Safeguarding Patients' Health Commands Delegates' Attention

Patient safety was top of mind among AAFP members who debated policy measures that came before the Reference Committee on Advocacy (Members-only, 15-page PDF; About PDFs) here on Sept. 12. Those spirited discussions continued the next day, when the Congress of Delegates called for the Academy to oppose any expansion of naturopaths' scope of practice that is not strictly supported by their training, such as extending them liberal prescribing authority or permitting them to perform work/school physical exams or surgery. And in no case, said the delegates, should these individuals be granted "primary care physician" status.

Delegates also directed the AAFP to support providing comprehensive family planning services at community health centers, or CHCs; disseminating accurate medical information at crisis pregnancy centers; and coverage of OTC contraceptive supplies by public and private insurers.

Members who testified at the reference committee hearing about the role and status of naturopaths in their respective states all agreed on one issue: The training these practitioners are required to complete is woefully limited and varies widely from state to state. Although often lacking in clinical or hospital experience, several members testified, naturopaths are licensed in more than a dozen states. In some states, they even are granted prescriptive authority.

Moreover, according to California delegate Jack Chou, M.D., of Baldwin Park, they frequently represent themselves as physicians. In his state, he said, the California State Legislature established a Naturopathic Medicine Committee under the Osteopathic Board of California two years ago, raising concerns that health consumers might misperceive naturopaths as being legitimate primary care doctors. "We need to really be on top of this," Chou warned.

Even more alarming, testified Alaska delegate Marin Granholm, M.D., of Anchorage, "Naturopaths are positioning themselves as the solution to the shortage of primary care physicians.

"We're asking the Academy to stand with us on this issue and to support our integrity as family physicians," she said. Delegates obliged, overwhelmingly adopting a resolution that directs the AAFP to oppose any expansion of naturopaths' scope of practice that is not in keeping with their training, such as extending them liberal prescribing authority or permitting them to perform work/school physical exams or surgery.

In testimony on a measure that asked the Academy to support efforts to ensure all CHCs provide a full array of contraceptive services, as well as to advocate that the centers offer comprehensive family planning services, a number of members voiced concerns that fulfilling these requirements would strain many CHCs' limited resources, perhaps resulting in curtailment of other health services.

Furthermore, for CHCs that are privately owned -- especially those owned by religious entities -- such a directive could impinge on each CHC's responsibility to decide what services it provides in the context of its own community and ethical constructs. In addition, said student delegate Jessica Johnson, of Newington, Conn., the measure doesn't take into account collaborative arrangements CHCs may have with other local entities, such as rural health centers.

In the end, delegates adopted a substitute resolution that calls on the Academy to "support the provision of comprehensive family planning services" at each CHC "within the context of the mission and available resources of the CHC system."

Another resolution that dealt with information and support provided by crisis pregnancy centers sparked lengthy discussion during the reference committee hearing. Such centers typically focus on counseling women with unintended pregnancies against terminating those pregnancies, according to members' testimony.

Proponents of the measure, which called for the Academy to urge federal, state and local governments to support only programs that provide these women with "medically accurate and unbiased information," testified that such centers are, by definition, biased and use scare tactics, such as telling women that abortion raises their risk of breast cancer or causes mental health problems, to convince them to carry their infants to term.

These supporters also agreed with the resolution's request that the AAFP urge the enforcement of laws "prohibiting the deceptive practices engaged in by pregnancy crisis centers."

"We have examples of crisis pregnancy centers that are clearly offering misleading information," Massachusetts alternate delegate Patricia Sereno, M.D., of Stoneham, told reference committee members. She also testified that workers at such centers may offer a pregnant woman a stroller, for instance, along with continuing support throughout her pregnancy and beyond if she decides to continue the pregnancy. But all too often, that support never materializes. "She may get the stroller," said Sereno, but nothing more.

Those who opposed the resolution, however, claimed the centers perform a valuable service, pointing to the fact that some of them do provide prenatal and even well-child care. One member also cited a recent study that she said did, in fact, suggest an increased risk for mental health problems in women who underwent abortions. Another pointed out that organizations such as Planned Parenthood of America could themselves be accused of providing biased information, given their varying perspectives on the issue of unintended pregnancy.

The substitute measure crafted by the reference committee and adopted by delegates sought the middle ground on this topic, calling for accurate information to be relayed but removing the reference to bias, and urging only the enforcement of "existing consumer protection laws prohibiting deceptive practices."

Similarly, members of the advocacy reference committee recommended adoption of a substitute measure that combined two resolutions directing the Academy to support the enactment of legislation and policies to provide Medicaid coverage for FDA-approved contraceptive medications and supplies and to urge private health insurers also to cover these items. In addition, both measures stipulated that no prescription be required to obtain the items.

Members were divided in their testimony, with proponents saying that a lack of insurance coverage for contraceptive medications and devices translates to a lack of access. California's Chou called it an example of a "social determinant of health," saying that low-income men and women, in particular, are disadvantaged under the current system.

District of Columbia alternate delegate Marguerite Duane, M.D., of Washington, raised a twofold concern. Allowing OTC status for contraceptive medications, she testified, would mean that women, who are fertile only a few days a month, could be at risk for health problems associated with ingesting hormones continually. It would also mean that these women need not visit their family physicians to discuss contraceptive therapy, Duane testified.

"So, they're not getting the counseling services they need to address cervical cancer" or a host of other preventive health issues, she said. "I ask you, do we want our patients to bypass us for a relationship with their pharmacist?"

Ultimately, delegates adopted a compromise measure that urged AAFP support for public and private plan coverage "for family planning drugs and supplies that are FDA-approved, including those for sale over-the-counter."