February 2001 • Volume 7 Number 2
AAFP asks America: What do you think?
President Richard Roberts, M.D., J.D., fields reporters' questions at the National Press Club while Board Chair Bruce Bagley, M.D., center, and Carlos Gonzales, M.D., listen.
T he Academy posted the above "want ad" to the nation Jan. 11 via a press event at the National Press Club in Washington. The event generated extensive exposure for the Academy's draft proposal for health care coverage for all.
AAFP President Richard Roberts, M.D., J.D., of Madison, Wis., and Board Chair Bruce Bagley, M.D., of Albany, N.Y., headlined the event. They were joined by Carlos Gonzales, M.D., of Patagonia, Ariz., a member of the Commission on Public Health, who gave reporters firsthand examples of what lack of coverage means to his rural patients. AAFP Executive Vice President Douglas Henley, M.D., moderated the event.
Regarding the current health care system, "We can't keep doing what we've been doing because it's not working," said Roberts, producing a quote that was echoed throughout the media in January. USA Today put it in print, and CNN.com was one of many Web-based news outlets that carried it electronically.
What Roberts, Bagley and Gonzales were talking about was not new in one sense: The Academy has long sought to achieve health care coverage for all.
But what was new was the effort to summon involvement from all corners, far beyond the health care provider arena, in finalizing a plan to reform the dysfunctional system. The story and splashy quotes weren't all that gained mainstream press -- the http://www.aafp.org/unicov site did, too.
"There is a new opportunity today to take action," Roberts said Jan. 11. "But action is predicated on understanding. That's why we present this proposal, to help all Americans walk through the core elements of this very complicated issue and to help make some fundamental decisions."
The deadline for responding to the AAFP's draft proposal is Feb. 28. Go to http://www.aafp.org/unicov to read the plan; use the e-mail address provided to comment on it.
Watch for it! Public awareness campaign kicks off this month
FPs Leonard Fromer, M.D., of Santa Monica, Calif., and D. Ann Travis, M.D., of Fairburn, Ga., are featured in this year's ads. It starts this month in USA Today, one of the nation's most-read newspapers, and The Washington Post, the top paper in the U.S. capital -- and on the airwaves with National Public Radio's highest-rated news programs.
"It" is the Academy's multimillion-dollar, multi-year public awareness campaign. Through newspaper ads and on-air sponsorship of NPR's Morning Edition and All Things Considered, the campaign tells Americans that the family physician represents the warm, caring values they most desire in a doctor, combined with specialized training in up-to-date treatments and technologies and an approach that treats the whole person.
USA Today reaches nearly 1.7 million readers daily; The Washington Post reaches nearly 850,000. Morning Edition and All Things Considered reach 13.5 million listeners each week in all major U.S. markets.
"Consider this to be an investment in improving the health of all Americans, by letting them know that having a family doctor is central to good health," AAFP President Richard Roberts, M.D., J.D., of Madison, Wis., says of the three-year campaign. "We intend to create a health system where every American will be able to choose a family physician and every American will want one."
"It's also a campaign that responds to member needs. Many members have told AAFP that they want a national effort to help build recognition and respect for the specialty. And the campaign's timing couldn't be better, with the Bush administration and the newly elected Congress getting up to speed on their plans for action for the coming years."
In 2001, two ads (see right) will give the specialty a sustained presence in the newspapers.
A new advertisement will be added in each of the campaign's remaining two years. The ads will reflect the diversity of AAFP members and their practices.
The NPR sponsorship line will tell listeners the program is brought to them by "the members of the American Academy of Family Physicians, 'specializing in all of you.' Traditional family practice combined with today's medical technology ... familydoctor.org."
Campaign materials are based on a two-year research effort (see article below). The campaign has a $1.5 million budget for its first year.
Campaign's foundation is based on extensive research
The Academy's new public awareness campaign stands on the foundation of a two-year research effort conducted by The Mellman Group, a nationally recognized research consulting firm. Research methods included a survey of 1,000 Americans and one-on-one research interviews. Ad concepts were tested twice to ensure their effectiveness.
"Not surprisingly, the highest-rated ad messages and images reinforced the positive perception that the family physician knows and treats the entire family, while still establishing the family physician's qualifications for providing up-to-date care," said Mark Mellman, president of The Mellman Group. "The best-testing ad concepts depicted families and a relationship with the family doctor. The research shows that even single individuals will respond positively to the family ads."
Federal appeals court rejects FP's lawsuit seeking Caesarean section privileges
BY JANE STOEVER
Eric Runte, M.D., of Sonora, Calif., trained hard as a resident to learn to do Caesarean sections. But he has reached his last roadblock to gaining C-section privileges in his town.
A federal appellate court, in a 3-0 ruling Jan. 8, affirmed a district court's refusal to try the FP's case seeking C-section privileges.
Runte and the County of Tuolumne, backed by the California Academy of Family Physicians, decided Jan. 17 to request a rehearing by the appeals court. Given the 3-0 ruling, however, this option did not bear much promise. And by Jan. 19, lawyers for both sides worked out an agreement: There would be no further appeals, and Runte and his county would not be asked to cover defendants' costs in the case.
"The court of public opinion may be our best future venue," said CAFP Executive Director Susan Hogeland Jan. 19. "While none of us is at all happy with the negative decision rendered by the appellate court, it should come as an incredible relief to conclude any additional potential financial liability."
History of the case
Runte was the primary surgeon at 70 C-sections during his residency, and in 1994, he applied for C-section privileges at the only hospital in his area with a birth center. "There were no restrictions whatsoever at Sonora Community Hospital concerning family doctors doing C-sections when I applied," he says.
The hospital developed its written C-section criteria in 1995, requiring board certification or board eligibility as an obstetrician or the completion of a 36-month residency in obstetrics-gynecology. In 1996, the hospital denied the request by Runte, the first FP to seek C-section privileges there in recent history. "They developed the C-section policy in an effort to keep me out of that arena," says Runte.
He and his county -- which employs him as head of its hospital's clinic -- sued Sonora Community Hospital and its three OB-Gyns. "It's been a very difficult path," says Runte. The restraint-of-trade lawsuit was rejected by a district judge without a trial and then, on Jan. 8, the U.S. Court of Appeals for the Ninth Circuit affirmed the district judge's decision.
Runte's defense cost about $600,000, primarily for court costs and not the contingency-based attorneys' fees. The costs were covered by the California AFP (about $390,000), the AAFP ($150,000), and other chapters and individual FPs (about $60,000).
Runte has continued to assist at C-sections at SCH with the OB-Gyns, including the defendants in the case. He sees closure as helpful: "The case has been a gaping wound, putting a strain on my family and me, affecting my relationships with other physicians in this small town, particularly the obstetricians involved in the lawsuit. Hopefully the wounds can heal with this whole effort coming to a conclusion."
Appellate court's ruling
In its Jan. 8 ruling, the appeals court admitted, "SCH's privileging decision ... effectively forecloses an entire class of medical suppliers, family practitioners, from performing C-sections."
However, it said, "In this case, any anticompetitive harm is offset by the procompetitive effects of SCH's effort to maintain the quality of patient care that it provides."
So "anticompetitive" is offset by "procompetitive." How so? According to another case, restricting privileges to doctors with a predetermined level of competence will enhance a hospital's reputation and the quality of its care, a procompetitive action permissible under the antitrust law's rule of reason.
The appellate court also said alternatives to a residency or board certification -- such as recommendations, reports from residency C-sections, and requirements of proctoring, peer review and consultations for difficult cases -- might not confirm the competence represented by board certification or a residency. Besides, said the court, the alternatives, if done effectively, might incur a hospital substantial costs.
Runte did present information in the case concerning family physicians' qualifications -- if trained in C-sections -- to perform them. "There's good evidence in the literature that family doctors can do C-sections with a very high level of quality of care," says Runte. "You have to question the judges' understanding of the level of family doctors' training and their understanding of the specifics of the case."
OB-Gyn Lawrence Brunel, M.D., a defendant in the case, says the appellate court's decision continues what has been the SCH standard of care for perhaps 15 years. Concerning the impact of the court ruling, Brunel says, "I don't think there'll be any change."
Call to action
"I call on family physicians everywhere to heed this decision as a wake-up call to action," says CAFP President-elect Leonard Fromer, M.D., of Santa Monica. "We must take more initiative and responsibility in our hospitals and become more politically empowered to ensure that departments of family medicine have enough clout to protect our specialty."
Fromer adds, "We must work together to combat the potential adverse effects of this ruling."
Underscoring the case's importance, AAFP President Bruce Bagley, M.D., of Albany, N.Y., says, "The fundamental premise for privileging is that privileges should be based on training, experience and current competence. This is a policy of the AMA, the AAFP and the American College of Obstetricians and Gynecologists. We believe the court did not recognize this premise."
Battling media violence from a physician's perspective
BY SHERI PORTER
Academy committed to finding the problem of youth violence solutions
Youth violence is one of the most daunting problems facing the United States: The nation has the highest youth homicide and suicide rates among the world's 26 wealthiest nations.
The AAFP has made a firm commitment to finding solutions to the epidemic of youth violence, as evidenced by its participation in the Commission for the Prevention of Youth Violence.
"In order to change this epidemic, we must protect our children from witnessing violence and teach them how to resolve conflicts peacefully," said Carolyn Lopez, M.D., of Chicago, vice speaker of the AAFP Congress of Delegates. Lopez contributed to the work of the commission.
The coalition of 10 health care groups, established in October 1999, is funded by the Robert Wood Johnson Foundation. The panel researched youth violence and developed an action plan to help health care professionals and others learning how to take active roles in violence prevention.
The commission's report, "Youth and Violence," was made public in December at the National Press Club in Washington.
The report's executive summary outlines priorities and key recommendations, such as:
- support and promotion of healthy families and communities;
- early identification of and intervention for families at risk;
- increased access to health and mental health care;
- reduction of youth access to firearms;
- a call for national advocacy, legislation and funding; and
- a reduction of exposure to media violence.
"Over the last 10 or 15 years, there's been an escalation of violent behavior among our youth that has reached epidemic proportions," said Board Chair Bruce Bagley, M.D., of Albany, N.Y., AAFP's commissioner on the panel. "Our society needs to address the issue of youth violence, and the Academy is proud to be part of this organized approach to improving the situation in our country."
A free copy of the "Youth and Violence" executive summary is available from AAFP by calling (800) 944-0000. Ask for item #R937. There is a prepaid $3 shipping charge. You can download the full report at http://www.ama-assn.org/violence on the Internet.
If you're a physician worried about the effects of media violence on your young patients, Victor Strasburger, M.D., offers this advice: Forget legislation. Forget petitioning movie executives. "We can do a whole lot more in our offices than we can do in Washington or Hollywood," he said.
Strasburger, a professor of pediatrics and family and community medicine at the University of New Mexico School of Medicine, Albuquerque, presented a seminar, "Sex, Drugs and Violence in the Media," at the Conference on Patient Education Nov. 16 -19 in Albuquerque, N.M.
He's also a dad who closely monitors the media consumption of his 7-year-old daughter and 10-year-old son.
"The average American child spends three hours a day in front of the TV -- it's the leading leisure-time activity for children. And that's three hours a day that child is not reading, not playing, not talking to his parents," said Strasburger. Ninety-nine percent of U.S. households have a television set, and that's more than have indoor plumbing, he added.
Studies suggest that as media time increases, a child's physical activity and creativity decline, while aggressive behavior goes up.
And it's the aggressive behavior that most worries Strasburger and brings to mind the troubling question: Do violent kids watch violence in the media, or does violence in the media make violent kids? Strasburger said four decades of research show an indisputable link between media violence and real-life violence. But based on what they're learning from the media, kids don't understand that violence has consequences.
"The context of how you display violence is extremely important," said Strasburger. "I had a young patient with a gunshot wound who actually said to me, 'I didn't know it would hurt.'"
Other factors
Children are also learning, through television, movies and violent video games, the concept of justifiable violence. Think: Arnold Schwarzenegger. "The media teach kids that violence is OK if you're the good guy," said Strasburger.
Over time, specific desensitization occurs. Media violence researchers even claim that the statistical correlation is greater between media violence and real-life violence than it is between smoking and lung cancer, Strasburger said.
"Violence becomes an acceptable solution, and then the child overreacts when put under stress," said Strasburger, citing the particular threat of violent video games. "Giving children pleasure in even the fantasy killing process, I think, is dangerous."
Guiding parents
How should you broach this topic with parents? A good icebreaker is taking a media history from the young patient (see box). In addition, try these tactics:
- Stress the negative effects of over-consumption and suggest that children should have no more than an hour or two a day of total media consumption. Include television, movies, video games and the Internet in the daily tally.
- Advise parents to stand firm about no television in the bedroom. Twenty-five percent of preschoolers and more than 55 percent of 12- to 17-year-olds in the United States enjoy this luxury.
- Ask parents to co-view with their children -- studies show that only 20 percent currently do so. "When parents watch with their children, the parents' view takes precedence. Watch with them. Interpret with them," Strasburger said.
- Share statistics with parents, and let them draw their own conclusions.
It's important for the physician to intervene early. "Talk to parents of 6-month-old babies. Talk to them when they bring in their 12-month-old for shots. If you're talking to parents of teenagers, you're too late," Strasburger said.
Want to take a media history?
Ask your young patients:
- How many hours each day do you watch TV?
- How do you decide which shows to watch?
- Where is the TV?
- Are there any house rules about watching TV?
- What are your favorite TV programs? Movies?
- Are there rules about music videos? Video games?
- Who watches TV with you?
- Do you go online?
What's AAFP's legislative agenda for coming years?
Think short-term and long-term. That's how Academy leaders are setting the Academy's legislative agenda.
"In the short term -- looking pragmatically at what we may be likely to achieve in 2001-2002 -- we'll work for Medicare prescription drug benefits, protections for patients through a patient's bill of rights, and adequate funding for family practice education and primary care research," says AAFP President Richard Roberts, M.D., J.D., of Madison, Wis.
"We'll support a little tinkering here, a little incremental change there, because that's what seems possible now," says Roberts.
"But our long-range, comprehensive vision is far broader," he adds. "Many patients and doctors have a sense the health care system is struggling -- it's too complicated, confusing and expensive, and sometimes it's dangerous. Its financing and structure have to change."
The Academy is floating a proposal for health care coverage for all (see story, page 1); the draft recommendations would overhaul the system's financing. As for its structure, says Roberts, "We'll work toward making sure every American is able to choose a family doctor."
That means informing the public and policy-makers about the system's problems and how a family practice model of care could solve them. The beginnings of that effort lie in AAFP's new public awareness campaign (see story, page 1), says Roberts.
Research will also strengthen the specialty's role in changing the structure of the health care system. "The model we have in mind for a better health care system can be tested and proven through research. AAFP's $7.7 million research initiative launched in 1997 -- one of the smartest investments the Academy has made -- will help FPs gain research skills, prepare them to conduct research and have it published," says Roberts.
The Robert Graham Center, AAFP's policy center in Washington, will translate research about the family practice model of care into ideas and statements policy-makers can understand and use, says Roberts.
He sums up: "We'll plant the seeds and invest the resources to help change public attitudes and policy about the basics of the health system and how it's funded and structured."
Congress boosts funds for key primary care programs
* Budgets in the millions of dollars for the Title VII cluster for primary care including family practice and dentistry, the Agency for Healthcare Research and Quality, and the National Health Service Corps. More money. That's what Congress has given three programs related to primary care education and research -- bottom lines the Academy applauds.
Title VII funding for training in primary care and dentistry, the Agency for Healthcare Research and Quality (which fosters primary care research), and the National Health Service Corps all won hefty increases in Congress' final budget legislation, passed Dec. 15 (see chart).
"It was hard for Congress, last year, to get anything done, but one thing it had to do was fund programs -- so the government wouldn't shut down," says Rosemarie Sweeney, AAFP vice president for socioeconomic affairs and policy analysis.
"Typically, it's easier to get increases in election years than in non-election years," says Sweeney. "There was an opportunity for the Academy to be pretty aggressive in pushing for funding." The strong lobbying by the AAFP and other primary care groups paid dividends expected to expand access to care.
The Title VII amount to be devoted to family practice training had not yet been announced at press time. Last year, close to two-thirds of the funds appropriated for the primary care and dentistry cluster were reserved for family practice.
New childhood immunization schedule includes additional vaccine
The 2001 Recommended Childhood Immunization Schedule is ready for prime time. A new vaccination series has been added to this year's schedule, which was jointly developed by the CDC's Advisory Committee on Immunization Practices, the American Academy of Pediatrics and the AAFP.
New this year: The heptavalent pneumococcal conjugate vaccine is on the schedule. All children between ages 2 months and 23 months should now be routinely immunized with heptavalent pneumococcal conjugate vaccine. The vaccine is administered at 2, 4, 6 and from 12 to 15 months of age.
The AAFP also recommends PCV immunization for children 24 to 59 months of age who are at high risk for invasive pneumococcal disease, such as those with certain medical conditions and children who are African-Americans, Alaskan Natives or American Indians. Vaccination of children in this same age group who attend day care or who have had frequent or complicated acute otitis media within the past year is considered a practice option. Consult the "AAFP Clinical Policy on Pneumococcal Conjugate Vaccine" at http://www.aafp.org/policy/camp/24.html for more information on pneumococcal conjugate vaccination.
Why was the PCV series added? "Data indicate that Streptococcus pneumoniae is responsible for about 3,000 cases of meningitis; 61,000 cases of bacteremia; between 100,000 and 135,000 cases of pneumonia necessitating hospitalization; and some 7 million cases of otitis media each year in the United States," says Richard Zimmerman, M.D., M.P.H., of Pittsburgh, who has been the Academy's ACIP representative. "The importance of routinely immunizing children against pneumococcal infection is further heightened by the increasing proportion of antibiotic-resistant S. pneumoniae strains."
For a copy of the new immunization schedule, go to http://aafp.org/x7666.xml, use the AAFP Express fax-on-demand system (see "Quick Fax" on page 8), or call the AAFP order department at (800) 944-0000 and request item #R974. Comprehensive AAFP immunization policies can be found at http://www.aafp.org/clinical.
How about a stint as an AAFP staff fellow?
Want to see what it's like working from inside the Academy? Here's your chance!
The AAFP is offering one-year, full-time staff fellowships in family medicine research, medical education, public health advocacy and medical editing.
Support TV -- Turnoff Week April 23-29
Once again, the AAFP endorses a challenge to all Americans to break free of the TV habit. You can help spread the word and show your support for TV-Turnoff Week 2001 by calling (800) 939-6737 for free fact sheets. Or visit http://www.tvturnoff.org to order posters, bumper stickers and other items promoting this national event.
The positions are available to Academy members who are U.S. citizens or who have permanent resident status. Completion of a residency in family practice is a preferred qualification. All positions begin July 2001; the first three are based at AAFP headquarters in Leawood, Kan.
- The research fellow will work with Academy staff and external investigators involved in the research activities of the National Network for Family Practice and Primary Care Research.
- The candidate chosen to fill the medical education fellowship will develop and implement a project in the area of CME, residency education, student interest, student and resident leadership development, international family medicine, Advanced Life Support in Obstetrics or another area of family medicine education.
- The public health fellow will work alongside staff in the Scientific Activities Division and communicate with members of the Commission on Public Health to promote public health issues near and dear to Academy members. Examples include health/patient education, antiviolence strategies, prevention of substance abuse, breast-feeding advocacy, and adolescent and school health.
- The medical editing fellowship entails a full-time academic appointment to Georgetown University's Department of Family Medicine in Washington. This fellow will assist the medical editor of American Family Physician with manuscript acceptance, rejection, revision and editing. Clinical and faculty development opportunities will also be available.
Please note that only two of the three Leawood-based positions and the Washington position will be filled. Applicants should submit a letter of interest and a curriculum vita to Brenda Flagler, AAFP, 11400 Tomahawk Creek Parkway, Leawood, KS 66211. Applications will be accepted until March 1 or until the positions are filled.
Questions? Call Flagler at (800) 274-2237, Ext. 1404; e-mail her at bflagler@aafp.org; or go to http://www.aafp.org/fellship for more information.
Online FMIG Manual up and running
Students, check it out: The Academy's Family Medicine Interest Group Manual has hailed the new millennium by going online. Visit http://fmignet.aafp.org/x643.xml to take a look.
The manual gives an overview of the FMIG Network, including its history and goals. It also lists the As to Zs of developing, financing and sustaining an active medical school campus FMIG. From recruiting student officers to planning successful promo events -- it's all covered in painstaking detail.
Likewise featured is information about the annual National Conference of Family Practice Residents and Medical Students. Links lead back to the main Virtual FMIG site, allowing easy access to all the information and resources that site has to offer medical students who wish to explore the discipline of family medicine.
You spoke -- we're acting
The most recent FP Report survey yielded some good news -- and some sobering insights.
The survey went to a sampling of active members, the Academy's largest membership category. The good news: Responses indicate that FP Report is generally on the right path since we refocused and redesigned it about a year ago. Examples:
- The majority of readers who responded said the quality of FP Report's contents and the publication's visual appeal have improved compared to a year ago.
- The paper's increased coverage of clinical news has been noticed by nearly two-thirds of those respondents, and its increased coverage of family practice issues has been noticed by three-quarters of them. In both cases, about 70 percent found the increased coverage useful.
- Nearly 40 percent said FP Report's value has increased over the past two years.
The sobering insights?
An open-ended question asked how FP Report could be made more valuable to respondents. More than 240 took time to write a response -- and nearly a third of those commented on the avalanche of publications they receive, the daunting amount of work they must do and the dearth of time they have to do it all. In a nutshell, they felt overwhelmed. And sadly, many of those who commented also indicated they read no issues of FP Report.
It's clear that active members who read FP Report think it's heading in the right direction. But how do we meet their needs even better? How do we make the publication more easily accessible for those who feel overwhelmed? And how about the needs of other membership groups?
Here's how we'll respond:
- We'll continue to refine the printed FP Report based on survey feedback.
- We'll create an electronic "FP Report in brief" to be e-mailed to members upon request. It will be linked to the full FP Report at http://www.aafp.org/fpr for readers who want more information.
- We'll survey members in other categories about FP Report and their preferred method of getting information from the Academy -- then act on what we learn. Stay tuned for more improvements.
Time for more cooperation among health professional groups?
BY CINDY McCANSE
Prescriptive authority for nurse practitioners, psychologists, pharmacists ... many physicians can't even think about the idea without gritting their teeth and sending their blood pressure through the roof.
Susan Kinast-Porter, M.D., and Bradley Fedderly, M.D., of the Wisconsin AFP discuss a landmark scope of practice agreement negotiated by their chapter. Yet to hear AAFP President Richard Roberts, M.D., J.D., of Madison, Wis., tell it, it's high time for health professional groups to bury their collective hatchets, look for ways to cooperate rather than deprecate, and get on with the business of providing the best possible health care for patients.
"Many of you are worrying about whether nurse practitioners should be prescribing drugs," Roberts told physicians, health policy-makers, lobbyists, Academy leaders and others during a lunch presentation at the recent State Legislative Conference in New Orleans. "You shouldn't be worrying about that -- you should be using that. Instead of pushing down, we need to reach up" he said.
And reach out, was the lesson conveyed by Bradley Fedderly, M.D., of Milwaukee and Susan Kinast-Porter, M.D., of Monroe, Wis., in their panel discussion of a landmark scope-of-practice agreement negotiated last year by the Wisconsin Academy of Family Physicians. Fedderly chairs the WAFP Legislative Affairs Committee. Kinast-Porter chairs the chapter's Committee on Resident & Student Affairs.
A lesson in creativity
In February 1995, Fedderly explained, the Wisconsin Department of Regulation and Licensing, acting on behalf of the state's advanced-practice nurses, pressed for and won legislative approval of administrative rules allowing APNs prescriptive authority. Although collaborative arrangements between APNs and physicians did exist, no language clearly defining the nature of those relationships was included in the statute, to the chagrin of many physicians.
The APNs went back to the legislature last year, asking for yet another scope-of-practice expansion -- this time, independent authority to order and interpret certain diagnostic tests -- sparking a firestorm from physicians of all specialties across the state. It was in this atmosphere that the WAFP decided to seek a solution amenable to all.
"We had to take into consideration the fact that many of these nurses worked with physicians," said Kinast-Porter. "We weren't trying to turn the clock back entirely, we were just trying to make things realistic and safe."
In formulating their response to the proposed legislation, WAFP leaders applied the following four principles:
- focus on improving the quality of patient care and increasing access to high-quality care;
- remain consistent with AAFP policy whenever possible;
- forge stronger relationships with others interested in the health of patients, including nonphysician health care professionals; and
- work to facilitate conflict solutions rather than pose obstacles to resolution.
They came up with alternative wording that allowed the proposed scope-of-practice expansion (score one for the APNs) but also set down the precise nature of the collaborative relationship that must exist between nurse and physician in order for APNs to exercise that expanded scope (score one for the physicians). It also called for documentation of that relationship by both parties.
What it boiled down to, Kinast-Porter noted, was simple: "Both groups wanted some assurance that if we worked together, we'd each be better serving our patients."
On the horizon
Future hot topics for the state's FPs, according to Fedderly, include pharmacists lobbying to administer immunizations at their pharmacies and an oldie but goodie -- prescriptive authority for psychologists.
Apparently the state's pharmacists plan to vie for the ability to order all but the routine series of childhood immunizations for their clients, with the vaccines most likely to be administered by a pharmacy tech or the like.
"The major concern is that even in physicians' offices, immunizations are not given without a physician, physician's assistant or APN present," explained Fedderly. "If an immunization was given at a pharmacy and there was an untoward reaction, such as a life-threatening allergic reaction, would the pharmacist know what to do?"
As for granting prescribing rights to psychologists, such a move would most definitely affect the state's family physicians and their patients, Fedderly added.
"This issue is particularly hot for FPs because primary doctors see the lion's share of mental illness -- at least at the point of entry into the medical care system -- and yet many insurance companies don't recognize an FP's ability to diagnose and treat mental illness," he said. Bringing another practitioner group into the mix can't help but further muddy the reimbursement waters. But, again, the biggest risk would be to patients receiving medications from practitioners who lack the extensive training of physicians.
Even with all that's at stake, the WAFP will strive to take the same constructive tack on any future scope-of-practice issues as it did with the APN issue, Fedderly noted. The Wisconsin Medical Society, he added, approached the APN matter with animosity and wound up burning bridges with nurses' groups. It's an important lesson, said Fedderly: "You just never know who you're going to need for a friend in the future."
Obesity discussion is incomplete
To the editor:
The obesity discussion in the November and December issues of FP Report accurately reflects much of what is currently being said and written on the topic. Unfortunately, the trend is to present a plethora of data and opinion that obstructs clear thinking, meaningful communication and maximal benefit for overweight patients.
Although the articles contain some useful nuggets, I'm uncomfortable with the advice to include "mental health professionals who can deal with associated psychosocial problems, if present" in the obesity care team. Few obese persons utilize such services because they imply stigmatization, are often inconvenient and/or unreimbursed, and because patients don't see themselves as psychologically disturbed. If doctors don't consider their patients' thoughts and feelings, they overlook opportunities to provide empathetic support and guidance. What about helping patients who are not going to succeed in losing weight? When should we stop futile treatment and help people be comfortable with themselves as they are?
Finally, is it really so bad that third-party payers are reluctant to pay for weight reduction programs, considering the lack of evidence of long-term benefit? Everybody complains about the high cost of medical care, but nobody seems willing to admit that he or she may be part of the problem.
Robert Gillette, M.D.
Poland, OhioError in 'weight-loss drugs' sidebar?
To the editor:
FP Report is to be commended for publishing the two-part series on obesity in its November and December issues. Too many physicians have ignored their patients' obesity problems for too long; consequently, the United States finds itself in the midst of a growing obesity epidemic. Hopefully, your articles will encourage AAFP members to become more active in helping their patients lose weight.
However, the December issue contained one glaring error when it listed dextroamphetamine among the appetite suppressants in the "weight-loss drugs" sidebar. Amphetamines have not been recommended for weight loss for some 15 to 20 years due to their side effects and potential for addiction. The appetite suppressants diethylpropion and phendimetrazine have been in use for many years but were not mentioned in the sidebar. Also, only one trade name for phentermine was listed, when in fact there are several proprietary versions of phentermine.
Regrettably, your list of obesity resources did not include the American Society of Bariatric Physicians. (Bariatricians specialize in treating overweight, obesity and associated conditions.) Since 1950, the ASBP has been teaching physicians how to safely and effectively treat their overweight and obese patients. Each year, the ASBP offers two accredited CME programs on obesity treatment. We would welcome AAFP members at these meetings.
J.P. Smith
Director, Public Relations
American Society of Bariatric Physicians
Englewood, Colo.
Editor's note: Information presented in FP Report reflects material gathered from the sources consulted and does not imply endorsement of a particular course of treatment. Regarding phentermine, Mr. Smith is correct: Our coverage should have listed either no trade names or all trade names. 
Order from AAFP at (800) 944-0000 unless otherwise noted. A shipping fee may apply; Kansas residents pay a 6.875 percent tax.
Hear about the latest issues in family practice research, earn up to 13.25 hours of Prescribed credit and hit the ski slopes during the 2001 National Network for Family Practice and Primary Care Research convocation. The theme for the event, to be held March 21-24 at the Cheyenne Mountain Conference Resort in Colorado Springs, Colo., is "Expanding the Horizons of Practice-Based Research." Presenters will focus on such topics as electronic data collection, collaboration efforts and human subject review requirements. Call the network at (800) 376-5463 or e-mail fpresearch@aafp.org for more information or to register.
Looking for a rural family practice recruitment tool for students and residents? Don't miss the new video, "The Path Less Traveled," produced by the Academy's Committee on Rural Health. This 16-minute video, produced in a vignette format, features five rural FPs and includes a discussion guide (#R721, $7.50). Another helpful tool for physicians considering rural practice is the updated monograph, "Rural Family Practice: You Can Make a Difference" (#R717, $7.50 for a single copy, or #R719, $5 apiece for 25 or more).
FP Report is published by the AAFP News Department.
Copyright © 2001 by American Academy of Family Physicians.
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