2015 NCCL

Family Physicians Debate Issues with Patients' Welfare in Mind

May 06, 2015 01:33 pm Sheri Porter Kansas City, Mo. –

Speaking in a reference committee hearing in support of a resolution on telehealth, women's delegate Lauralee Yalden, M.D., of New York City, says the resolution was not intended to replace primary care or face-to-face medicine. "But we do seek to supplement health care to the population as a whole," she added.

For the 25th straight year, AAFP members gathered for a three-day conference -- newly renamed for 2015 as the National Conference of Constituency Leaders (NCCL) -- to discuss issues of importance to family physicians, their practices and their patients.

From April 30 to May 2, members representing five constituency groups -- women; minorities; new physicians; international medical graduates (IMGs); and gay, lesbian, bisexual or transgender (GLBT) physicians or physicians who support GLBT issues -- as well as some members representing themselves, wrote and debated resolutions during reference committee hearings.

The Reference Committee on Practice Enhancement considered a variety of issues, from telehealth to hepatitis C infection, but the underlying theme repeatedly heard was one of helping family physicians take better care of their patients.

Physicians Debate Telemedicine, FP/NP training

A number of physicians lined up to testify about the pros and cons of telemedicine services.

Story Highlights
  • AAFP members attended the newly renamed National Conference of Constituency Leaders in Kansas City, Mo., April 30-May 2 to write, debate and vote on resolutions about issues that affect family physicians, their practices and their patients.
  • The Reference Committee on Practice Enhancement tackled a variety of topics, including telemedicine, nurse practitioner training, care for patients with hepatitis C and issues surrounding physician conscience rights.
  • Debate on some of the issues spilled over into the May 2 business session, with delegates offering substitute language before voting to adopt, not adopt or refer measures to the AAFP Board of Directors for further discussion.

Benjamin Simmons, M.D., a GLBT delegate from Concord, N.C., testified on his own behalf against the resolution, which sought to promote access to telemedicine services, along with adequate payment. "Each state medical board has different policy regarding the appropriateness of telemedicine and physical exam and diagnosis," said Simmons. He wondered if the resolution violated individual state medical requirements for telemedicine.

Bruce Echols, M.D., a GLBT delegate from Dallas, also spoke against the resolution and pointed out that most physicians practicing across state lines are not giving physical exams. "In Texas, there has to be some physician contact at some point."

But Shayla Toombs-Withers, D.O., a minority delegate from Omaha, Neb., said telemedicine is considered an "adjunct service," in her part of the country. "We recognize there are rural and underserved areas where health care is limited and where patients can't easily get to a health care provider," she said.

Samuela Manages, M.D., a new physician delegate from Van Buren, Maine, testified that as a rural practice physician, she depends on telemedicine in some situations. For instance, she said, "We incorporate face-to-face visits with telemedicine" in consults with rheumatologists whereby the first patient visit is face-to-face "and subsequent visits are by telemedicine."

Ultimately, delegates referred the resolution to the Board of Directors for further discussion.

Family physicians also were eager to express their opinions -- both pro and con -- on dissemination of additional patient education resources detailing how family physician training differs from that of nurse practitioners (NPs).

Resolution co-author Michelle Sell, M.D., a women's constituency member from Central City, Neb., explained in the hearing that her resolution asked the AAFP to review resources already available from the Nebraska Medical Association or create its own resources and make them available to members, "So we can have intelligent discussions with our patients and make recommendations to them."

Ann Messer, M.D., of Austin, Texas, registered with the women's constituency but speaking on her own behalf, testified that it was important for the general public -- as well as legislators crafting state laws -- to understand how different medical professionals carry out their work. As an example, Messer said she had recently discovered that some Texas state legislators "didn't know that chiropractors don't use a stethoscope" when conducting a well-child exam, a detail that would preclude discovery of, for instance, a heart murmur.

Christopher Gaynor, M.D., of Seattle, speaking as a general registrant, opposed the resolution and said his state has had independently practicing NPs for years; psychiatric NPs, in particular, had alleviated a shortage in that field. "My sense is that we need everyone at the table caring for all these people newly insured under the ACA (Patient Protection and Affordable Care Act), he said.

Julie Anderson, M.D., from St. Cloud, Minn., a general registrant, said she had testified recently before the Minnesota legislature about NP scope-of-practice issues. Although some legislation favoring NPs did pass, "We were able to make some strides in terms of nurse practitioners not being able to use the term "doctor" and needing extra hours in training," said Anderson. "This can help us even if we can't stop all the laws."

Ultimately, the delegates adopted a substitute resolution that asked the AAFP to research and/or develop patient education materials on the topic and make them readily available to members and patients.

Benjamin Simmons, M.D., a gay, lesbian, bisexual and transgender constituency delegate from Concord, N.C., tells the reference committee that a physician's first priority is to take care of patients. "If there is any discomfort, we should refer to another provider," he said.

FPs Focus on Hepatitis C, Physician Conscience Rights

During the same hearing, several physicians testified about difficulties getting treatment for their patients with chronic hepatitis C infection. Manages, co-author of a resolution on the topic, said she has many patients who need treatment for the disease but face significant obstacles thrown up by insurers.

In fact, she testified, "I'm trying to get one of my patients covered." Manages is on her third appeal with the health insurance company.

Amy Matheny, M.D., a new physician delegate from Missoula, Mont., said insurance companies routinely provide a list of requirements for coverage that always ends with "and the patient has had a consultation with a specialist." She noted that this requirement adds to the cost of care and presents barriers for the patient.

Ada Stewart, M.D., a minority delegate from Columbia, S.C., co-authored a similar resolution that was assigned to the Advocacy Reference Committee. "We have trouble getting specialty care for underserved patients," she testified, but once family physicians have appropriate training, "We can provide this care for our patients."

Ultimately, delegates adopted a substitute resolution that directed the AAFP to work with public and private payers to ensure that approval of treatment for chronic hepatitis C be based on the prescribing physician's expertise rather than first requiring a subspecialist consultation.

A resolution about protecting a physician's right to practice medicine in accordance with his or her conscience -- but without abandoning patients -- also evoked spirited debate. Echols, a co-author of the measure, testified to the reference committee that physicians "have a responsibility to see that the patient gets the best care," and if matters of conscience prevent a physician from providing that care, he or she should make an appropriate referral.

Co-author Sarah McNeil, M.D., a general registrant from Martinez, Calif., added, "We want the AAFP to recognize that that physicians-in-training need to be able to know how to address this (issue) and provide appropriate referrals but act within their own conscience."

Debate spilled over into Saturday's business session, where Peggy Brooks, M.D., a women's delegate from Kingsport, Tenn., testified, "Not everywhere does referral mean a patient will get the service; sometimes referral to another physician causes a geographic burden."

Lauren Oshman, M.D., a women's delegate from Wilmette, Ill., said she'd like to see the resolution result in the creation of educational materials for members "that would allow us to address our own biases and limitations" and that would account for individual physician beliefs without offending patients.

In the end, delegates referred the resolution to the Board.

Additional Issues Resolved

In addition to the topics covered above, delegates asked the AAFP to

  • work with CMS and other public and private payers to create a billing modifier or other means as part of a system to ensure the confidentiality of adolescent patient mental and reproductive health visits;
  • encourage residency programs to provide education about contract negotiations;
  • explore creation of a voluntary physician database to include information about credentials, privileges and procedures;
  • provide education to help family physicians create a welcoming office environment for all patients, including LGBTQ (lesbian, gay, bisexual, transgender or queer) families; and
  • advocate for expanded gender identification options in electronic health record software.

Delegates also agreed with the reference committee's recommendation to refer to the AAFP Board of Directors resolutions regarding

  • patient-ordered testing, and
  • confidentiality regarding gender identity, sexuality and sexual orientation.

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