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FP Report
November 2000 • Volume 6 Number 11

'Keystone III' sparks rich discussion on-site and online

BY SARAH THOMAS

Colorado Springs, Colo.

What was it like -- "Keystone III," the Oct. 4-8 family practice think tank in the mountains of Colorado? Did it accomplish what it set out to do? The answer is yes, if participants' comments are any measure.

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Keystone's diverse attendees assessed the specialty's present and envisioned its future. Some faces of Keystone, clockwise from top left: practicing FP David Loxterkamp, M.D., Belfast, Maine; academician Rosemary Stevens, Ph.D., Philadelphia; resident Erika Bliss, M.D., Seattle; new practicing physician Terrence Steyer, M.D., Charleston, S.C.; solo FP Regina Benjamin, M.D., M.B.A., Bayou La Batre, Ala.; and family practice pioneer Eugene Farley Jr., M.D., M.P.H., Verona, Wis.

Keystone III aimed to "examine the soul of the discipline of family medicine" -- to take stock of the present and grapple with the future of family practice. To begin the specialty's evolution to the next level, if you will.

To get a sense of the discussion, check out these comments:

"A regenerating experience."

"I found the sessions stimulating, challenging, sometimes frustrating and often reassuring."

"Intense."

"What next?"

"I'm thinking about issues like our social contract, moral authority -- I wasn't before this conference."

"I feel this meeting will be a turning point, in ways yet to be determined, in my career."

"Yes, people are listening on the Web. This technology absolutely amazes me. Thank you so much for opening the door -- I mean, the information highway."

"This is a great idea -- it allows me to participate from the comfort of my own home."

These are just a few of the comments from the 82 conference attendees and from online participants who accessed the live webcasts of the conference.

The event followed in the footsteps of Keystone I and II, held in 1984 and 1988 at Keystone, Colo.

Gayle Stephens, M.D., of Birmingham, Ala., an early pioneer of the specialty, created the early Keystones as times of meditation in the mountains -- times for family physicians to stimulate each other's thinking, provoke each other, inspire each other. Stephens planned this Keystone, too, along with John Frye, M.D., professor and chair of the family medicine department, University of Wisconsin-Madison; Robert Graham, M.D., of Bethesda, Md., former AAFP executive vice president; and Larry Green, M.D., director of The Robert Graham Center: Policy Studies in Family Practice and Primary Care in Washington.

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While participants' opinions often clashed, the end result was unity. Embodiment of that unity: conference planner Gayle Stephens, M.D., right, of Birmingham, Ala., walks arm in arm with Kent Smith, M.D., of Cleveland to discuss a Keystone session.

 
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Keystone III drew together 82 attendees and even more online participants to discuss "next steps" for family practice.

Attendees were diverse -- academics, practicing FPs, men, women, minorities. And they represented three "generations" of family physicians, from early leaders to those joining the specialty in the '90s.

Three participants were assigned the task of summarizing the four days of intense discussion on the final day.

No action items were identified during the conference -- which is exactly what was intended.

"What we planned -- what we hoped for -- was a rich dialogue where we could come together for an ongoing discussion of multiple topics at various levels. The degree of our success will be measured by our ability to maintain the discourse," said Green. Ultimately, that discourse should lead to consensus on a vision for the future of family practice, he said.

Discussion papers presented during the conference will be published in the April 2001 issue of the Society of Teachers of Family Medicine's journal, Family Medicine, with complete proceedings to follow later in the year. You also can find the discussion papers archived at http://www.aafp.org/keystone.

The meeting was sponsored by the AAFP, AAFP Foundation, American Board of Family Practice, Association of Departments of Family Medicine, Association of Family Practice Residency Directors, North American Primary Care Research Group and STFM.

Remind your patients: Come December, it's not too late to vaccinate for flu

Steps you can take

  • Reassure your patients that getting vaccinated in December is worthwhile. It takes about two weeks for full protection -- and flu season peaks in February or March, the CDC says.
  • Determine which patients are most vulnerable to the effects or complications of the flu. Vaccinate those high-risk patients first when your supply arrives.
  • Finally, remember to give your high-risk patients pneumococcal vaccine if they haven't been immunized with it yet.

Your patients want the shot, but you can't provide it -- yet. Is that the scenario in your practice regarding the influenza vaccine?

The vaccine supply problem has created an extraordinary situation this year. According to the CDC, vaccine supplies should
be about equal to what was distributed last year -- but much
of it will reach providers later than the usual October delivery. As much as 24 percent of the vaccine is expected to be distributed in December, the CDC says.

Some AAFP members have called the Academy to report they haven't gotten their vaccine supply, while grocery store flu clinics down the street are in
full swing.

The Academy has been in contact with vaccine manufacturers about the situation, said Herbert Young, M.D., director of the Scientific Activities Division.

Manufacturers have said that shipments usually are made on a first order in, first order out basis.

"We've been reassured that vaccine is moving through the system, and, if you ordered vaccine, you will get it eventually," Young said.

According to manufacturers, vaccine is shipped as soon as it's released. No vaccine is currently being delivered outside of existing orders.

And the CDC has contracted with one manufacturer to produce an additional 9 million doses that will be made available to providers who haven't yet ordered vaccine.

Visit CDC's National Immunization Program Web site at http://www.cdc.gov/nip/flu-vac-supply/ for more information on vaccine availability. Go to http://www.cdc.gov/od/oc/media/pressrel/r2k1006.htm for updated flu vaccination recommendations.

One more time, patient's rights bill flounders

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At press time, it seemed likely the U.S. Congress -- for the third year in a row -- would adjourn without passing a comprehensive bill for patient's rights.

"This has been the Congress of missed opportunities and misplaced priorities," said AAFP President Richard Roberts, M.D., J.D., of Madison, Wis., early this month. "Patients and their doctors have been struggling for years with arbitrary HMO rules and red tape, and all this Congress can do is tell them to wait another year for help."

"We need Congress to step up and get the job done," said AAFP Board Chair Bruce Bagley, M.D., of Albany, N.Y. "It's important to have a strong bill of rights for patients so all health plans have to put the patient first and put profit further down on their priority lists."

Some HMOs -- those Bagley considers the most responsible -- already apply key provisions found in the Bipartisan Consensus Managed Care Improvement Act. For example, contracts Bagley has reviewed lately call for ready access to emergency care, an end to gag clauses, and internal and external appeals processes for patients denied care. The bipartisan consensus bill would have ensured that all health plans, not just some, gave patients needed protections. The bill would also have allowed patients to sue HMOs, something no HMO welcomes.

The House of Representatives passed the bipartisan consensus bill in 1999, but it floundered in the Senate this year. The Academy and many other medical groups criticized the watered-down bill of rights the Senate passed this summer.

Last-ditch efforts this fall to craft a compromise -- initiatives the Academy was deeply involved in -- had failed at press time.

Why? The sticking point is the patient's right to sue managed care companies. Insurers object to that, saying it will drive up health care costs. Senate leaders in the end refused to compromise and enact modified liability provisions letting patients sue HMOs.

Where do we go from here?

Differences in what are acceptable liability provisions had narrowed as the 106th Congress was winding down. Both the Republican and Democratic leaders of the House would like to pass a patient's rights bill.

"The key to success in the 107th Congress again will be with the Senate leadership, but sentiment in both chambers has moved in favor of a patient's bill of rights," said Jeffrey Human, director of the Academy's Washington office. "We hope to turn the tide in 2001."

Dealing with Obesity

Why bother with obesity?

The last decade of the 20th century left one statistic behind that America shouldn't be proud of: From 1990 to 1999, there was an unprecedented increase -- a whopping 60 percent increase -- in the number of overweight Americans.

That's got everyone worried, from parents of obese children, to physicians who observe the condition in their patients every day, to officials at the CDC. Experts compare the rapid spread of obesity to that of a communicable disease.

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Obesity contributes to 300,000 deaths annually in the United States, making it the second leading cause of preventable mortality in this country. The World Health Organization estimates that more than half of U.S. adults are overweight, and about one-quarter are clinically obese. Perhaps even more alarming is the fact that one out of four American children and teens is overweight or obese.

Overweight and obesity are big business in the United States, too, with weight loss programs and special foods pulling down a hefty $30 billion or more annually. That amount, however, pales in comparison with the drain on the U.S. economy from obesity-related health problems. That drain now hovers around $100 billion -- nearly 7 percent of total U.S. health care expenditures.

Got your attention? Good. On this and the following two pages, here's a closer look at dealing with America's obesity epidemic. And watch for the December FP Report for more on the topic.

Create an 'obesity-friendly' office

BY SHERI PORTER

It may take a small investment in time and money, but consider it your job to ensure that obese patients feel welcome in your office. So says family physician Raul Zimmerman, M.D., co-director of the Halifax Medical Center Weight Management Program in Daytona Beach, Fla.

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Zimmerman promotes an "obesity-friendly" office, and it starts with attacking America's collective heftiness for what it is -- a serious national health problem -- instead of sweeping it under the rug. "There are a lot of us out there who aren't acknowledging the problem and advising patients," says Zimmerman, citing a study in which 58 percent of obese patients said their physicians didn't bring up their weight during the course of the office visit.

The next hurdle is attitude -- which should be open and nonjudgmental. "This is a chronic illness," Zimmerman says. "No one laughs at other chronic illnesses such as diabetes or coronary artery disease. Obesity can be just as deadly." Train your staff to be sensitive by being a good role model, he says. Don't tolerate behind-the-back whispers and jokes about obesity, even in private.

Your office equipment and instruments may need an update as well. Some examples:

Lastly, Zimmerman urges physicians to turn defeat into victory: "When a patient comes in, one of the first things I focus on is what went right since the last visit. I give a lot of positive strokes for those good behaviors. Once I've done that, then we talk about slip-ups."

'Apples' and 'pears': defining the shape of the problem

BY CINDY McCANSE

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Think about it: Lugging around those extra pounds can't possibly be good for you in the long run. Just consider the strain on the heart and joints, boosting the risk of cardiovascular complications and ost eoarthritis. And then there are the psychosocial implications: Obesity remains highly stigmatized in our society.

To make matters even more complex, it's now a well-established scientific fact that it's not just the extra weight that's problematic, but how that weight is distributed. Patients with an abdominal fat distribution pattern ("apples") face even greater health risks than those whose fat is deposited primarily in the thighs and buttocks ("pears").

The reason?

Abdominal fat cells are larger than those deposited in the lower body -- and they're more efficient at breaking down lipids into fatty acids, says Ahmed Kissebah, M.D., professor of medicine and chief of endocrinology, metabolism and clinical nutrition at the Medical College of Wisconsin, Milwaukee. Circulating free fatty acids hamper muscle cells' glucose uptake, which, in turn, elevates blood glucose levels and increases the risk for type 2 diabetes.

The picture is further complicated by the fact that fatty acids from abdominal fat can travel directly along the portal vein to the liver, where they suppress insulin breakdown. Resulting increases in circulating insulin can lead to decreased insulin sensitivity and insulin resistance.

The flood of circulating fatty acids may have other consequences as well, Kissebah and others believe. Namely, it appears to stimulate hepatic release of triglycerides, leading to atherosclerosis and increasing the risk of heart attack and stroke. Some even postulate that this barrage of fatty acids may in and of itself raise blood pressure, perhaps by increasing arterial sensitivity to hormones that mediate blood vessel contractility, such as epinephrine.

Upper-body obesity also affects respiratory function, according to obesity researcher Peter Kopelman, M.D., a professor at the Royal London School of Medicine who has studied the problem. Increased fat deposition in the chest wall and abdomen alters the mechanical properties of the chest and diaphragm, reducing lung volume and necessitating increased respiratory effort to compensate for decreased ventilatory capacity.

Typically, a waist-to-hip ratio value of greater than .80 in women and greater than 1.0 in men confers an increased risk for these complications.

Obesity-related respiratory changes are exaggerated during sleep, often producing apnea and associated hypoxia, Kopelman says. Prolonged, severe hypoxic episodes can result in cardiac arrhythmias. Alternatively, chronic hypoxia and hypercapnia, pulmonary hypertension overlying an already stressed circulatory system and right-sided cardiac failure form the clinical picture of obesity-hypoventilation syndrome, previously known as pickwickian syndrome.

Although standardized height-for-weight charts, calculation of body mass index and measurements of skinfold thickness are all used to identify overweight and obese patients, waist-to-hip ratio is considered the most reliable method to differentiate apples from pears. Typically, a WHR value of greater than .80 in women and greater than 1.0 in men confers an increased risk for these complications.

While the science of obesity may be complex, the take-home message seems clear: Yes, size does matter, but in the end, it may be the shape that determines things to come.

Nature vs. nurture

Is obesity grounded in genetics or behavior -- or both?

BY CINDY McCANSE

Seldom in medicine has the relationship between genetic predisposition and environmental influences been more ardently investigated than in obesity research.

Are patients, simply by virtue of their genotype, sentenced to a lifetime of struggling against weight gain regardless of their eating and exercise behaviors? Or should the rising prevalence of obesity in this and other developed countries be attributed to behavioral responses to changing environmental factors -- from fast food to the television remote control?

Apparently, the answer is both.

According to Raul Zimmerman, M.D., director of the Halifax Medical Center Family Practice Residency in Daytona Beach, Fla., and co-medical director of the center's weight management program, the genetic basis of obesity is best viewed in terms of what's known as the discordance hypothesis. Speaking at a Sept. 20 session on obesity at the AAFP Scientific Assembly in Dallas, Zimmerman put it succintly: "The problem is that we have old genes in a new environment."

Raul Zimmerman, M.D.
"The problem is that we have old genes in a new environment."

Our genetic makeup, Zimmerman noted, originated in a harsh environment in which subsistence depended on hunting and gathering, physical activity was mandatory for survival and periodic famine was the norm. The human gene pool, he added, has not changed substantially since that time. Thus, in today's environment, where food is more plentiful and in most cases easier to obtain, those same genes favor obesity.

Using this concept as a starting point, researchers conducting studies of comparative body mass index values among twin pairs and other family members have estimated that genetics contributes to about 40 percent of obesity variance. Variations in prevalence according to demographic and/or socio-economic factors suggest a model in which susceptibility to obesity is largely a function of genetics, but the environment determines phenotypic expression.

Studies using animal models have helped identify gene loci that, in the presence of specific environmental variables, produce obesity. Recent advances in mapping the human genome have confirmed that some of these areas have homologues in humans.

Gregory Barsh, M.D., Ph.D., associate professor of pediatrics and genetics at Stanford University School of Medicine, Stanford, Calif., uses animal genetics as a model system to study human body weight regulation. He cited one example of a determinant of human obesity first hinted at by genetic studies in mice.

"MC4R, or melanocortin 4 receptor, is the gene identified to date that is a major contributor to human obesity," said Barsh. "As many as 5 percent of morbidly obese patients have been found to have an alteration in MC4R."

Using both mendelian and quantitative genetic approaches, researchers have now identified more than 200 genes and gene markers that contribute to human obesity. But that's just the beginning. Much still remains to be done to translate these findings into appropriate and effective prevention and treatment strategies.

Basically, Barsh said, genetics may serve two primary functions in helping obese patients.

"This is all hypothetical at this point," he noted, "but we may be able to identify patients who are deficient in a certain protein. Type 1 diabetes presents an excellent example in which patients are treated by replacing insulin." In much the same manner, he went on, "We may be able to use genetics to replace genes that are defective."

Also, Barsh added, clinicians could use genetics to reveal whether a patient's obesity is due to inappropriately high appetite or inappropriate peripheral utilization of nutrients. "If you can identify which of those mechanisms is responsible for a patient's obesity, you can target drug therapy specifically to that cause," Barsh said.

Diet, exercise

Look to lifestyle changes to battle obesity, these FPs say

BY SHERI PORTER

There's no arguing with statistics that show Americans are bulking up. But there is a lot of discussion about how to deal with it.

Researchers pursue the perfect weight-loss drug as if it were the Holy Grail -- yet for most

overweight Americans, the current choices are the familiar twosome: what you put in your mouth, and how much you move your body.

It makes sense that if we're not burning up calories at our jobs, then we're going to have to plan other times for physical activity. Yes, enter that dreaded concept so many Americans avoid -- exercise. And it's not just adults who need it. Too many children spend too much time indoors. Remember when kids played outside until sundown -- or some adult -- made them come in?

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Izabela Riffe, M.D., of Jacksonville, Fla., is one FP worried about the lack of exercise in children. Her concern led her to submit a resolution from the Women Physicians Constituency that was adopted by the 2000 AAFP Congress of Delegates Sept. 18-20 in Dallas. The resolution encourages Academy support of a public health initiative to provide and promote exercise education to the general public and to school-age children.

Why is an initiative needed? Look at the school curriculum in your hometown, Riffe says. In her district, physical education requirements for high-school students have dropped to an all-time low.

"How can we approach this topic in a positive way? I would like to see us emulate Tar Wars," she says, referring to the popular and successful anti-tobacco education program supported by the Academy. Train FPs to go into neighborhood schools and talk to kids about exercise, Riffe urges.

It's not punishment

No matter what their age, when you give heavy patients a prescription for exercise, the prescription shouldn't sound punitive, says Raul Zimmerman, M.D. He's co-director of the weight management program at Halifax Medical Center in Daytona Beach, Fla., and director of the center's family practice residency.

Instead, says Zimmerman, be upbeat and realistic when discussing the issue of exercise with these patients. Ultimately, you want that patient to exercise five to seven days a week, but start small. "For some individuals, that may mean as little as sitting in a chair and moving their arms around for five minutes," he says.

If you ask Zimmerman, who is a runner, to recommend the best exercise, his stock response is, "What will you stick with?" For example, he says, "If the patient wants to swim, but the nearest pool is 12 miles away, it's just not going to happen."

Promote healthy eating

Another Academy member taking a positive approach to combating obesity is Javette Orgain, M.D., of Chicago, the immediate past president of the National Medical Association and current chair of the Illinois AFP's urban health committee. Orgain laments the poor nutritional choices schoolchildren encounter every day.

"They have hamburgers, nachos, pizza and very few vegetables, very little fruit," Orgain says. "Any child who wants an alternative diet has to bring it to school. School officials are catering to the popular taste buds of the children."

Orgain actively supports Healthy School Nutrition, a plan endorsed by five leading medical associations, including the AAFP, and the U.S. Department of Agriculture.

Coming in the December FP Report: the link between obesity and diabetes, an update on treatments for obesity and how a poor reimbursement track record hurts everyone.

The national initiative, unveiled this past summer, challenges schools and communities to promote healthy eating in America's schools. To view the 10 key elements highlighted in the Healthy School Nutrition plan, go to http://www.aafp.org/news/tenkeys.html.

"We need to put some pressure on those who are providing the food, to provide nutritious, delectable meals, something that is attractive to the children," says Orgain. Then she goes one step further: "We need to remove those vending machines that sell junk foods in schools."

Unfortunately, many parents don't do much better at home, Orgain says: "Parents provide children with junk food -- they're buying it as part of the daily staple when they go grocery shopping."

And don't discount the power of advertising. It's hard to combat clever marketing by fast food companies, says Zimmerman. "My kids are offered the latest Disney toy to buy a Happy Meal, but nobody ever offers my kids anything to eat steamed broccoli -- and that's a national problem."

Explore these resources

American Family Physician has published many articles in 2000 to help family physicians deal with obesity in their practices. Check out the following issues at http://www.aafp.org/afp: Sept. 1, July 15, June 15, April 1 and Feb. 1. In addition, check out http://familydoctor.org for AAFP patient education resources on obesity and related topics.

Below are more resources available for physicians and patients.

Web sites:

Journals and journal supplements:

Books:

'Extreme' or otherwise: Wear protective gear for sports

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Should the new "extreme" sports make a difference in doctor's orders?

Not really.

Whether you're talking about an extreme sport such as skysurfing -- or a perennially popular one such as bicycling -- if your patients participate in them, you should encourage use of protective equipment.

Take bicycling, for example. The stats tell the story: The Bicycle Helmet Safety Institute (http://www.bhsi.org) reports that bike crashes kill 900 every year and send about 567,000 to emergency rooms with injuries. The use of a bicycle helmet can reduce the risk of head injury by 85 percent, the institute says -- but the Consumer Product Safety Commission (http://www.cpsc.gov) reports that 50 percent of bike riders do not regularly wear one.

And adults, not just kids, need protection. According to CPSC, sports-related injuries among adults ages 35 to 54 increased about 33 percent from 1991 to 1998.

A policy adopted by the AAFP Congress of Delegates Sept. 18-20 in Dallas calls for family physicians to counsel patients about protective equipment, including:

The policy, actually an update of an existing policy, "wasn't necessarily in response to the fact that there are these new, potentially dangerous sports out there," says Robert Pallay, M.D., of Belle Mead, N.J., a member of the Commission on Public Health, which developed the policy. But the updated policy is timely in light of today's take-it-to-the-edge, extreme activities, he says.

AAFP sets deadlines for awards, proposals

Take note of these upcoming AAFP deadlines in 2001. For each listing below, call the contact person at (800) 274-2237 and the extension number provided, or send an e-mail to the e-mail address provided.

The Thomas W. Johnson Award honors Academy members who have made outstanding contributions to family practice education at the undergraduate, graduate and continuing education levels.

The Exemplary Teaching Awards recognize members who have demonstrated excellence in teaching as well as those who have implemented outstanding educational programs and/or created innovative teaching models. Nominations may be submitted only by AAFP constituent chapters.

Application materials for the Exemplary Teaching Awards will be mailed to all chapter executives in January. Nomination packets for the Thomas W. Johnson Award will be available in mid-January and can be obtained by contacting Stacy Singleton at Ext. 6705 or ssinglet@aafp.org. Questions about both awards may also be directed to Singleton.

Financial Summary

This financial summary has been prepared to present an overall picture of AAFP's financial condition and operations.

CONSOLIDATED STATEMENTS OF FINANCIAL POSITION
  May 31, 2000 May 31, 1999
Assets    
Cash and cash equivalents $7,747,710 $11,249,567
Receivables (net) 8,514,261 6,989,824
Income tax refund receivable 2,275,000 1,895,547
Inventory of publication materials 109,266 100,739
Prepaid expenses and other assets 3,270,410 2,529,569
Marketable securities at fair value 38,840,809 47,490,180
Property and equipment:    
Land 5,781,848 495,000
Office buildings 29,785,415 2,011,609
Office equipment, furniture and fixtures 9,128,013 11,623,337
  44,695,276 14,129,946
Less allowance for depreciation (4,951,591) (6,774,910)
  39,743,685 7,355,036
Investments in deferred compensation plan at fair value 1,969,523 2,155,379
Total assets $102,470,664 $79,765,841
     
Liabilities and Net Assets    
Liabilities and deferred revenues    
Accounts payable $4,370,383 $4,327,313
Accrued expenses and other liabilities 4,662,479 4,069,737
Unearned revenue 18,138,878 17,297,976
Mortgage note payable 23,487,400 --
Liability for deferred compensation plan 1,969,523 2,155,379
Income taxes payable 2,234,257 2,037,619
Deferred rent concessions -- 283,387
  54,862,920 30,171,411
Net assets    
Unrestricted 47,607,744 49,594,430
Total liabilities and net assets $102,470,664 $79,765,841
CONSOLIDATED STATEMENTS OF ACTIVITIES
Revenues    
Membership dues and fees $14,074,193 $13,492,260
Publications 21,379,880 21,379,880
Programs and miscellaneous 23,922,925 23,749,399
Investment income 4,753,091 4,384,218
  64,130,089 60,585,660
Expenses    
Membership services and programs 33,069,641 1,440,186
Publications 12,880,494 11,127,888
General and administrative 14,885,357 11,282,495
Income taxes 1,440,186 2,389,132
  62,275,678 56,132,028
Revenues in excess of expenses 1,854,411 4,453,632
Other income (expense):    
Income tax refunds 28,029 60,663
Net unrealized gains (losses) on marketable securities (3,869,126) 1,458,914
Insurance refund -- 3,047,925
Change in net assets (1,986,686) 9,021,134
Net asstes, beginning of year 49,594,430 40,573,296
Net assets, end of year $47,607,744 $49,594,430

The above data are only a part of the complete financial statements examined by PricewaterhouseCoopers LLP, certified public accountants.

Inside the Beltway

Pro/con pain relief bill

To the editor:

After reading the September FP Report regarding the "pain relief bill," H.R. 2260, I am confused. I wonder if AAFP leaders are discussing the same bill as William Toffler, M.D., author of a letter in the September issue. The bill is in response to the dangerous and unfortunate assisted suicide law in Oregon. I have to agree with Toffler's comments -- the Academy is on the wrong side of this issue.

AAFP's opposition to the bill seems to stem from concerns about unwarranted restrictions on the professional autonomy of physicians. The profession has failed to live up to its responsibility and to its ethical code in this area.

The House bill addresses two failures by the medical profession. The more recent failure is not consistently providing adequate and compassionate end-of-life care. The bill addresses that by provisions for CME to disseminate knowledge of state-of-the-art pain relief and by protecting physicians from prosecution for deaths possibly related to the "double effect" of large doses of narcotics needed to control terminal pain.

The other failure is a weak response to the challenge of the culture of death that assisted suicide represents. I believe we would not now be where we are regarding this legislation, had the medical profession not caved in to pressure from nonrepresentative cultural élites to participate in legalized abortion.

Roger Kimber, M.D.
Lancaster, Pa.

To the editor:

In a letter expressing his disapproval of AAFP's opposition to the Pain Relief Promotion Act, Dr. Toffler writes of the "specter of agents interfering with medical practice." His "specter" is in fact written into the proposed legislation, which creates programs to train law enforcement personnel, both federal and nonfederal, in the "legitimate use of controlled substances in pain management." That provision, inviting federal agents to second-guess the intent of physicians caring for the terminally ill, may not scare Dr. Toffler. It did scare the majority of the houses of delegates of both the Oregon Medical Association and the Oregon AFP. Both organizations are on record as opposing the bill.

Dr. Toffler writes, "The truth is that the PRPA provides no new authority to the Drug Enforcement Administration." In fact, according to the legal counsel of the OMA, the bill authorizes the DEA to make rules to implement the "legitimate medical purpose" of alleviating pain. This provision appears to supersede what in the past has been the responsibility of state licensing boards.

Apart from the provision of a paltry $5 million for physician training in palliative care, the bill, now supported by the AMA, is in substance the same bill as the AMA opposed a year before. I applaud the AAFP's stand.

Peter Goodwin, M.D.
Portland, Ore.

Chiropractic subluxation: for real?

To the editor:

WE WANT LETTERS
Address letters to:
FP Report
11400 Tomahawk Creek Parkway
Leawood, KS 66211-2672
fax to (913)906-6089; call (800) 274-2237;
or contact pbinder@aafp.org via e-mail

Please keep your letters to a maximum of 200 words; all letters are subject to editing.

The tone of the September FP Report story about partnering with the chiropractic ("Chiropractic: From Taboo to Partner in Care for Some Physicians") does not reflect my views. Ever since formulating a lecture presentation in 1994, "The Unquenchable Quest for Questionable Cures," I have been awaiting the then-promised research proving the contention that the chiropractor's theory of subluxation has basis in reality.

Most recently when I researched the Web site http://www.chiroweb.com/forum/important.html, I was again told ongoing studies just yet cannot substantiate the basic premise of this lay alternative to health care ... i.e., subluxation resolution. Until chiropractors have definitive proof of their "cures," I remain skeptical of the nonscience they practice. I encourage other discerning family practitioners to do the same.

I am of the opinion subluxation does not even occur in the first place. If my opinion is correct, the U.S. health care dollar is too precious to expend in partnering with the chiropractic.

John Records, M.D.
Franklin, Ind.

In support of birth control services

To the editor:

We were appalled by the letter "Birth Control Services" in the September FP Report. According to the American Medical Women's Association, more than 50 percent of pregnancies in this country each year are unintended, and more than half of all unintended pregnancies end in abortion. Inadequate access to birth control methods is at the root of this public health issue. Clearly, the AMA House of Delegates (the only "force" that the AAFP is aligned with on this issue) sees the wisdom in this position. It recently passed a resolution upholding access to "pregnancy prevention services" in the face of mergers and/or acquisitions of health care systems ("AAFP Speaks up for Access to Reproductive Care," August FP Report).

Catholics for a Free Choice reports that in approximately one-third of the mergers of Catholic and non-Catholic facilities in 1996 and 1997, all reproductive health services were discontinued at the non-Catholic facility. In addition, CFFC reports that the number of Catholic "sole provider" hospitals (a federal designation) rose by 65 percent between 1994 and 1997. Some serve counties where Catholics make up less than 1 percent of the population. According to the Religious Coalition for Reproductive Choice, "When a provider with restrictive religious rules dominates most or all health care services in one market, patients are in danger of losing their access to the full range of health services -- regardless of their religious affiliation. In a nation founded on religious freedom, it is fundamentally wrong for one religion to impose its beliefs on all citizens."

Rebecca Keim
Kelly Ramsey, M.P.H.
Medical students
Milwaukee, Wis.

How are we doing? AAFP wants your input!

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The AAFP wants to ask you three quick questions -- to learn what you think about whether the Academy is providing good ways for you to give feedback.

When you call the Academy and speak with the Membership Division, or when you access the member side of the AAFP Web site at http://www.aafp.org, you'll have the opportunity to answer those three questions.

Some members will also have the opportunity to speak directly to AAFP President Richard Roberts, M.D., J. D., of Madison, Wis. He's calling one member a day to learn about issues important to that member.

Halt 2000 proposal appears dead; pain relief bill still pending

Inside the Beltway

Congress had not yet adjourned for the year at press time, but the Academy and other office-based groups appeared to have succeeded in protecting resource-based practice expenses.

However, it was still possible the Pain Relief Promotion Act, which the AAFP has fought, might become law.

Halt 2000 -- RBPE. Hospital-based specialists have asked Congress for a partial halt in the 1998-2002 transition to resource-based practice expenses, a factor in the Medicare fee schedule.

The halt would have frozen at year 2000 levels the cuts in practice expense payments for hospital-based specialties. The AAFP and other office-based groups argued that the highly technical specialties had been unfairly favored when practice expenses were repaid according to historical charges.

Seeing the logic in the office-based groups' viewpoint, Congress -- at press time -- was not even considering halting the carefully planned RBPE transition.

Pain relief bill. "We urge you to actively oppose the Pain Relief Promotion Act and to veto it in any legislative vehicle to which it may be attached," said AAFP Board Chair Bruce Bagley, M.D., of Albany, N.Y., writing to President Bill Clinton Oct. 31.

The bill aimed to stop assisted suicide. The Academy opposes assisted suicide but still lobbied aggressively against the PRPA. Why? Because the PRPA would have amended the Controlled Substances Act and called for training Drug Enforcement Administration agents to investigate physicians' prescribing practices for the terminally ill. The bill could have put physicians at risk for civil and criminal penalties for prescribing needed pain medicine for dying patients, the AAFP contended.

At press time, with Washington in gridlock, there were questions about whether the Senate would pass an omnibus bill with the PRPA attached and about whether the omnibus bill would be signed into law or, if vetoed, overridden by Congress.

New For You
Order from AAFP at (800) 944-0000 unless otherwise noted.
A shipping fee may apply; Kansas residents pay a 6.875 percent tax. photo

American Family Physician on CD-ROM lets you research or review key topics from articles in the past six years of AFP. Request #R576 for $112.50. If you already have last year's edition, your update, #R575, costs $85.50.

Access the e-mail discussion lists titled Quality Improvement and Clinical Procedures to share ideas on what works and what doesn't in your efforts to boost quality of care and patient satisfaction. Go to http://www.aafp.org/members/lyris/ and use your AAFP ID number to subscribe.

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Thinking about e-mailing with your patients? Check out http://www.aafp.org/quality/module/mod6/ for a sample brochure and patient consent form on e-mailing, adaptable to your practice.

AAFP Patient Education Handouts on CD-ROM -- with more than 450 handouts in both English and Spanish -- provides printable handouts on a multitude of health conditions, and the handouts are easy to read. The CD-ROM is #R1598, costing $175. If you bought the last version, you can purchase the update, #R1599, for $95.

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

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