills. "Other types of birth control, like the diaphragm, are too messy for adolescents; they just won't use them," she says.

Silva senses a hesitation among physicians about volunteering. They fear that if they volunteer once, they might not be free to do it later.

"Doctors today are overwhelmed," she says. "With HMOs, there's much more of a business sense of medicine than there used to be, and doctors are afraid to take time away from their practice or family or personal interests. But I tell them, 'Start with something simple, something manageable, so you won't feel so stressed. It will enrich your work in your practice when you reach out to the community. Don't think of it as a commitment; it's okay if you can't ever do it again.'"

Silva, whose children are 2 and 6, adds, "It's easy to be a role model for young people. You can work at a health fair, give a talk in your child's classroom, or, better yet, coach your kids' ball teams or be their 'team mom.'"

• Grassroots Advocacy •

Child's comment sparks 'no smoking at school' bill

BY JANE STOEVER

Sometimes anger breeds advocacy.

Tim Alford, M.D., of Kosciusko, Miss., was at home one night last fall, sitting in the kitchen while his wife did the dishes. His wife and son were talking.

"Matthew caught the third-grade teacher smoking behind the school today," said John Paul, a fourth-grader.

That riled up his father. "I did some soul-searching," said Alford, vice president of the Mississippi AFP.

The next morning, before seeing patients, Alford called the local school superintendent.

"We don't have a no-tobacco policy," said the superintendent. Some schools have smoking zones intended to be out of the children's sight. The teacher may have been in a smoking zone.

Alford recalled seeing football coaches smoking. "Local politics is a formidable force," he thought.

John Paul, fourth grader:
"Matthew caught the third-grade teacher smoking behind the school today"

So he went up the chain of command. He called the state superintendent of education, who said he'd rather not grapple with the issue; he saw it as a local matter. "You'd do local districts a favor if you carried the battle for them," said Alford.

The state superintendent replied that if Alford could get support, the state department of education might back a statute for smoke-free schools across the state.

So Alford called the state health officer. "I've wanted to make our schools smoke-free for a long time," the officer said. Then the Mississippi Medical Association got on the bandwagon. On Feb. 2, a representative introduced the bill backed by the MAFP, MMA and the department of education.

"We've got a tobacco bill with teeth in it," said Alford. The bill would levy fines of $50, $75 and $150 for first, second and later convictions of adults for tobacco use anywhere on school property within the state.

"Our bill's prospects are good," said Alford. "In early February, the House of Representatives passed a bill to eliminate smoking in all state office buildings. The time is right."

Why did John Paul's statement kick off a legislative campaign?

"Perhaps it was the bulging otitis media I've seen in kids whose parents smoke," said Alford. "Maybe it was giving thrombolytic agents to a man with a 30-year history of smoking the night before in the ER. He's now a cardiac cripple. Anyway, I had zero tolerance for kids seeing teachers smoke."

• Grassroots Advocacy •

Residency finds partners to promote rural health

Rural America is prime territory for public health initiatives like those of the Carbondale, Ill., residency.

The Carbondale, Ill., family practice residency has taken on three projects that mix advocacy with public health.

The residents will present a one-day farm safety program this month at a family farm close to Benton, Ill.

Several residents will start a boat factory project this year at a West Frankfort, Ill., factory with 525 employees. "The company wants us to help the employees prevent accidents," says Penelope Tippy, M.D., residency director. In addition, the residents will conduct cardiopulmonary resuscitation and smoking cessation classes.

The residency is also involved in mental health support, responding to a county health survey that identified the need to address heart disease, dysfunctional families and mental health.

During a meeting with community members to start developing a federally funded, community-oriented primary care curriculum at the residency, Tippy asked the school superintendent what she most needed. "A counselor," said the superintendent. "I've got funding for one half-time."

Tippy laughed and said, "So do I," and they struck a deal. They hired a counselor in November.

In the next few months, residents and the counselor will analyze data from an adolescent health risk survey the school system just gave. They will decide how to start addressing the health risks, including the teens' mental health needs.

The counselor was hired none too soon. While working at the clinic in December, he got an emergency call to come to the high school. He counseled a new student who left "home" after being repeatedly shifted from one far-flung relative to another. The counselor placed the student with a foster family within a week.

That was possible only through the residency's pursuit of the federal grant, the collaborative meeting on the curriculum and the decision to share the counselor.

In other words, administration as advocacy.

• Grassroots Advocacy •

Advocacy: Dangerous to patients' health?

Patient advocacy can be flat-out wrong. Sometimes patients turn up the pressure, seeking care they may not need.

For example, Karen Johnson of Louisville, Ky., sued Humana Health Plan for not covering the hysterectomy her doctor advocated. She won a $13 million verdict in 1998; Humana said it would appeal.

"From what was published about this case, it appears the patient didn't need a hysterectomy. She probably only needed conization of the cervix," says Thomas Felger, M.D., of Fort Wayne, Ind., a member of the AAFP Commission on Health Care Services.

He has not heard of patients being denied care they clearly needed. At medical meetings, when physicians have complained about tight-fisted HMOs, he has asked for specific examples and has gotten no response.

Some legislatures have gotten into medicine and have required the coverage of autologous bone marrow transplants after high-dose chemotherapy for metastatic breast cancer.

That disturbs AAFP President-elect Richard Roberts, M.D., J.D., of Madison, Wis., who says the transplants result from the myth that doing more is doing better.

He adds, "Worse than no hope is false hope."

Roberts serves on the Blue Cross Blue Shield Association Technology Evaluation Program. "Our BCBS panel spent 10 years saying autologous bone marrow therapy doesn't work," he says. "States have mandated it. And you know what? It doesn't work."

• Grassroots Advocacy •

Gun safety finds niche in Wisconsin, hunter haven

Wisconsin has about 6 million people, and every November, about a fourth of them go hunting. "They're all out there shooting Bambi, and about a fourth of the hunters are women," says AAFP President-elect Richard Roberts, M.D., J.D., of Madison, Wis. "You can't make these people agree to restrict the availability of guns." Where legislation wouldn't work, Roberts took a different tack.

As the Wisconsin State Medical Society president in 1993, he launched CHILD SAFE, Children's Health Initiative with Local Doctors for Safety and Firearms Education. It blended four components that continue through a 501(c)(3) foundation:

a speakers' bureau of physicians,

public service campaigns on gun safety each fall,

a WSMS resource center on children and gun injuries, and

community partnerships pairing physicians and local groups in trigger-lock giveaways, hunter safety courses and dispute resolution training at high schools.

Roberts took a box of trigger locks around the state for giveaways. "Every time a camera came up, I'd show the box," he says. By now, CHILD SAFE has distributed some 30,000 trigger locks.

"We felt we could reduce children's gun injuries if we taught people to lock up their weapons in gun safes, use trigger locks and lock up the ammunition separately," says Roberts. "Then kids can't get to the guns. Mom or dad has the key."

Readers respond to presidential contender story

To the editor:

An article in your January issue ("Access to Health Care: It's One Hot Potato for Presidential Contenders") has Robert Reischauer saying, "The country has no shortage of health care resources" -- this is doubtful -- "but they are poorly distributed. Redistribution will mean taking away some resources currently enjoyed by one sector of the population for another."

This idea of declaring that some individuals have too much and forming a system in which people are only permitted to have according to their perceived needs was not successful when tried in the 20th century. It is known as communism.

In addition, the article improperly assumes that those without health insurance have no access to health care. The article also omits that many of the uninsured have chosen to go without health insurance because they prefer to spend the money on other things. Instead of discussing the uninsured, we should discuss those truly without access to health care, and this number is fractional by comparison.

Further socializing our already over-socialized medical system will not resolve this issue.

Bryan Jefferies,
fourth-year medical student,
Indianapolis

To the editor:

In the recent FP Report, you address the issue of the uninsured. While I read about lots of solutions, I never read about the obvious. I practiced in Canada before socialism, and we employed a very simple device to treat the uninsured or underinsured.

The device was charity. It is not a dirty word. It ennobles both giver and receiver. The uncollected fees from this charity work were deductible from our ordinary income, which provided some incentive to continue the care at a fraction of the cost of government programs.

Calvin Ennis, M.D.
Pascagoula, Miss.

A pill that cures every ill? Tell patients: Not gonna happen!

When a patient demands unneeded antibiotics, sometimes you just have to say no. But you can soften the blow with a good dose of education, according to family physician John Hickner, M.D., of East Lansing, Mich.

"Patients are most satisfied when their doctors listen to them and provide them with access," he said. "I'm seeing more patients who accept my explanation that they don't need antibiotics."

So what should you do if a patient demands antibiotics?

First, "get behind the patient's demand," said Hickner. "Why are they demanding it?" If the request is based on misinformation, spell out the facts about viral vs. bacterial infections and explain the risks involved in taking unneccesary antibiotics.

Next, offer suggestions for treating the patient's symptoms, such as over-the-counter remedies, more fluids and rest. If the patient remains unconvinced, Hickner said you have two options.

Just say no. "You can tell the patient, 'It wouldn't be good medicine for me to provide an antibiotic. If you don't get better, give me a call and let's talk about it,'" said Hickner.

Or prescribe drugs -- with a caveat. "Some doctors are writing a prescription and telling the patient, 'Just wait a few days to fill the prescription and see if you get better,'" Hickner said. If you opt for this solution, write a time-dated prescription (so the patient doesn't save it for the next time he's sick) and choose a basic, narrow-spectrum antibiotic.

Regardless of your approach, you might appreciate a little help. The CDC offers an abundance of resources on a section of its Web site called "Antibiotic Resistance: A new threat to your and your family's health." Just surf to www.cdc.gov/ncidod/dbmd/antibioticresistance/. The site also includes an order form with many free patient education materials.

And if you need a refresher course in antibiotic resistance, download the slide presentation or check out the other resources for health care providers.

Immunization schedule has footnote change

The 2000 Recommended Childhood Immunization Schedule, United States, has a change in its second footnote. The line regarding infants born to HBsAg-positive mothers should read, "Infants born to HBsAg-positive mothers should receive hepatitis B vaccine and 0.5mL hepatitis B immune globulin (HBIG) within 12 hours of birth at separate sites. The 2nd dose is recommended at 1 to 2 months of age and the 3rd dose at 6 months of age."

You can get a copy of the schedule with the updated footnote by visiting the AAFP Web site at www.aafp.org/x7666.xml or by calling AAFP Express, the Academy's document-by-fax system (see "Quick Fax" for directions).

AAFP has 19 AMA delegates

The Academy may send 19 delegates and up to 19 alternates to the AMA House of Delegates in 2000, thanks to votes by FPs and GPs.

The AMA, since 1997, has allowed each medical society within the AMA to gain added delegates through an annual ballot. The Academy has garnered more delegates than other medical groups, meaning the AAFP can cast more votes at AMA meetings.

SOCIETY*

DELEGATES

AAFP
ACOG
ACP/ASIM
ACR
ASA
APA
AAP 19
11
10
10
8
7
6

* Societies listed include the American College of Obstetricians and Gynecologists, American College of Physicians/American Society of Internal Medicine, American College of Radiologists, American Society of Anesthesiologists, American Psychiatric Association and American Academy of Pediatrics.

AAFP cancels complementary and alternative medicine course

Low registration has forced the cancellation of the AAFP's first national CME course on alternative medicine. The course, "Complementary and Alternative Practices: What Your Patients Are Asking," was scheduled for March 23-25 in Kissimmee, Fla.

The registration numbers came as a surprise in light of extensive member feedback expressing interest in such a program, said Pam Williams, acting assistant director of the Academy's CME Division. "We'll try to meet their needs by incorporating more programming on complementary and alternative therapies at our other courses throughout the year," she said.

AAFP Candidates

The Kansas AFP announces the candidacy of Deborah Haynes, M.D., of Wichita for AAFP president-elect.

The Uniformed Services AFP announces the candidacy of Warren Jones, M.D., of Kapolei, Hawaii, for AAFP president-elect.

The Louisiana AFP announces the candidacy of Michael Fleming, M.D., of Shreveport for re-election as AAFP speaker.

The Illinois AFP announces the candidacy of Carolyn Lopez, M.D., of Chicago for re-election as AAFP vice speaker.

Administration's budget plan for family practice training in 2001: $0

For the second year in a row, the Clinton administration has "zeroed out" family practice training funds in the proposed Title VII budget.

The budget would boost spending for the National Institutes of Health to $18.8 billion, giving NIH a 5.6 percent increase. But the budget would eliminate Title VII funds for primary care training, including family practice training.

"You cannot have state-of-the-art medical care without state-of-the-art medical training," said AAFP President Bruce Bagley, M.D., of Albany, N.Y., in a news release Feb. 7, the day Bill Clinton released his proposed budget for 2001.

Forty-two percent of graduates of family practice programs funded by Title VII entered practice in medically underserved communities in fiscal year 1999, according to the Health Resources and Services Administration. That figure is three to four times higher than the percentage of all health professionals who entered practice in underserved areas.

"To get health care to the American families who need it most, we need more training for family physicians," said Bagley. "The proposed Clinton budget takes us in the wrong direction, and it must be fixed."

For 1999, the specialty's Title VII funds were $50.5 million. For 2000, although the administration called for no funding, the specialty will receive about $49.5 million because of Congress' support.

For fiscal year 2001, the Academy has already begun lobbying to maintain federal backing for family physicians' training.

About one-third of family practice residencies applying for and qualifying for Title VII funds last year were funded. The other 44 applicant residencies met the underserved preference criteria, but no federal funds were available for those programs.

Bagley objected, "Funding should not be cut; it should be increased."

Order from AAFP at (800) 944-0000 unless otherwise noted.

Stay current with AAFP This Week, the new e-mailed update. Each issue contains key information, often linked to other Web sites. If you've given AAFP your e-mail address, you're already receiving the update each Wednesday. If you haven't, go to www.aafp.org/members/thisweek to subscribe. Unsubscribe at any time by visiting the same site.

Make sure you see the Family Practice Management articles that interest you. Sign up to get the FPM table of contents by e-mail before the issue hits your desk. Visit www.aafp.org/fpm, enter your e-mail address and click the button. Or e-mail fpmedit@aafp.org and ask for the new e-mail service.

The Lecture Highlights of the 1999 AAFP Scientific Assembly CD-ROM lets you hear Assembly speakers' voices while you view their slides and visual aids (#R027, $99).

The research brochure "Is Our Health Care System Losing Its Balance? The AAFP Research Initiative" describes the $7.7 million initiative to boost the specialty's research. Call for a free copy (#R965).

Proven value: Family Practice Board Review courses prepare you for certification or recertification (#R225; $910 for early registrants; see "Quick Fax" for dates and locations). Other board review materials: an audio CME package has audiotaped lectures, a syllabus and post-test (#R275, $695); a resource packet is available in audio form (#R272, $35) and video form (#R274, $45).

FP Report is published by the AAFP News Department.
Copyright © 2000 by American Academy of Family Physicians.

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