August 2001 -- FP Report

August 2001 • Volume 7 • Number 8

FPs, Academy go to bat for patient protection bill

BY PAULA BINDER
The Academy and its members kicked into high gear to support the Bipartisan Patient Protection Act, S. 1052, in the weeks right before the Senate adopted the bill 59 - 36 on June 29. The bill was introduced by Sens. John McCain, R-Ariz., and Edward Kennedy, D-Mass.
"Nearly 400 AAFP members went to the Academy's 'Speak Out' Web site and sent letters to senators in support of S. 1052 during the pivotal two-week period that the bill was being debated," said Kevin Burke, director of the Government Relations Division. "Their letters made a difference, and they showed that family physicians are opinion leaders in the lawmakers' communities."

AD SUPPORTS BILL

The Academy's support for the bill was also crystal clear during those critical weeks. "It's time to pass a real Patients' Bill of Rights that holds managed care companies accountable and puts patients and their doctors back in charge of health care," trumpeted an AAFP ad that premiered in the beltway publications Roll Call and Congress Daily AM June 21, the day after the Senate began debating the bill. Challenging senators to pass the bill before the Independence Day recess, the ad made four more appearances June 25 - 27 in those publications and CQ Daily Monitor.

"As doctors, we are fighting hard for our patients," FP Darlene Lawrence, M.D., top photo, told reporters at a June 20 press conference on the Senate lawn. She called on lawmakers to fight hard, too, by passing the patient protection act. Standing by Lawrence, from left, are: Sens. Harry Reid, D-Nev.; Tom Harkin, D-Iowa; and Byron Dorgan, D-N.D. Bottom photo: Signs at the press event also encouraged the bill's passage.

"We've heard from Sen. McCain's staff, who told us the senator thought the ad was particularly effective," says Burke. "They encouraged us to do a similar ad for the House." (See "At Press Time ..." on page 1.)

A PATIENT'S STORY

On June 20, the media heard a specific example of how a patient's health can be damaged by managed care. On that day, family physician Darlene Lawrence, M.D., of Washington spoke at a press conference on the Senate lawn that was organized by Sen. Harry Reid, D-Nev., and attended by him and six other Democratic senators.

Lawrence told the story of her young patient Joshua, who at age 3 didn't have intelligible speech -- in large part because of insurance company delays and denials of care for ear infections since infancy. "As a result of the insurance company's actions, Joshua's development is severely delayed, despite his parents' and my best efforts," Lawrence said.

"This little boy's future has been put at risk," she said. "His parents and I are understandably angry and disgusted with the injustice brought on by a broken system."

Lawrence called on senators to hold insurance companies accountable. "As doctors, we are fighting hard for our patients," she said. "We need you to fight hard for them, too -- this legislation will do just that."

At press time ...

The House was slated to act on patient rights legislation the week of July 23. That same day, the Academy ran another ad in Roll Call, telling the House that the "Senate has passed a real Patients' Bill of Rights. It's time for the House to hold managed care companies accountable and put patients and their doctors back in charge of health care."

Go to http://www.aafp.org/media/rights.html to see the ad. Visit the AAFP's weekly "Washington Update" at http://www.aafp.org/update.xml to learn about the progress of patient rights legislation in the House.

Flu vaccine may carry sticker shock; doctors advised to prioritize by risk

BY TONI LAPP

Flu vaccine manufacturers are offering a good news/bad news scenario for the 2001-2002 flu season. The good news is that there should be a larger supply than last year. The bad news is that vaccine costs are going up anywhere from 22 percent to 67 percent over last year, and shipments could be delayed.

At least one manufacturer -- Aventis Pharma -- is making an effort to ensure that customers receive at least part of their order early on for high-risk patients. Aventis is splitting orders so that all customers receive at least 25 percent of the order in September, a move recommended by the CDC Advisory Committee on Immunization Practices.

Len Lavenda, spokesman for Aventis, says the list price for its vaccine is increasing to $5 per dose, up from a range of $2.80 to $4.20 last year. Lavenda cites several reasons for the increase: Improvements were made to Aventis' production facility to improve safety, Aventis has expanded its capacity to increase production, and the cost of shipping has increased as a result of the decision to split orders.

Wyeth Lederle is increasing the cost of its vaccine from $4.25 to $5.29 per dose, a 24 percent increase, says spokeswoman Natalie deVane. The company expects to have 60 percent of its doses shipped by November, deVane says.

Even though the delays this year are not expected to be as extensive as last year, physicians are advised to prioritize patients by risk.

"This has been a challenging issue for family physicians who had come to expect that they would have the vaccine their patients -- especially their high-risk patients -- needed," says Herbert Young, M.D., M.A., director of AAFP's Scientific Activities Division. The Academy has been working with the CDC to encourage changes -- such as urging that mass immunization programs be done in November rather than earlier, says Young.

The July 13 Morbidity and Mortality Weekly Report carries updated vaccination recommendations from the ACIP. Go to http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5027a3.htm to access the recommendations online. The Academy is now updating its risk prioritization policy for the 2001-2002 flu season. Those recommendations should become available in the coming weeks. Visit http://www.aafp.org/policy/camp/27.html for the current policy statement.

Two faces of OxyContin
AAFP concerned about abuse, diversion of drug

BY TONI LAPP

To some patients, OxyContin is a miracle drug, an effective medication that relieves chronic, severe pain. To others, it's a potent, addictive narcotic -- and they'll lie and steal to get it.

The latter group has sparked concern among physicians and drug agency officials. Citing reports of the drug's abuse, the Drug Enforcement Administration says that physicians are overprescribing OxyContin, the time-released form of oxycodone. Abusers get an immediate high by crushing the pills and snorting or injecting the powder, compromising the safety conferred by the time-released coating.

The drug, which was labeled by the FDA in December 1995 and introduced in 1996, has been blamed for 120 overdose deaths.

As a result, the DEA is lobbying the FDA to limit prescribing privileges to pain management specialists -- in effect restricting family physicians' prescribing rights.

Academy officials are deeply concerned about reports of diversion and abuse, says Kevin Burke, director of the AAFP Government Relations Division. But AAFP officials think the solution is to educate FPs to ensure that they prescribe the drug appropriately, not to restrict their right to prescribe.

Diversion of OxyContin has been most widespread in Appalachian states and rural communities, "areas that would be the hardest hit if physicians' prescribing privileges were limited," says Burke. Only about 3,000 pain management specialists nation-wide would have the exclusive prescription rights under DEA's proposal, says Burke.

DEFENDING FP'S PRESCRIBING PRIVILEGES

The FDA will hold a fact-finding hearing Sept. 14; Board Chair Bruce Bagley, M.D., of Albany, N.Y., will testify on AAFP's behalf.

Academy officials are taking the DEA's proposals seriously, says Burke, who sees any attempt to limit FPs' prescribing privileges as diminishing their ability to care for patients.

Thus, the Academy is taking a two-pronged approach, Burke says. The first approach is to educate physicians about how powerful OxyContin is and how rarely it should be used. The second approach is to collect data on FPs' prescribing practices in order to defend their prescribing privileges.

Besides the DEA, other government agencies are starting to take action on OxyContin. Attorneys general from several states formed a task force in May with the goal of developing strategies to reduce the illegal use of prescription drugs -- particularly OxyContin -- through increased coordination of law enforcement efforts and community education.

AAFP staff will meet with task force staff members "to educate them about primary care and our concern about how important an issue access to pain medication is," says Fay Fulton, the Academy's senior manager on state government relations.

And in the courts, West Virginia's attorney general filed a complaint charging that Purdue Pharma, OxyContin's maker, used "highly coercive and inappropriate tactics" to encourage physicians to prescribe the drug.

Such developments cause Burke to bristle. "The lawsuit implies that physicians are merely tools of pharmaceutical companies, that they don't have the wherewithal" to prescribe appropriately, when that's not the case, says Burke.

WHO'S TO BLAME

OxyContin's maker is on the defensive as a result of recent developments. James Heins, Purdue's associate director of public affairs, blames much of the negative publicity on sensationalism.

"It's the drug du jour" in the consumer media, says Heins. The coverage creates an atmosphere in which doctors are less aggressive about treating pain out of fear of government reprisal, he says.

Purdue has met with the DEA and has announced several initiatives to prevent OxyContin's abuse. The company is giving tamper-resistant prescription pads, opioid documentation kits and brochures on stopping drug diversion to nearly 500,000 physicians in the states where the abuse is most prevalent.

Purdue has also established guidelines on prescribing OxyContin. According to Purdue, the drug should be prescribed to patients only in cases where opioid use is appropriate for moderate to severe pain lasting more than a few days, and it should be prescribed only by physicians who are knowledgeable about the use of opioids in pain management.

The DEA's proposal to limit prescribing of the drug doesn't sit well with Purdue."It basically takes a useful tool for pain control away from a large population of physicians," says Heins. "It could mean that a lot of people who rely on primary caregivers for pain management won't be able to get care if a 'specialist' doesn't practice in their region.

"We think the answer is to do education on proper assessment of pain; the whole use of the range of management tools, including opioids; and how to recognize addiction and diversion."

Use these tips to stop OxyContin diversion

The federal Center for Substance Abuse Treatment offers many protocols for improving the treatment of drug abuse. For more information, go to http://www.samhsa.gov/centers/csat/csat.html and scroll down to "Treatment Improvement Protocols" -- or contact CSAT at (800) 729-6686. Purdue Pharma has developed the following steps to stop diversion of OxyContin:

Protect your prescriptions:

Keep prescription pads in your pocket or lock them up.

Never sign an incomplete prescription.

Use tamper-resistant prescription pads -- they can't be photocopied.

Write the quantity and strength of drugs on your prescriptions in both numbers and letters (the way you write checks).

Write on the prescription the name of the pharmacy the patient intends to use.

Consider faxing the prescription to the pharmacy for authentication by pharmacists.

Don't print your medical license number on the pad -- write it in when you write a prescription.

Be wary of the stranger who:

wants an appointment toward the end of office hours or telephones/arrives after regular hours;

insists on being seen immediately/demands immediate action;

is not having a physical exam, giving permission to obtain past records or undergoing diagnostic tests;

is extremely slovenly or is overdressed;

is unwilling/unable to give name of regular physician -- may claim to have no health insurance;

can't recall hospital/clinic where past records are kept or says it went out of business;

claims to have lost a prescription or forgotten to pack a medication or says it was stolen;

exaggerates/feigns medical problems;

recites textbook symptoms/gives vague medical history;

has no interest in diagnosis/referral -- wants a prescription now;

shows unusual knowledge of controlled substances;

requests a specific controlled drug and is unwilling to try another medication; or

states that specific nonopioid analgesics do not work or that she or he is allergic to them.

AAFP delegates speak out at AMA house

BY JANE STOEVER

From pain control to direct-to-consumer ads, issues affecting America's patients and physicians came up for action by the AMA House of Delegates this summer.

AAFP's 19 delegates and eight alternates spoke out frequently during the annual meeting of the AMA house June 17 - 21 in Chicago. Here's a sampling of the AAFP delegates' testimony:

Pain relief standard. "Pain is a big concern to family doctors. We take care of a lot of patients with chronic pain and acute pain," said delegate Glenn Loomis, M.D., of Fishers, Ind. The pain relief standard of the Joint Commission on Accreditation of Healthcare Organizations took effect Jan. 1, and hospital nurses are documenting patients' pain levels and physicians' response to continued pain. "A lot of outpatient centers owned and operated by hospitals are implementing these guidelines that were meant for inpatient centers," said Loomis.

Michael Adams, M.D., above, discusses a disclaimer for direct-to-consumer ads. Warren Jones, M.D., right, suggests the AMA should study the idea of limiting the gifts drug companies offer physicians.

He supported a resolution that, after revision, asked the AMA to develop scientifically based, objective standards of pain measurement. The house referred the measure to the AMA board.

Nursing shortage. "Designate this problem of shortages among nurses and other allied health personnel an emergency," delegate Ross Black II, M.D., of Cuyahoga Falls, Ohio, challenged the AMA. "Advocate urgent response." Black, an AAFP director, commented on a report and resolution on the nursing shortage.

The AMA house asked the AMA to work with other groups to remove nurses' administrative burdens, such as excessive paperwork, and to enhance the recruitment and retention of nurses.

In an interview, Black said, "We have an extreme need for nurses right now, and it'll be awhile before we can repair the shortage."

Recertification. One reference committee handled resolutions revealing disagreements between the American Board of Internal Medicine and the American College of Physicians-American Society of Internal Medicine.

One internist asked why internists couldn't be like family doctors in regard to recertification, receiving assistance to pass the exam.

In response, delegate James Martin, M.D., of San Antonio, an AAFP director, gave this input: "The American Board of Family Practice and the AAFP work closely together. The board has set standards for certification, and the Academy offers courses to help members review for recertification."

The AMA house referred the resolutions about internists' certification to the AMA board.

Gifts from pharmaceutical companies. Some delegates said gifts from drug companies did not influence their prescribing patterns. AAFP President-elect Warren Jones, M.D., of Ridgeland, Miss., a delegate, disagreed. "The reason why we get offered these gifts is because it moves the needle (the sales indicator). It's as simple as that," said Jones. "If it didn't move the needle as the companies watch the flow of sales through an area, we would not be invited to lunch, we would not be offered all the other things."

He added, "We need to develop tools to help guide physicians in their interactions with pharmaceutical representatives."

Jones advised referring to the AMA board a resolution on placing specific limits on the gifts drug companies can offer physicians. The AMA house, however, defeated the resolution.

Direct-to-consumer ads. One resolution sought the placement of this disclaimer on direct-to-consumer ads: "Your physician may recommend other treatment options that may be equally or more effective."

Delegate Michael Adams, M.D., of Portland, Ore., the resident member of AAFP's delegation, speaking on the floor of the AMA house, urged delegates to retain the word more in the disclaimer. Adams said, "There are situations where there are more effective or appropriate treatments" than those pitched to consumers.

The house, however, asked the AMA to seek to have this disclaimer added to all direct-to-consumer ads: "Your physician may recommend other appropriate treatments."

Protect physicians from lawsuits over drugs withdrawn from market

At AAFP's request, the AMA is now committed to seeking a law exempting physicians from liability in class action lawsuits over drugs withdrawn from the market.

Delegate Dale Moquist, M.D., of Bryan, Texas, spoke at the AMA House of Delegates in support of an AAFP resolution calling for the new legislation. He said involvement in lawsuits "has been a problem for many of our members who have prescribed FDA-approved medicines. After they're prescribed, they're being taken off the market, Rezulin being one."

In an interview, Moquist said AAFP members are also defending themselves for prescribing Redux and fenfluramine when those drugs were still FDA-approved. The AMA house, which met in Chicago in June, adopted the AAFP resolution.

Juggling the HRT hot potato

BY SHERI PORTER

Hormone replacement therapy is one hot topic these days. An Internet search for March to June 2001 turned up close to 140 newspaper stories and 50 health periodical articles. More recently, a three-day window in July netted a dozen HRT-related headlines, including "Cancer Warning Over HRT Drug," "Hormone Therapy Tied to Heart Ills" and "Early Menopause Doesn't Up Risk of Ovarian Cancer."

How do FPs sift through the surplus to find the right answer for each patient who asks, "Is HRT right for me?"

William Phillips, M.D., of Seattle, past chair of the AAFP Commission on Clinical Policies and Research, says he tries to strike a balance in what he reads and digests about HRT. "I deal with the information coming in to me by trying to be aware of the big studies that come out, paying attention to evidence-based reviews ... but not allowing myself to be buffeted by the latest report."

One major study currently under way is the hormone trial of the Women's Health Initiative of the National Heart, Lung and Blood Institute (http://www.nhlbi.nih.gov/whi/). Jacques Rossouw, M.D., WHI's acting director, says the study is following 27,000 women for 11 years. "It is the biggest study to date by a factor of 10," he says. Study results will be released in 2005 or 2006.

According to Rossouw, the WHI study was launched to provide a randomized, controlled clinical trial to test, among other things, whether HRT prevents heart disease. "There was promise from the observational studies, but there were not trials ... and so many older women are using hormones under the impression that hormones prevent heart disease."

Ironically, a surprise midway through the study illustrates the uncertainty surrounding the HRT debate: Early last year, WHI alerted women in the trial that "contrary to expectation, we were finding a small increase in both heart disease and stroke in the early years of the study," says Rossouw.

But the big question, says Rossouw, "is not so much whether hormones prevent heart disease, but whether older women, by and large, should take them (hormones) for a long period of time. To answer that question, you have to look at all the health outcomes. We still don't know the overall balance of benefits and risks."

Researchers are interested in the overall effects of hormones on health "because older women also get breast cancer, they get fractures, they get dementia," says Rossouw. He adds that to date, there is no proof that HRT prevents colorectal cancer, hip fractures or dementia.

A sampling of HRT resources:

New England Journal of Medicine, July 5, 2001, "Postmenopausal Hormone-Replacement Therapy."

Journal of the American Medical Association, June 13, 2001, "Postmenopausal Hormone Therapy for Prevention of Fractures: How Good is the Evidence?"

Journal of the American College of Cardiology, July 2001, "Postmenopausal Hormones and Heart Disease."

American Family Physician, March 1, 2000, "Managing Menopause," which can be found at http://www.aafp.org/afp/20000301/1391.html.

By year's end, the U.S. Preventive Services Task Force plans to issue an evidence-based recommendation on HRT.

AAFP policy says all perimenopausal women should receive counseling about the benefits and risks of postmenopausal HRT as it relates to osteoporosis, circulatory disease and symptoms of menopause.

When Rossouw lectures, he counsels physicians, including his hardest-sell audience, gynecologists, to wait until results of the large long-term trials are in before recommending hormones to women on a long-term basis.

Short-term use is another story entirely. "Nobody is saying that the short-term treatment -- meaning less than five years -- of menopausal symptoms should be discouraged,"says Rossouw.

There is a positive family practice slant to this topic, argues Phillips. The HRT puzzle showcases family medicine at its best, incorporating the FP's long-standing relationship with a patient. That connection, and the FP's often firsthand knowledge of a patient's family history, enable the physician to "ask the right question of the patient, rather than having the right answers from the expert," says Phillips.

Discussing HRT requires that you listen to the patient and ask some "evocative, open-ended questions," says Phillips. If a woman's biggest fear is breast cancer and she has a family history of breast cancer, then "breast cancer is the driver of her health maintenance decisions," he says. For this woman, the modest increase in risk of breast cancer associated with HRT takes on added significance.

Both Phillips and Rossouw stress the value of proven preventive therapies over the largely unproven benefits and unknown risks of long-term HRT.

For example, Phillips laments the time required to discuss the intricacies of HRT, when a woman's overall health might be better served with a heart-to-heart talk about tobacco use.

"Look at what you've got in your armamentarium to prevent heart disease," urges Rossouw, clicking off blood pressure control, cholesterol reduction, smoking cessation, aspirin use, beta-blockers and ACE inhibitors. Plug the potential health benefits of diet, exercise and weight management. "That's where you should focus your attention," says Rossouw, "because we have clinical trial data backing up their use."

OxyContin: On the front line

Family physician Robert Drake, M.D., of Somerset, Ky., welcomed OxyContin when it was introduced in 1996. But since then, he says his willingness to prescribe it has waned because of its abuse in Appalachian towns such as his. Now, he says he reserves it for terminal patients and those with osteoporotic fractures whose pain has been unresponsive to other drugs or to surgery.

In patients for whom addiction is less of a concern than pain relief, OxyContin is "wonderful," says Drake.

But even patients who use OxyContin justifiably for pain control are wary of the stigma attached to it, he says: They don't want to be seen at the local Wal-Mart picking up their prescriptions.

Although Drake rarely prescribes OxyContin -- he estimates that about eight patients out of 7,000 in his practice use it -- he says he needs to continue to have this drug as an option.

"I think that family physicians should have the opportunity to use this product, but we have to use it cautiously and realize it has extreme potential for abuse," he says.

And although he's prescribing it less, it's out of concern for his patients, says Drake, not fear of government oversight.

"Our ultimate concern should always be what is best for the patients and morally and legally correct, and then we'll be able to defend that," he says.

His wheels are smokin', but he's not

BY TONI LAPP

Tar Wars proponent and NASCAR driver John Baumgartner will bring a racecar to the Assembly in Atlanta. Meet him at the exposition hall of the Georgia World Congress Center.

Usually, John Baumgartner drives a company car -- a silver Chevy Impala. But on NASCAR race weekends, the pharmaceutical rep from Los Angeles chases a checkered flag in a 450-horsepower NASCAR Pontiac Grand Prix -- and it's emblazoned with the logo for Tar Wars, the Academy's tobacco-free prevention program.

Academy members and their guests attending the AAFP Scientific Assembly in Atlanta will be able to meet Baumgartner on-site Oct. 4 - 6 and sit in an authentic race car, courtesy of a grant from Novartis Pharmaceuticals. The car, retrofitted by Denver, N.C.-based Last Lap Restorations Inc., features computer equipment that simulates the experience of driving a race car for the person in the driver's seat.

Taking a stand against tobacco is a bold move in the racing business, a sport in which the name for the highest prize -- the Winston Cup -- is synonymous with cigarettes.

But Baumgartner, once a sales representative for Philip Morris, is motivated. He lost his father -- a lifelong smoker -- to cardiovascular disease in 1997. That's when he quit his job and went to work as a pharmaceutical rep. With money from his father's estate, he began to build his race car -- a rolling tribute to his father, a racing fan.

"I figured I would just race a couple times a year, but I found I really liked it," says Baumgartner. Fueled by a desire to counter tobacco's pervasive presence at the racetrack, he pledged to use his car to promote the anti-tobacco message.

Finalists in the annual Tar Wars National Poster Contest gathered for an awards ceremony July 17 on Capitol Hill. The winning poster, above, was created by Leah Norsworthy, 11, of Choctaw, Okla.

Yet Baumgartner lacked a curriculum for his message. That's where Tar Wars came in.

He was moved to find out more about the program when he visited a family physician's office last year and saw the children's Tar Wars posters on the wall.

The Tar Wars staff couldn't be happier to have Baumgartner on board. Baumgartner gives a powerful presentation, says Sarah McMullen, Tar Wars manager. "He draws you in, and you want to be part of his tobacco-free racing campaign."

Baumgartner receives no money from Tar Wars or the Academy; the alliance is strictly for each party's mutual benefit. Tar Wars receives free advertising in a venue that is popular with youngsters, and Baumgartner receives the credibility of the Tar Wars name in promoting his message.

He still has a long way to go to achieve his dream of fielding the first tobacco-free race car in the Winston Cup series. Although he has six top-10 finishes in his short racing career, he has yet to garner a first-place finish. But Baumgartner says all the building blocks are in place, and he's optimistic about his future in racing. Yet something higher is at stake than mere standings at the races, he says.

"If I could reach kids and at the same time pay tribute to my father, it would be incredible," he says. "It's like a dream."

Geriatric assessment addresses quality of life

BY SHARON DICKINSON DENT

With the dramatic rise in the number of older patients, physicians are learning that assessing the elderly means much more than just asking health-related questions. Getting a feel for how well a patient deals with the challenges of daily life can open the door to better medical care and improved quality of life.

Peilan Sun, who lives at home with her daughter in Bellevue, Wash., sees Wayne McCormick, M.D., for an exam at Harborview Senior Care Clinic.

"It's almost never about cure; it's always about functional improvement," says Wayne McCormick, M.D., M.P.H., associate professor at the University of Washington School of Medicine and program director for long-term care services at Harborview Medical Center in Seattle.

"It's additive and synergistic," says McCormick, who has helped teach the Family Practice Board Review course. "If older people have trouble with a couple things that you might think are minor, those are the kinds of things that could land them in the hospital. If they can't bathe well or at all, then they get skin problems, which in a diabetic can turn into infections and become life threatening."

Patients who visit McCormick at the Harborview Senior Care Clinic succumb to the typical blood pressure, pulse and weight checks, but they also answer a series of questions designed to ferret out cognitive concerns or problems with daily activities. Nurses use three tools -- the Mini-Mental Status Exam, Instrumental Activities of Daily Living and Physical Activities of Daily Living -- to assess a patient at intake and later as indicated by patient complaints or symptoms. The information is then added to the patient's chart for easy review by the physician.

The Mini-Mental Status Exam calls on patients to answer basic orientation questions (day of the week, name of the town, etc.), list three unrelated objects and be able to recall them later, perform serial subtraction, name two objects identified by the nurse, write a sentence, copy a geometric design, follow written and oral directions, and repeat a phrase.

The Instrumental Activities of Daily Living tool surveys how well the patient can use the telephone, shop, prepare food, maintain the home, do laundry, use transportation, take medication and manage finances.

The Physical Activities of Daily Living tool determines whether the patient needs help bathing, dressing, grooming, using the toilet, getting in and out of bed, or walking and eating. The test also asks for the names of anyone who helps the patient with these tasks.

"In geriatrics, often the underlying diagnoses -- like osteoarthritis or heart failure -- matter, but maybe they don't matter as much as trouble bathing or trouble dressing. We might address those directly without needing another physical diagnosis to attach to it. So if someone's having trouble bathing, we might arrange to have a bath aide come in once a week," says McCormick.

Most physicians haven't been trained to use these types of assessments and often don't realize how valuable they can be, he says. "Recognize that each visit is part of a long conversation and allow for that," he suggests. "When these assessments come up, driven by intake or complaints, remember that the serial use of them is useful to add weight or perspective to the visit. Knowing these types of things about people adds a lot to the conversation."

For more articles on care of the elderly, access http://www.aafp.org/fpr/20010700 and click on stories listed under "Geriatric Medicine." Use "Quick Fax" on page 8 for materials on the next AAFP geriatrics course.

Go online for AAFP candidate information

Want to know who's running for AAFP offices and the Board of Directors this year? Visit the AAFP Web site. The 2001 candidate directory will be available in late August.

The directory includes photos and biographical information on candidates vying for these positions. The Congress of Delegates, meeting Oct. 1 - 3 in Atlanta, will elect the 2001-2002 officers and three 2001-2004 directors.

In addition, the Congress will elect delegates and alternates to the AMA House of Delegates, as well as candidates for the AAFP's position on the American Board of Family Practice Board of Directors. Photos of these candidates also will appear in the online candidate directory.

AAFP Congress of Delegates will act on proposed Bylaws amendments

This year's Congress of Delegates will act on these proposed amendments to the AAFP Bylaws when it meets Oct. 1 - 3 in Atlanta:

The first proposed amendment would provide delegate and alternate seats in the Congress for international medical graduates, with a sunset provision that would discontinue the seats at the conclusion of the 2010 Congress. The Committee on Bylaws recommends adoption of the amendment.

Two related proposed amendments set out different methods for providing the new physician constituency with a representative on the AAFP Board of Directors. The committee recommends adoption of the amendment that would have the representative elected in the manner that's used for the resident and student Board members, instead of the manner used for at-large Board members.

Another proposed amendment would delete Bylaws restrictions on student members in regard to leadership positions at the chapter level. The committee recommends adoption.

The final proposed amendment would clarify the requirement that only active members are eligible to serve as AAFP officers and directors. The committee recommends adoption.

To view the proposed amendments, go to http://www.aafp.org/members/bylaws/ (AAFP ID number required for access), or call (800) 274-2237, Ext. 6602, for a copy of them.

Get training in all areas

To the editor:

I respectfully disagree with chief resident Paul Lewis, M.D. (June FP Report), who asks why he's obligated to do several months of obstetrics training even though he doesn't plan to practice obstetrics. "My time would be better spent mastering other skill sets that I would more frequently use," he says.

Family medicine is a practice that "specializes" in knowing something about all aspects of the family and the disease process.

As a family medicine residency faculty member for many years, I am amazed that many residents fear that everything they will ever learn, they must learn in these three years, and anything they might not want to do should be excluded. Most of my skill sets were learned after residency. Residency is the basis for all you will learn in the future. Leave out an area and you have no basis to build on, or even refer to, when anything comes to your office that involves that organ system, that set of family experiences.

A much better way to tailor our training would be to offer more "fellowship" opportunities to add to the basics, or perhaps the "diploma" system used in Britain, for further credentialing generalists into their areas of interest, without sacrificing what makes us special: our very generalism.

Rebecca Bingham, M.D.
Anchorage, Alaska

Problem with mandated coverage

To the editor:

I was happy to see that the issue of health care coverage for all is still in the forefront of at least two congressmen (May FP Report). Although I agree with many of the proposals by Reps. McCrery and McDermott, there is a simple reason why "mandated" health coverage in the private sector will not work: money.

Health care reform that provides even the basics of coverage for all is not inexpensive; within the current system, the two major payers are employers and governmental agencies. If you don't have a job, and you've not been able to get on disability, where will you fall within the proposed system? After reading this article, I couldn't but wonder what provisions this plan makes for the unemployed/underemployed.

Under this plan, low-income patients will be forced to choose, again, between health care and other necessities. Doctors will continue to find themselves searching for ways to provide health care to those who can often ill afford it. I, for one, am tired of having to make these choices. It is time for the AAFP to join many other health organizations and lobby for meaningful health care reform. Who else is the best advocate for our patients?

Pamela Cobb, M.D.
Yellow Springs, Ohio

Editor's note: The May coverage noted that "some mechanism should be established to get funds to people who can't afford to pay for insurance and then wait for the tax credit."

Bipartisan patient protection bill

To the editor:

In this bill's case, nothing is being done for the uninsured in America; in fact, it may create more uninsured. If passed, it will probably hurt many FPs who will have to pay higher premiums for their families (most of us aren't covered by employer plans anyway).

A key component of the bill is making sure patients can bypass FPs and go straight to specialists. How's that for PR for FPs? I will urge my congressmen not to support it.

Bruce Burton, M.D.
Corydon, Ind.

To the editor:

Regarding the bill, the AAFP has lobbied for our protection, for "immunity from liability for health plan errors such as denial of treatment." But physicians are not to deny treatment due to lack of insurance coverage. Health plans may deny payment, but their denials are not to affect adversely the delivery of your medical care.

I know quite well that this stance may cause a strain in our personal and corporate character and commitment. However, if we have not faced the question before, I ask us: "Why are we here, in this profession, in this place, at this time?" Our failure to answer that question, or to answer it properly, has and will continue to lead us down the trail of more and more problems, laws, regulations, penalties, professional cephalgia, loss of freedom, poorer patient care, physician dissatisfaction and burnout -- and to a new breed of conformant physicians who expect to practice medicine under close state scrutiny and direction, with its logical police actions.

We have the responsibility to treat the patient -- to simply treat them as we would like to be treated if we were in their situations. Draw your own line in the sand. The rewards are too great to be missed.

Robert Eckert, M.D.
Athens, Texas

Medicare drug benefit

To the editor:

To the reader: Write us letters of 200 words or fewer (subject to editing), using the FP Report addresses at the bottom of page 2.

I disagree with Dr. John Parham's suggestion (May FP Report) that a Medicare drug benefit should be scaled by recipients' ability to pay. Medicare is a social contract between those who pay the tax and those who use the services. Those taxed will receive the benefit when eligible. If charged more for benefits, they're less likely to support Medicare.

We should instead support a sound financial basis for Medicare. Currently, surplus taxes are tossed into the General Fund. This money should be invested. Additionally, we should support a level of tax to provide a drug benefit. Lastly, we should cap drug prices for all Medicare benefits. Currently, my patients who are least able to afford full price must pay it, since they cannot afford insurance that protects beneficiaries from high prices.

Charles Nester Jr., M.D.
St. Louis, Mo.

August: It's prime time to hop on Title VII bandwagon

Section 747 of Title VII of the Public Health Service Act helps fund family practice training. Congress relies on two key subcommittees to help it decide how high or low Title VII funds should go.

Appropriations health subcommittees

Senate

Tom Harkin, D-Iowa, chair
Arlen Specter, R-Pa.
Thad Cochran, R-Miss.
Larry Craig, R-Idaho
Mike DeWine, R-Ohio
Judd Gregg, R-N.H.
Ernest Hollings, D-S.C. Kay Bailey Hutchison, R-Texas
Daniel Inouye, D-Hawaii
Herb Kohl, D-Wis.
Mary Landrieu, D-La.
Patty Murray, D-Wash.
Harry Reid, D-Nev.
Ted Stevens, R-Alaska

House

Ralph Regula, R-Ohio, chair
David Obey, D-Wis.
"Duke" Cunningham, R-Calif.
Rosa DeLauro, D-Conn.
Kay Granger, R-Texas
Steny Hoyer, D-Md.
Ernest Istook Jr., R-Okla.
Jesse Jackson Jr., D-Ill.
Patrick Kennedy, D-R.I. Nita Lowey, D-N.Y.
Dan Miller, R-Fla.
Anne Northup, R-Ky.
Nancy Pelosi, D-Calif.
John E. Peterson, R-Pa.
Don Sherwood, R-Pa.
Roger Wicker, R-Miss.
C.W. "Bill" Young, R-Fla.

President George W. Bush recommended zero funds for family practice programs in 2002, following a pattern set by President Bill Clinton. In the past, Congress has ignored the presidential zero and sometimes even increased the Title VII funds.

To make that happen for 2002, the specialty needs your help.

Title VII comes under the purview of appropriations subcommittees on Labor, HHS and Education. If your lawmakers sit on these subcommittees (see lists right), ask them to support increased funding of Title VII, which this year includes about $50 million for the specialty.

AAFP's "Speak Out" service -- at http://capitol.aafp.org -- lets you easily e-mail members of Congress or use the sample letters in writing your legislators.

Don't underestimate the power of a visit to your lawmakers when they're home this month.

Media contacts will also help rally support for Title VII. For a letter to the editor, opinion column, talking points and other resources, access http://www.aafp.org/members/titlevii or request "Title VII press materials" by fax (see "Quick Fax").

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

Home Study subscribers can now receive the audio portion of the program in cassette or CD format. Members pay $124 for a year of Home Study Audio on CD. To learn more, call (800) 274-2237, Ext. 5298.

Brighten your wall with a new Tar Wars wall calendar. The 2001-2002 academic year calendar features colorful artwork that teaches "Being smoke free is as easy as ABC." Get your pack of five calendars (#R2966) for $5.

Proven value: Promoting October as Family Health Month just got easier -- and the materials are free! No need to order anymore; simply visit http://www.familyhealthmonth.org and download a public service announcement script, letter to the editor, opinion column and more. AAFP's public awareness campaign brochure also appears on the site, along with ordering information.

Proven value: Ensure the accuracy of your physician office lab tests by subscribing to AAFP-PT, AAFP's proficiency testing program. Annual registration costs $70 for the paper format for reporting, $50 for the online format. Sign up by requesting #R767 or by visiting http://www.aafp.org/pt.xml.

Proven value: Preregister now for the Scientific Assembly. The meeting Oct. 3 - 7 in Atlanta features more than 300 courses. To avoid on-site registration, make sure the AAFP has received your registration form by Aug. 29. Register online at http://www.aafp.org/assembly.xml. If you have questions or need a brochure, call the Assembly hotline at (800) 926-6890.

A shipping fee may apply; Kansas residents pay a 7 percent tax.

Available on AAFP Express

Call the AAFP Express toll-free number -- (800) AAFP EXP [223-7397] -- and supply your AAFP ID number to have selected materials sent almost immediately to your fax machine for free. Some documents available:

Description of document Doc. no.

Title VII press materials 1003

Information on the 2001 conferences

Geriatric Medicine for the Family Physician
Sept. 12 - 16, Monterey, Calif.
2002

Infant, Child and Adolescent Medicine
Oct. 22 - 26, Washington, D.C.
2012

Emergency and Urgent Care for the Family Physician
Oct. 29 - Nov. 1, Paradise Valley, Ariz.
2009

23rd Annual Conference on Patient Education
Nov. 15 - 18, Seattle
7004

State Legislative Conference
Nov. 15 - Nov. 17, Bernalillo, N.M.
8006

FP Report is published by the AAFP News Department.
Copyright © 2001 by American Academy of Family Physicians.

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