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August 2000 • Volume 6 • Number 8

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Ask senators to defeat pain relief bill -- vote is imminent

BY JANE STOEVER

Pain management: top priority for the terminally ill

It's crunch time for contacting Congress about the pain relief bill. What's up? The final vote -- this time in the Senate -- is expected late this month on the Pain Relief Promotion Act, H.R. 2260. The Academy has fought the legislation for more than two years. Now the AAFP is seeking your help in letting senators know why the bill won't work.

H.R. 2260 challenges Oregon's assisted suicide law. The bill calls for training Drug Enforcement Administration officers to review physicians' prescriptions of federally controlled substances for terminally ill patients.

The Academy continues to oppose assisted suicide as being contrary to physicians' responsibility to save lives, to heal.

But this bill -- designed to relieve pain and prevent assisted suicides -- could backfire. It could tie physicians' hands in countering pain effectively.

AAFP letter. "Proper and effective pain management is the number one priority of terminally ill patients and their families," said AAFP Board Chair Lanny Copeland, M.D., of Albany, Ga., in an Aug. 3 letter to all senators. "We are concerned that this bill could leave federal agents second-guessing physician prescribing of necessary pain medication."

Penalties. H.R. 2260 could make physicians liable for civil and criminal penalties for prescribing pain medicine patients needed.

Coalition. The Academy has been a leader of a 41-member coalition of national and state organizations fighting H.R. 2260. The bill's opponents include the American Geriatrics Society, American Cancer Society, American Nurses Association, Oncology Nurses Society, American Pharmaceutical Association and American Pain Foundation.

Speak Out. To e-mail your senators or review a sample letter urging them to defeat H.R. 2260, open http://www.aafp.org/gov and click on "Speak Out" and then on "Write to Congress."

Act now. The House of Representatives passed the bill last year by a bipartisan vote of 271-156. Please contact your senators right away and ask them to defeat the bill.

Immunization update: PPV and influenza

When it comes to adult immunizations, the pneumococcal polysaccharide vaccine gets no respect. And while patients generally know to seek out an annual flu shot, they may not find it so easy this year as distributors deal with a vaccine shortage.

Counsel patients about once-in-a-lifetime PPV

The AAFP Commission on Clinical Policies and Research has conducted an in-depth literature review followed by focus groups with physicians and patients to identify reasons for the low PPV immunization rates. Barbara Yawn, M.D., of Rochester, Minn., a commission member, says the AAFP hopes to help family physicians overcome those barriers to protect patients against bacterial pneumonia.

The Academy recommends that FPs discuss the immunization with all patients who are aged 65 years and older and with high-risk patients. Yet only 54 percent of adults 65 and older had received the immunization by 1997, the most recent year with available statistics. So why aren't people getting the vaccine?

AAFP influenza immunization prioritization policy The AAFP Board recently approved a new policy recommending prioritization of the influenza immunization in the event of a shortage. The policy: The American Academy of Family Physicians recommends that those individuals at highest risk for influenza should be given priority to receive the influenza vaccine. These include individuals who have medical conditions that put them at increased risk, including chronic cardiopulmonary disorders and metabolic diseases including diabetes mellitus, hemoglobin-opathies, immunosuppression and renal dysfunction; those who are residents of chronic care facilities; and health care providers, followed by other individuals aged 65 years and older, then by individuals aged 50 years and older.

"The primary barrier for everybody seems to be awareness," said Yawn. "There's just not a sense that this is a big deal." In fact, pneumococcal infections are the most common cause of bacterial pneumonia requiring hospitalization in the United States and result in about 40,000 deaths annually (twice the number caused by influenza).

In addition to a general lack of awareness about the PPV, people also think they're safe as long as they get an annual flu shot, Yawn said. "I think they may have the misperception that you get the flu first, and then you get pneumonia."

Another barrier is patients' sense that they're not at risk for pneumonia. Patients who are institutionalized; have chronic cardiac or pulmonary disease, diabetes or anatomic asplenia; or live in areas with an increased risk of pneumococcal disease should definitely receive the vaccine, Yawn said. "But there are some pretty clear indications that otherwise healthy people over 65 should get it, too."

Patients cite cost as another impediment, but Medicare covers the PPV for patients 65 and older, and insurance plans may cover it for younger patients if it's deemed appropriate.

Yawn said every adult patient's chart should include an immunization page, which can be quickly reviewed to ensure that the once-in-a-lifetime PPV has been administered. (Some patients require a booster.)

The new "Periodic Health Examinations: Summary of AAFP Policy Recommendations and Age Charts" includes recommendations for the PPV, as well as tools such as flow charts. They're free; just call the AAFP order department at (800) 944-0000 and request item #R962, or check them out at http://www.aafp.org/exam on the Academy's Web site.

"Just like with children, you can't always count on elderly people coming in for a well visit or a preventive care visit," Yawn said. "You have to take advantage of other opportunities. If they come in for something that is not life-threatening and you deal with their concerns, they'll talk to you about other things that need to be done."

Yawn said the AAFP is studying ways to help FPs incorporate the PPV into their care of older patients. She encouraged physicians to share their success stories by sending a letter to Bellinda Schoof, AAFP scientific affairs manager, 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672.

Flu vaccine in short supply

Anticipating a shortfall of this year's influenza vaccine, the CDC's Advisory Committee on Immunization Practices has issued recommendations regarding flu immunization efforts.

The recommendations are published as a "notice to readers" in the CDC's July 14 Morbidity and Mortality Weekly Report. Read it at http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/mm4927a4.htm online.

"For the 2000-01 influenza season in the United States, lower than anticipated production yields for this year's influenza A(H3N2) vaccine component and other manufacturing problems are expected to lead to a substantial delay in the distribution of influenza vaccine and possibly substantially fewer total doses of vaccine for distribution than last year," the article says.

Noting that many vaccine providers are planning their fall vaccination activities, the ACIP offers the following recommendations:

• Delay implementation of organized influenza vaccination campaigns until early or mid-November.
• Continue routine vaccination of people who are at high risk for complications from influenza and their close contacts.
• Develop a provider-specific contingency plan for an influenza shortage in order to maximize vaccination of high-risk patients and health care workers with available vaccine.

Calling all FPs

Join the push to increase minority organ donations

BY SHERI PORTER

The very concept of organ transplantation still inspires a sense of awe in many Americans. But for some minority groups, that second chance at life is elusive.

Statistics tell the story. Every day, 14 Americans die while waiting for an organ or tissue transplant. Half of those are minorities.

Margo Ferguson, M.D., works up a sweat in the MOTTEP of Detroit 5K walk Aug. 12 to draw attention to the critical need for minority organ donors.

In 1998, 50 percent of the 53,000 people listed on the national transplant waiting list were minorities. But minorities represented just 25 percent of the donor pool. That's not good news, considering that compatible matches are most often found within the same racial or ethnic group.

Blacks are particularly hard hit, because diabetes and hypertension, leading causes of dialysis and organ failure, affect this group disproportionately.

"We recognize that the need for donors must be indelibly etched into the hearts and souls of the minority population because we are in much greater need than the majority population," says Clive Callender, M.D., a transplant surgeon at Howard University Hospital in Washington, D.C.

Callender, founder of the national Minority Organ Tissue Transplant Education Program, knows the numbers and understands the reasons behind them. Minority groups, particularly blacks, don't donate for five reasons: lack of awareness, religious misperceptions, fear, mistrust of the medical community and racism.

MOTTEP, funded by the National Institutes of Health, has grown since its inception in 1993 into a network spanning 15 American cities. MOTTEP targets five minority groups, including Latinos, Native Americans, Arabic Americans and Pacific Islanders. But the biggest push -- and the biggest need -- is in black communities.

What can you do to help? Make organ donation information available in your office. Display it prominently, or, better yet, hand it directly to patients. Utilize routine office visits -- don't wait for an emergency. Talk statistics with your minority patients. Emphasize family communication. Check out these resources: Minority Organ Tissue Transplant Education Program: http://www.lifegift.org/mottep.htm Institute for Minority Health Research: http://www.sph.emory.edu/bshe/imhr/organdonation.html Archives of Family Medicine, July 2000, "Family Physicians' Role in Recruitment of Organ Donors," by AAFP members Susan Bidigare, M.D., Detroit, and Aaron Ellis, M.D., St. Clair Shores, Mich. The AAFP Board of Directors approved a policy statement on organ donation at its March 14-18, 2000, meeting. Call (800) 274-2237, Ext. 4130, to request a copy of the statement.

Remonia Chapman, program director of MOTTEP of Detroit, says the organization's grass-roots strategy works by tapping messengers such as religious leaders, donor families, organ recipients and wait-listed patients.

But there's another type of leader that both Callender and Chapman would like to see in the trenches with them: the family physician.

"Here's a person that is really involved in the total health care of entire families -- and here's an issue that can be the focus of family discussions. I cannot think of a better person to serve as a catalyst for that particular discussion," says Chapman.

Family physician Margo Ferguson, M.D., of Detroit says broaching the subject of organ donation can be difficult, especially in her inner-city clinic. "I have to deal with a lot of stereotypes and myths about organ donation -- it's a cultural thing," she says. Still, she takes advantages of opportunities when they arise. When a 10-year old patient recently went on the heart transplant waiting list, Ferguson gently approached the child's mother about becoming involved with MOTTEP.

Similarly, when a patient is diagnosed with hypertension or diabetes, Ferguson snatches the opportunity to teach other family members -- first about their own health and preventive measures such as losing weight and lowering blood pressure, and secondly, more discreetly, about the need to sign an organ donor card.

FP Linda Davenport, M.D., of Ann Arbor, Mich., also works closely with MOTTEP. She knows that the ER is not the best place to begin a family discussion about organ donation. "It's a time of high stress, and that's really a bad time to initially present the subject," she says. Instead, Davenport uses the window of opportunity at the end of a health maintenance exam. After she's reviewed smoking cessation or STD prevention, after she's talked about high blood pressure, she might just turn the conversation in a different direction.

"It's just another opportunity to present the topic, and then if they're faced with the issue, it's nothing new ... 'This is something I've heard over and over -- my family doc talks about it, has information on it.' It's old hat by the time the procurement specialist approaches them in the ER. It's okay, it's expected," Davenport says.

She also tells all patients, adults and teens, to discuss their wishes about organ donation with their families. "If your next of kin are there and they say no, then it's no. The thrust now is to be a donor and tell your family."

2001 ACF kicks off at Assembly

The launch of the coming year's Annual Clinical Focus, ACF 2001: Asthma, Allergy and Respiratory Infections, at the Scientific Assembly in Dallas promises to be anything but dull. If you attend, be prepared to bounce out of your seat, clap your hands and follow along with some powerful lyrics.

The official jumping-off point isn't until a Sept. 22 press conference at the Dallas Convention Center featuring AAFP President Bruce Bagley, M.D., of Albany, N.Y., and ACF medical director Stephen Spann, M.D., of Houston. However, ACF 2001 will likely get a pre-emptive boost at a special presentation the evening before, "Musical Medical Education for Adolescents."

In sensitized patients, allergens encounter IgE antibodies bound to mast cell or basophil membrane receptors. An antigen-antibody complex is formed that provokes a chain of reactions leading to release of inflammatory mediators.

That session will feature two dynamic FPs, John Clarke, M.D., and his brother Matthew Clarke, M.D., both of New York City. The brothers Clarke rocked the house during the Aug. 2-6 National Conference of Family Practice Residents and Medical Students in Kansas City, Mo. They told of their success in using music to appeal to adolescent patients with asthma -- and then followed up with a rousing rendition of their hit rap single, "Asthma Stuff."

One can only hope the Scientific Assembly session will be as -- shall we say -- moving.

ACF is an educational initiative created to bring family physicians state-of-the-art information about a specific area of medical practice. Core ACF elements offered free at Assembly include two main-stage lectures, two three-hour courses and a Video CME program.

Additional core elements include articles in AAFP publications, an American Family Physician monograph and patient education handouts. ACF-related topics will also be included during national CME meetings throughout the year, and members will receive a wrap-up ACF CD-ROM at year's end.

ACF 2001 has been developed in cooperation with the National Heart, Lung and Blood Institute; American Lung Association; National Institute of Allergy and Infectious Diseases; and American Thoracic Society. The 2001 initiative is supported by educational grants from Bristol-Myers Squibb Co.; Schering Laboratories/Key Pharmaceuticals; Aventis Pharma; Glaxo Wellcome Inc.; Roche Laboratories; Pharmacia Corp., Diagnostics Division; and Alcon Laboratories Inc.

In its previous three years, ACF has given you the tools to break down barriers to patient care. In 2001 -- thanks to the Clarke brothers -- it'll also give you a chance to bust a move.

AAFP takes a stand against media violence

The Academy recently took a stand against media violence and joined other medical organizations in a statement about the problem that gained plenty of media attention.

More than 1,000 studies "point overwhelmingly to a causal connection" between violent entertainment and the likelihood that children will become aggressive, mistrustful and emotionally desensitized to violence in real life, the statement said.

The Commission on Public Health has been studying the problem.

Commission member Leah Raye Mabry, M.D., of Pleasanton, Texas, said the commission's ongoing look at media violence has opened her eyes to the size and prevalence of the problem.

"Our study showed that the majority of violent acts on TV are carried out on Saturday mornings, when parents and adults use television to distract their children so they can get things done," Mabry said. "We were stunned at the violent acts carried out on those so-called 'comedy hours.'"

That's why the Academy signed on to the July 26 statement decrying violence on TV and in films, music, computer games and video games that was issued by the American Medical Association, American Academy of Pediatrics, American Psychological Association and American Academy of Child and Adolescent Psychiatry, along with Sen. Sam Brownback, R-Kan. Then the AAFP Board of Directors adopted a policy against violence at its July 25-30 meeting in Vancouver, British Columbia.

"America's children are caught in the cross fire," said AAFP President Bruce Bagley, M.D., of Albany, N.Y., during the flurry of media activity following the initial statement.

"The key to stopping violence among youth is communication, education, awareness and action on the part of parents, other role models and communities. Quality television programming and educational Internet sites are available. We want to be sure America's children and youth are receiving positive messages, not negative ones," he said.

Mabry agrees. She said that following the commission's initial work -- and presentations about media violence by fellow commission members Marshall Kubota, M.D., of Santa Rosa, Calif., and Jeannette South-Paul, M.D., of Burtonsville, Md. -- the commission furthered its studies to confirm that media violence was contributing to child and elder abuse, as well as a full range of family problems.

This is not just a child problem, in other words.

"This directly speaks to the catchall of antisocial behavior," Mabry said. "We see it develop in children, and we know what it's going to look like when they get older."

HHS launches national campaign to improve care for underserved people

BY SHARON DENT

Comparing the nation's health care system to a patchwork quilt, Assistant Surgeon General Donald Weaver, M.D., told attendees at the Aug. 2-6 National Conference of Family Practice Residents and Medical Students in Kansas City, Mo., that some mending is in order.

Donald Weaver, M.D., National health Service Corps director, details ways to provide high-quality care to underserved groups.

"I believe that we really don't have a health care system in the United States of America," said Weaver, National Health Service Corps director. "What I believe we have is a patchwork quilt. It's a quilt that's warm and secure for many, to be sure, but it's threadbare and worn and nonexistent for many others. We still have work to do."

Repairs will involve three major steps, he said.

First, everyone should have health insurance. Weaver reminded the crowd about the State Children's Health Insurance Program, which has the potential to enroll 10 million children.

However, he stressed that insurance is useless if the patient has no access to health care services. "Once someone has that insurance card, they need to have a quality primary care home that has a base in prevention," said Weaver.

Finally, he said, "keep your eye on the prize." The third step of health system reform involves improving care of individuals and communities.

The Bureau of Primary Health Care in the U.S. Department of Health and Human Services has launched a new campaign with those three steps in mind, Weaver said. The campaign's theme is "100 Percent Access and Zero Health Disparities."

To promote those lofty goals, the bureau examined models in communities that were successfully meeting the health needs of their patient populations.

What were some common threads in these models?

• Each included community-responsive health care providers and administrators.
• Each demonstrated a working knowledge of the importance of cultural com-petency.
• The use of interdisciplinary teams enabled each model to tap the strengths of every team member.

For more details on the campaign, go to http://bphc.hrsa.gov/campaign.htm on the Web.

National Conference offers full plate of activities

Practice tips, career advice, hands-on procedures classes, leadership seminars, a huge exhibit hall and even a little rap music filled out the agenda for attendees at the Academy's National Conference for Family Practice Residents and Medical Students Aug. 2-6 in Kansas City, Mo. More than 2,800 people participated in the meeting, including 746 students and 642 residents.

Sangita Doshi, M.D., of Jenkintown, Pa., left, and Christine Crowder, M.D., of Philadelphia honing their soft-tissue surgical skills.

Delegates at the student and resident congresses sent 62 resolutions to the AAFP Committee on Resident and Student Affairs. The following is a sampling of those resolutions. The source of each resolution -- the National Congress of Family Practice Residents or the National Congress of Student Members -- is listed:

• Investigate development of a task force on complementary and alternative medicine. (NCSM)
• Commit to at least one high-quality research journal for original clinical research by family physicians. (NCFPR)
• Work with the pharmaceutical industry to streamline the process of acquiring and dispensing products for indigent patients through Patient Assistance Programs. (NCFPR)
• Establish a goal of reducing smoking to 10 percent of the U.S. population by 2005 and 5 percent by 2010. (NCSM)
• Work with existing gun violence education programs or develop a new program to educate children about the consequences of gun violence. (NCSM)
• Encourage incorporation of Tar Wars into family medicine interest group programming. (NCSM)

One resolution will come before the Congress of Delegates this month in Dallas: The student and resident congresses each called on the AAFP to take a leadership role in developing and maintaining a coalition to address student interest in family practice.

Next year's National Conference will be July 25-29. Mark your calendar, and ask your constituent chapter for help in getting one of about 70 scholarships to attend.

Closing ceremonies at the National Conference, left photo, included a square dance for residents, students and their families. Kenneth Fink, M.D., of Chapel Hill, N.C., right photo, testifies on a resolution before the resident congress.

Student and resident congresses elect leaders

The National Congress of Family Practice Residents and the National Congress of Student Members elected the following new leaders Aug. 5.

Members of AAFP Board of Directors: Jennifer Aloff, M.D., of Midland, Mich., and Andrew Mills of Tulsa, Okla.

Resident National Conference Chair: English Gonzalez, M.D., of Silver Spring, Md.

Student National Conference Chair: Chris Lupold of Wayne, Pa.

Alternate delegates to AAFP Congress: Elizabeth Jo Johnson, M.D., of Greeley, Colo.; Michael Sevilla, M.D., of Warren, Ohio; Saria Carter of Gainesville, Fla.; and Russell Kohl of Oklahoma City

Representatives to the Society of Teachers of Family Medicine Board of Directors: Lou Lukas, M.D., of Allentown, Pa., and Nancy Pandhi of Front Royal, Va.

National family medicine interest group coordinator: Jaime Hartung of North Canton, Ohio

Observer to the Association of Family Practice Residency Directors Board of Directors: Wendy Madigosky, M.D., of Denver

Jennifer Aloff, M.D.

Andrew Mills

English Gonzalez, M.D.

Chris Lupold

Get on board to practice abroad

BY CINDY McCANSE

You don't have to join the Navy to see the world. If you have a hankering to travel, why not give it an altruistic bent? Opportunities to practice international medicine are out there, according to the presenters of a workshop, "International Medicine: Career and Service Opportunities," at the Aug. 2-6 National Conference of Family Practice Residents and Medical Students in Kansas City, Mo.

Ariel Cole, M.D., and Kira Zwygart, M.D., both of the Florida Hospital Family Practice Residency in Orlando, spoke about their experiences providing medical care in other countries.

First of all, said Cole, don't do it for the wrong reasons. "Don't think you're going to go in there to 'show 'em how it's done,'" she admonished. "And don't view it as an opportunity to try a procedure or equipment that you wouldn't do here." It's not a vacation, either, she added. You go expecting to work -- and work hard.

Cole listed personal attributes essential to a successful stint as an international physician, including flexibility, creativity and humor. Good interpersonal skills are a must, she said, to communicate effectively with patients and the colleagues you'll be working alongside. The language barrier shouldn't necessarily put you off. She asked, "Are you good at charades?"

Zwygart discussed funding opportunities available to medical students and residents wanting to make an international contribution. Some pharmaceutical firms offer financing for such endeavors, she noted, but check regulations to ensure that you're not in violation of state law by accepting industry support.

"Look to your community first," Zwygart advised. Cole agreed, adding that you'll often be surprised by just how willing local businesses and individuals are to help.

But nothing, of course, can happen if you don't know where to go to find out -- well -- where to go. Fortunately, there are online resources to help (see box below).

Once you've finalized your destination and made your funding arrangements, said Cole, the rest is pretty obvious: Get your shots, read up on where you're going ahead of time, and, once you get there, don't go into areas where you shouldn't be.

Despite the hardships, Cole said, it's an experience you don't want to miss.

"You'll gain an appreciation for how blessed we are. We're brought up with food and clothing and health care. A lot of people around the world don't have that," she said.

Where in the world ... ? The International Medical Volunteers Association at http://www.imva.org International Health Electives Web Page at http://www.amsa.org/resource/intl/intlintro.html Diversion Magazine Web Page at http://diversionmag.com

It's the online FMIG

The Academy's new Virtual Family Medicine Interest Group Web site has gone live. Go to http://fmignet.aafp.org/ to find it.

Modeled after the Academy's successful campus FMIGs, Virtual FMIG provides information and resources that empower medical students to explore the discipline of family medicine and learn about topics such as career choice, role models, leadership development, residency, the "match" between residency candidates and residencies, clinical resources, technology and more.

Though parts of the site are still under construction, it is updated regularly and organized by year -- look at M1 your first year, M2 your second and so on.

"Beyond the Classroom" is another good place to start. It allows you to gain the experience and insight you can't get from a textbook.

Academy and AAFP Foundation offer new opportunities for residents

Speakers at the Aug. 2-6 National Conference of Family Practice Residents and Medical Students in Kansas City, Mo., announced several new opportunities for family practice residents:

• Resident Community Outreach Award. Modeled after the Academy's student award, this new program recognizes community service projects of family practice residents who are AAFP members. Winners will receive a $600 travel grant to attend the National Conference. Up to two awards will be presented annually. Application details will soon be available at http://www.aafp.org/residents; the deadline to apply is May 5, 2001.

• Resident position on the AAFP Foundation Board of Trustees. Apply by Sept. 27 to be a full-voting member of the foundation's board. The foundation board meets twice a year -- in May and November -- and you'll also represent the foundation at the National Conference. For an application and more details, call (800) 274-2237, Ext. 4450.

• Research Skills Workshop for Family Practice Residents. This new National Conference program will kick off at the 2001 meeting. Supported by a grant from Pfizer Inc., the one-day workshop will introduce medical students and residents to the field of medical research. Residents who attend the session will then be eligible for 10 AAFP Foundation grants of up to $2,000 to perform research projects, and some of those residents will receive travel grants to present scientific papers at the 2002 conference. Interested? Just register at next year's meeting.

• Physicians With Heart Scholarship. Travel to Vietnam Feb. 16-25, 2001, as part of the Physicians With Heart airlift, a joint venture of the Academy, AAFP Foundation and the humanitarian organization Heart to Heart International. The foundation scholarship, supported in part by a grant from McNeil Consumer Healthcare, will cover travel expenses for a resident to join the delegation, which will deliver pharmaceutical products and medical supplies, present CME programs and participate in a nonmedical humanitarian project. Call (800) 274-2237, Ext. 4450, for an application and more information; the application deadline is Sept. 27.

• Resident Reporter Program. This new AAFP Foundation program supported by Wyeth-Ayerst will select 40 family practice residents to attend the Academy's Scientific Assembly. The residents will have an opportunity to write a paper about a session they attend at the meeting for possible inclusion in a bound journal to be distributed to all residency programs. For more information, call (800) 274-2237, Ext. 4410.

Integrative medicine, or 'keeping body and soul together'

BY CINDY McCANSE

Ginkgo biloba shows promise in managing cerebral insufficiency.

Family physician Jane Murray, M.D., has for two and a half years shared her Mission, Kan., office space with a veritable smorgasbord of complementary/ alternative medicine providers.

She practices alongside two specialists in Oriental medicine, a massage therapist, a Taoist counselor, and a specialist in craniosacral and other natural therapies, as well as a more traditional cadre of nurses and ancillary health care personnel. Together, she and her colleagues at the Sastun Center of Integrative Health Care help people find ways to tap into their own inner healing power.

"I honestly think that's what family medicine is," Murray explained. "It's integrating whatever helps the patient."

Family physician Donald Novey, M.D., medical director of the Center for Complementary Medicine in Park Ridge, Ill., holds a similar view of CAM.

"It's a set of useful tools to help people," said Novey. "What we've been able to show here is that you can implement complementary medicine in a safe setting and keep everybody happy."

His center boasts a staff of 12 CAM practitioners and provides a wide range of services, including chiro- practic; acupuncture; massage, nutritional and craniosacral therapies; homeopathy; and herbal medicine.

Oriental medicine specialist Joseph Thomas, Ph.D, uses acupuncture for pain relief.

Novey and his colleagues are also involved in the educational aspects of CAM. Lutheran General Hospital, which sponsors the integrated center, initiated the nation's first family practice residency rotation in alternative medicine. The result: a class of FPs comfortable with mixing Western medicine with complementary practices.

A logical integration

Murray seems genuinely puzzled by the fact that more physicians don't see the logic of integrating traditional and nontraditional care.

"I've always been interested in nonconventional care, especially the whole issue of the mind-body connection," said Murray. "I don't know why it's looked upon as such an outlier, because the whole psychosocial connection to health is the main thing we do in family medicine."

Dealing with psychosocial issues is an integral part of Murray's practice. She spends an hour or more with each new patient because, she explained, "Patients want to sit here and talk and be heard. I want to see what they want from me."

Herbal remedies play a role in patient care in some integrated practices.

Sometimes, what a patient needs is best provided by another member of the clinic's staff. And often, two or more Sastun providers are simultaneously involved in any one patient's care.

Needless to say, Murray doesn't see herself in the role of the traditional physician/authority figure -- far from it. Patients, she said, need to invest in their own well-being.

Making a personal health investment

One way she and her colleagues ensure that patients make that commitment is by eschewing participation in health insurance plans. All patients pay for their care out-of-pocket.

The simple act of pulling the cash out of one's pocketbook, Murray said -- even if the patient later files for insurance reimbursement -- makes that patient more cognizant of what he or she is receiving in return, thus increasing the chance that patients will work hard to protect their health.

There's another reason for handling payment this way: Many insurers refuse to pay for CAM services. It's a problem with which David Frank, M.D., of Middletown, Pa., is all too familiar.

Jane Murray, M.D., and Joseph Thomas, Ph.D., discuss patient care at a weekly staff meeting at the Sastun Center.

A board-certified family physician specializing in sports and rehabilitative medicine, Frank is medical director of WellQuest, a collaborative health institute created last June by PinnacleHealth System of central Pennsylvania. The four-hospital health care system owns 22 family medicine practices, six of which now integrate a variety of CAM services.

"We try to make it as easy for our patients as we can," Frank said. "We code everything for them, give them the ICD-9 codes, the CPT codes -- everything. But we tell them it's not necessarily going to be reimbursed."

It's not that managed care is inherently bad, said Murray, but she does believe it has fostered a "huge disconnect" between payer and patient, a breach that the physician is often expected to fill.

"I don't want to be the interpreter of the health plan," Murray said. "I want to love my work; I want to love my practice. I believe you should do medicine for love. Make your money another way."

Chiropractic

From taboo to partner in care for some physicians

BY CINDY McCANSE

To say "You've come a long way, baby" isn't the half of it when you're talking chiropractic. Just ask family physician Carl Anzerillo, D.O., a solo practitioner at De Soto Family Practice in De Soto, Kan.

"At one time, it was totally taboo," said Anzerillo. "Now it's practically mainstream." Once maligned and discredited by the AMA, chiropractors now command a patient base of 12 percent to 15 percent of the U.S. population. They currently number about 60,000 and are licensed in all 50 states. Chiropractic services are covered by Medicare, Medicaid, workers' compensation programs and many private insurers.

Manipulative therapies have been around for millennia. Their early presence has been documented in such diverse locations as China, Babylon and Tibet. Hippocrates practiced spinal manipulation, as did Greek-born Roman physician Galen in the second century A.D.

The birth of modern chiropractic can be traced back to the turn of the 20th century, when Daniel David Palmer founded it on the premise that vertebral subluxation was the cause of virtually all disease. Chiropractic adjustment, he asserted, provided the sole cure.

Although few contemporary chiropractors would fully embrace Palmer's "one cause, one cure" philosophy, correction of spinal subluxations remains at the heart of today's chiropractic science.

Chiropractic is based on the tenet that an inseparable link exists between structure and function: Proper physiologic function requires balance among the bony structures of the body, particularly the spine.

Also integral to the chiropractic philosophy is a belief in the body's innate healing ability. Patient and practitioner work in concert to bring about a return to equilibrium and promote overall wellness.

That last part sounds familiar, no doubt. It's that very similarity between the missions of chiropractic and family medicine that led Anzerillo to team up with Ella Ladd, D.C., last January.

Anzerillo said he's been combining traditional and complementary practices for 25 years. "I find it to be a good marriage, if you will," Anzerillo said.

He said he's had success using manipulation -- whether his osteopathic version or Ladd's chiropractic rendition -- in combination with nonsteroidal anti-inflammatory drugs to treat lower back pain. A certified acupuncturist, Anzerillo also incorporates some elements of Eastern medicine when treating patients with certain structural complaints, such as sinusitis.

His philosophy of healing? "We try to look at the whole patient," Anzerillo said.

He explained that the so-called Cartesian divide in Western medicine came about in medieval times, when philosophers such as René Descartes concerned themselves with the head, while scientists focused solely on the body. The church declared the head to be the seat of spirituality, and never the twain should meet.

"Eastern medicine has always incorporated mind, body and spirit," Anzerillo said. "It's what we should have been doing all along."

Now, he added, "We're seeing all of this re-engineered, and it's producing good results."

Policy center sports new name to honor former EVP

A surprise announcement came after dinner one evening at the AAFP Board of Directors meeting in Vancouver, Canada, July 25-30. The Academy's policy center in Washington is now the Robert Graham Center: Policy Studies in Family Practice and Primary Care, in honor of former Executive Vice President Robert Graham, M.D.

Graham acknowledged the honor with these words: "Your generosity in naming the center for me will have a double meaning because, for the 30 years of my professional career, I have essentially worked in only two places, the Academy and Washington. To have something in Washington that is in my name and something that makes a contribution to the discipline ... I'd never have thought of this, so the surprise is even more profound. Thank you very much."

The policy center, which opened July 8, 1999, serves to bring a family practice point of view to the frequent health care debates that are spawned in Washington.

HCFA responds to physicians' concerns about fraud/abuse audits

Your Medicare carrier tells you your billing's incomplete. Or your carrier says you're overbilling. You disagree. You get audited. And you fear penalties if it's discovered that you or your staff made a few honest mistakes.

Frustration with the Medicare watchdog has led physician organizations, including the AAFP and the AMA, to urge the government to adopt a more sensible approach to preventing fraud and abuse.

Now, a breakthrough: Someone's been listening.

On Aug. 7, the Health Care Financing Administration issued a program memo requiring carriers to take "corrective action." A few corrections carriers must make:

• Validate potential problems by taking a sample of claims (up to 40) to see whether a physician is filing claims in error.
• Subject providers only to the amount of medical review necessary to address the nature and extent of the problem.
• Consider the provider's current error rate and the history of the provider when deciding how to address the problem. (In other words, it's now harder for carriers to go after physicians with clean records.)
• Educate the provider and give feedback about the problem.
• Remove providers from medical review as soon as possible when they demonstrate compliance with billing requirements.

"We need a fair and just system," says AAFP President Bruce Bagley, M.D., of Albany, N.Y. "HCFA's memo indicates the government appreciates what we've been saying: It's time to stop harassing well-intentioned physicians and focus on deliberate institutional fraud and abuse."

Future of family practice

To the editor:

I am writing in response to the July FP Report article, "Specialty Will Assess Itself, Brainstorm Possibilities." As a second-year family practice resident, I am very concerned about the integrity of family practice in the future. I am most concerned with obtaining hospital and obstetrical privileges.

I am still convinced that family medicine is the pioneer in primary care. However, in our specialist and subspecialist society, family practice physicians are losing privileges because of competition.

I think a solution to this dilemma is for the AAFP to support the creation of additional boarded subspecialties, especially in obstetrics and emergency medicine. They would have fellowship training for from one to two years in a program that is recognized as board certified and would have board examinations equivalent to those for OB-Gyns or emergency physicians. Therefore, a family practitioner who chooses to practice full-spectrum family medicine would not be forced by today's (and tomorrow's) political environment to practice in a smaller community.

Steven Koerth, M.D.
Fort Worth, Texas

Birth control services

To the editor:

I was appalled to read in the August FP Report that the AAFP has aligned itself with forces that seek to force hospitals to provide birth control services.

Let us be clear that we are talking about the elective procedures of vasectomy and tubal ligation. No Catholic hospital is refusing to provide necessary obstetrical care.

I believe that mandating convenient community access to elective sterilization procedures sets a dangerous precedent. It is only a small step away from mandating community access to other elective procedures. The pressure to provide services that conflict with the moral principles of an institution will be extended to physicians. Physicians will be dropped from insurance plans if they refuse to prescribe RU-486, the "morning- after" pill. They will be required to utilize IUDs. It is not difficult to see this scenario expanded to include mandated access to abortion, euthanasia and physician-assisted suicide. The AAFP should rethink its position on this slippery slope.

Denise Hunnell, M.D.
Niceville, Fla.

Pain relief act

To the editor:

I was disappointed in your coverage of the Pain Relief Promotion Act (PRPA), "Pain Relief Act Might Inhibit Use of Drugs to Fight Pain" (FP Report, July). I would have hoped for better balance in a paper which describes itself as providing "news for today's family physician."

The article mentions the concerns of the current leadership of the AAFP but fails to note that the majority of medical organizations, including the AMA and the National Hospice Association, favor the PRPA. These organizations and many others do not share the fears being promulgated, including the specter of "agents" interfering with medical practice.

The truth is that the PRPA provides no new authority to the Drug Enforcement Administration. This legislation seeks to promote more and better pain relief with millions of dollars of funding for educational efforts to teach advanced pain management and palliative care to health care providers. In addition, rather than placing physicians "at risk," the PRPA actually provides new protections for both patients and physicians. Patients will benefit by having assurance that the best (and adequate) pain relief will be more readily accessible in all 50 states. Physicians will be protected in that for the first time, the concept of "double effect" will be codified into DEA regulations. That is, physicians will be able to give pain relief medication to whatever level is necessary to control pain even if an unintended consequence might be a hastened death.

Your article does correctly identify some of the current gaps in providing adequate pain relief to those who need and deserve help. The PRPA is a sensible and much-needed step toward filling this need. As such, I am particularly disappointed that the energy and resources of our organization are being spent in a misguided effort to undermine such sensible legislation.

William Toffler, M.D.
Portland, Ore.

Editor's note: Refer to page 1 of this issue for an update on AAFP's opposition to the pain relief bill.

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

Enroll now in the AAFP Proficiency Testing program for 2001 to help keep your lab in compliance with federal regulations. New modules include tests for blood lead, Mycoplasma antibody, Giardia antigen, sickle cell and special immunology. For annual enrollment (#R767), costs vary from $50 to $70; prices also vary for lab testing packages. See http://www.aafp.org/pt or call (800) 274-7911 for more information.

Are you part of the handheld computer generation? If so, you can get a little help at http://www.aafp.org/fpnet -- the FPNet Web site. Read articles on palm computers in clinical practice, and then click on "Hardware" and visit Web sites on personal digital assistants.

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

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