Mary Ellen Schneider

As physicians push for professional liability reform at the national level, the Maryland legislature signed off on a bill aimed at halting rising malpractice premiums.

The centerpiece of the legislation is a rate stabilization fund for medical professional liability insurance that will be funded through a tax on HMOs.

The Maryland State Medical Society (MedChi) and the Maryland Hospital Association estimate that the fund would cover about 95% of the increase in premiums for 2005. Obstetricians in Maryland are paying about $120,000-$160,000 for insurance coverage this year.

Maryland physicians have been pushing hard for reform—especially since last fall, when the state's largest malpractice carrier, Medical Mutual of Maryland, said it would raise its premium rates in 2005 an average 33%. The move follows a 28% increase a year ago.

Maryland is considered a medical liability insurance crisis state by the American College of Obstetricians and Gynecologists. And physicians of all specialties in the state are choosing to lay off staff, close practices, or move, in order to deal with the malpractice problem, according to MedChi.

The new legislation was passed in dramatic fashion during an end-of-the-year special session called by Gov. Robert Ehrlich. But he objected to the HMO tax and said the bill didn't contain meaningful tort reform.

Gov. Erlich then vetoed the measure in January, but legislators returned to work to override the veto.

The saga is expected to continue as Mr. Ehrlich prepares to introduce other legislation with more comprehensive reforms.

The state's physician and hospital groups are applauding the new legislation as an important first step. "While we agree with the governor and others that Maryland needs more comprehensive reform, it does offer important positive elements that we cannot walk away from, given the need to assure access to health care to the citizens of Maryland," MedChi and the Maryland Hospital Association said in a joint statement. "We believe this bill will keep physicians on the job."

The groups pointed out that the measure contains a reduction in the cap on noneconomic damages in death cases, reform of how past medical expenses are calculated, and new requirements for expert witnesses. However, the legislation fails to include needed reforms that include mandatory structured settlements of awards, an expansion of the Good Samaritan Act to include emergency department professionals, and parameters on the calculation of future economic damages, the groups said.

Although there is still more work to be done, the attention brought to medical liability reform through the special session is good news for physicians, said Willarda V. Edwards, M.D., an internist in South Baltimore and MedChi president.

The increased awareness and the better understanding of the issues that resulted from the special session will help as physicians seek increased reform this year, she said. MedChi plans to pursue limits on lawyers' fees, structured settlements that can be paid over time, reforming the calculation of economic damage payments, and enactment of a Good Samaritan law.

"This is just a little taste of what we think should be done," Dr. Edwards said.

But physicians in Maryland are still waiting to see what the current legislation will mean in terms of premiums. "It's too early to say how this is going work," said Miriam Yudkoff, M.D., an ob.gyn. in Annapolis.

And Dr. Yudkoff said she has some concerns about what the insurance reform provisions in the legislation will mean for liability carriers. If Maryland becomes an unprofitable place for insurers, it could have a significant impact on physicians' ability to obtain coverage. "We need a bill that will make Maryland a favorable state for carriers," she said.

Carol Ritter, M.D., a solo gynecologist in Towson, who gave up obstetrics last year, said she sees the legislation as a first step in reform. However, the changes prescribed by the legislation aren't enough to make her able to afford to practice obstetrics again.

The rate stabilization fund is likely to limit the 2005 average premium increase, Dr. Ritter said, but it will still be more than 2004 rates, which were already more than she could afford. However, Dr. Ritter said she's hopeful that it will allow some of her colleagues to stay in practice in the short term.

The legislation also won't help David Zisow, M.D., a gynecologist in Bel Air, to start practicing obstetrics again. Like Dr. Ritter, Dr. Zisow gave up obstetrics at the beginning of 2004 when the rates became too high. But even though the new legislation contains significant reforms, Dr. Zisow said he wouldn't be able to afford to buy the tail coverage that would be necessary to start practicing obstetrics again.

His insurer, Medical Mutual, allowed him to forego paying tail coverage for obstetrics because of his many years with the company. However, he would have to pay a significant amount if he were to go back into obstetrics, he said.

As it is, Dr. Zisow has already seen a major increase in his premiums for gynecology alone in 2005, and he said he isn't optimistic that the legislation will result in too much change in premiums.

"It's business as usual," he said.

This is a wake-up call to physicians to get politically active, said Mark Seigel, M.D., an ob.gyn. in Gaithersburg and the former president of MedChi. Passing meaningful changes to the system takes time, he said, and ultimately it may mean voting officials out of office who fail to take on medical liability reform. "Doctors have to do more than just go to the office and see patients," Dr. Seigel said.

As physicians push for professional liability reform at the national level, the Maryland legislature signed off on a bill aimed at halting rising malpractice premiums.

The centerpiece of the legislation is a rate stabilization fund for medical professional liability insurance that will be funded through a tax on HMOs.

The Maryland State Medical Society (MedChi) and the Maryland Hospital Association estimate that the fund would cover about 95% of the increase in premiums for 2005. Obstetricians in Maryland are paying about $120,000-$160,000 for insurance coverage this year.

Maryland physicians have been pushing hard for reform—especially since last fall, when the state's largest malpractice carrier, Medical Mutual of Maryland, said it would raise its premium rates in 2005 an average 33%. The move follows a 28% increase a year ago.

Maryland is considered a medical liability insurance crisis state by the American College of Obstetricians and Gynecologists. And physicians of all specialties in the state are choosing to lay off staff, close practices, or move, in order to deal with the malpractice problem, according to MedChi.

The new legislation was passed in dramatic fashion during an end-of-the-year special session called by Gov. Robert Ehrlich. But he objected to the HMO tax and said the bill didn't contain meaningful tort reform.

Gov. Erlich then vetoed the measure in January, but legislators returned to work to override the veto.

The saga is expected to continue as Mr. Ehrlich prepares to introduce other legislation with more comprehensive reforms.

The state's physician and hospital groups are applauding the new legislation as an important first step. "While we agree with the governor and others that Maryland needs more comprehensive reform, it does offer important positive elements that we cannot walk away from, given the need to assure access to health care to the citizens of Maryland," MedChi and the Maryland Hospital Association said in a joint statement. "We believe this bill will keep physicians on the job."

The groups pointed out that the measure contains a reduction in the cap on noneconomic damages in death cases, reform of how past medical expenses are calculated, and new requirements for expert witnesses. However, the legislation fails to include needed reforms that include mandatory structured settlements of awards, an expansion of the Good Samaritan Act to include emergency department professionals, and parameters on the calculation of future economic damages, the groups said.

Although there is still more work to be done, the attention brought to medical liability reform through the special session is good news for physicians, said Willarda V. Edwards, M.D., an internist in South Baltimore and MedChi president.

The increased awareness and the better understanding of the issues that resulted from the special session will help as physicians seek increased reform this year, she said. MedChi plans to pursue limits on lawyers' fees, structured settlements that can be paid over time, reforming the calculation of economic damage payments, and enactment of a Good Samaritan law.

"This is just a little taste of what we think should be done," Dr. Edwards said.

But physicians in Maryland are still waiting to see what the current legislation will mean in terms of premiums. "It's too early to say how this is going work," said Miriam Yudkoff, M.D., an ob.gyn. in Annapolis.

And Dr. Yudkoff said she has some concerns about what the insurance reform provisions in the legislation will mean for liability carriers. If Maryland becomes an unprofitable place for insurers, it could have a significant impact on physicians' ability to obtain coverage. "We need a bill that will make Maryland a favorable state for carriers," she said.

Carol Ritter, M.D., a solo gynecologist in Towson, who gave up obstetrics last year, said she sees the legislation as a first step in reform. However, the changes prescribed by the legislation aren't enough to make her able to afford to practice obstetrics again.

The rate stabilization fund is likely to limit the 2005 average premium increase, Dr. Ritter said, but it will still be more than 2004 rates, which were already more than she could afford. However, Dr. Ritter said she's hopeful that it will allow some of her colleagues to stay in practice in the short term.

The legislation also won't help David Zisow, M.D., a gynecologist in Bel Air, to start practicing obstetrics again. Like Dr. Ritter, Dr. Zisow gave up obstetrics at the beginning of 2004 when the rates became too high. But even though the new legislation contains significant reforms, Dr. Zisow said he wouldn't be able to afford to buy the tail coverage that would be necessary to start practicing obstetrics again.

His insurer, Medical Mutual, allowed him to forego paying tail coverage for obstetrics because of his many years with the company. However, he would have to pay a significant amount if he were to go back into obstetrics, he said.

As it is, Dr. Zisow has already seen a major increase in his premiums for gynecology alone in 2005, and he said he isn't optimistic that the legislation will result in too much change in premiums.

"It's business as usual," he said.

This is a wake-up call to physicians to get politically active, said Mark Seigel, M.D., an ob.gyn. in Gaithersburg and the former president of MedChi. Passing meaningful changes to the system takes time, he said, and ultimately it may mean voting officials out of office who fail to take on medical liability reform. "Doctors have to do more than just go to the office and see patients," Dr. Seigel said.

As physicians push for professional liability reform at the national level, the Maryland legislature signed off on a bill aimed at halting rising malpractice premiums.

The centerpiece of the legislation is a rate stabilization fund for medical professional liability insurance that will be funded through a tax on HMOs.

The Maryland State Medical Society (MedChi) and the Maryland Hospital Association estimate that the fund would cover about 95% of the increase in premiums for 2005. Obstetricians in Maryland are paying about $120,000-$160,000 for insurance coverage this year.

Maryland physicians have been pushing hard for reform—especially since last fall, when the state's largest malpractice carrier, Medical Mutual of Maryland, said it would raise its premium rates in 2005 an average 33%. The move follows a 28% increase a year ago.

Maryland is considered a medical liability insurance crisis state by the American College of Obstetricians and Gynecologists. And physicians of all specialties in the state are choosing to lay off staff, close practices, or move, in order to deal with the malpractice problem, according to MedChi.

The new legislation was passed in dramatic fashion during an end-of-the-year special session called by Gov. Robert Ehrlich. But he objected to the HMO tax and said the bill didn't contain meaningful tort reform.

Gov. Erlich then vetoed the measure in January, but legislators returned to work to override the veto.

The saga is expected to continue as Mr. Ehrlich prepares to introduce other legislation with more comprehensive reforms.

The state's physician and hospital groups are applauding the new legislation as an important first step. "While we agree with the governor and others that Maryland needs more comprehensive reform, it does offer important positive elements that we cannot walk away from, given the need to assure access to health care to the citizens of Maryland," MedChi and the Maryland Hospital Association said in a joint statement. "We believe this bill will keep physicians on the job."

The groups pointed out that the measure contains a reduction in the cap on noneconomic damages in death cases, reform of how past medical expenses are calculated, and new requirements for expert witnesses. However, the legislation fails to include needed reforms that include mandatory structured settlements of awards, an expansion of the Good Samaritan Act to include emergency department professionals, and parameters on the calculation of future economic damages, the groups said.

Although there is still more work to be done, the attention brought to medical liability reform through the special session is good news for physicians, said Willarda V. Edwards, M.D., an internist in South Baltimore and MedChi president.

The increased awareness and the better understanding of the issues that resulted from the special session will help as physicians seek increased reform this year, she said. MedChi plans to pursue limits on lawyers' fees, structured settlements that can be paid over time, reforming the calculation of economic damage payments, and enactment of a Good Samaritan law.

"This is just a little taste of what we think should be done," Dr. Edwards said.

But physicians in Maryland are still waiting to see what the current legislation will mean in terms of premiums. "It's too early to say how this is going work," said Miriam Yudkoff, M.D., an ob.gyn. in Annapolis.

And Dr. Yudkoff said she has some concerns about what the insurance reform provisions in the legislation will mean for liability carriers. If Maryland becomes an unprofitable place for insurers, it could have a significant impact on physicians' ability to obtain coverage. "We need a bill that will make Maryland a favorable state for carriers," she said.

Carol Ritter, M.D., a solo gynecologist in Towson, who gave up obstetrics last year, said she sees the legislation as a first step in reform. However, the changes prescribed by the legislation aren't enough to make her able to afford to practice obstetrics again.

The rate stabilization fund is likely to limit the 2005 average premium increase, Dr. Ritter said, but it will still be more than 2004 rates, which were already more than she could afford. However, Dr. Ritter said she's hopeful that it will allow some of her colleagues to stay in practice in the short term.

The legislation also won't help David Zisow, M.D., a gynecologist in Bel Air, to start practicing obstetrics again. Like Dr. Ritter, Dr. Zisow gave up obstetrics at the beginning of 2004 when the rates became too high. But even though the new legislation contains significant reforms, Dr. Zisow said he wouldn't be able to afford to buy the tail coverage that would be necessary to start practicing obstetrics again.

His insurer, Medical Mutual, allowed him to forego paying tail coverage for obstetrics because of his many years with the company. However, he would have to pay a significant amount if he were to go back into obstetrics, he said.

As it is, Dr. Zisow has already seen a major increase in his premiums for gynecology alone in 2005, and he said he isn't optimistic that the legislation will result in too much change in premiums.

"It's business as usual," he said.

This is a wake-up call to physicians to get politically active, said Mark Seigel, M.D., an ob.gyn. in Gaithersburg and the former president of MedChi. Passing meaningful changes to the system takes time, he said, and ultimately it may mean voting officials out of office who fail to take on medical liability reform. "Doctors have to do more than just go to the office and see patients," Dr. Seigel said.

WASHINGTON — Physicians are experimenting with better ways to communicate with patients with low health literacy, Joanne Schwartzberg, M.D., said at a conference on health literacy sponsored by the American College of Physicians.

"It's right in the lap of every physician," said Dr. Schwartzberg, director of aging and community health at the American Medical Association. "Physicians can't say it's someone else's problem."

Using simple language, distributing patient education materials, speaking slowly, reading instructions aloud, asking patients how they follow instructions at home, using teach-back techniques, and drawing pictures are some of the ways health care providers say they are trying to do a better job of reaching out to patients with low health literacy, Dr. Schwartzberg said.

The AMA has developed a health literacy kit with a video and manual for clinicians. The group has also started a train-the-trainer program. To date, the group has trained 11 teams from state and specialty societies. In 6 months, the first 5 teams have conducted 57 trainings and reached more than 1,500 physicians, she said.

Preliminary results show that after the training, a majority of the physicians changed their communication with patients. For example, many reported that they were more often asking patients to repeat back instructions. "People are trying this," noted Dr. Schwartzberg.

Reaching out to patients with low health literacy is especially important in managing chronic disease because there is a "mismatch" between the capabilities of individuals and the demands of their diseases, said Dean Schillinger, M.D., associate professor of medicine at the University of California, San Francisco.

For example, in examining the interactions between physicians and patients with type 2 diabetes, Dr. Schillinger found that physicians used a lot of medical jargon when providing recommendations or education to patients.

Patients with low health literacy were confused by terms that physicians might expect a person with chronic diabetes to know, such as "glucometer," or by hearing that their weight is "stable."

But simply raising awareness among physicians may not be enough, Dr. Schillinger said. Physicians say they need more systemic support, such as more appropriate educational materials and improved labeling of pill bottles.

More research is still needed on what interventions work, especially if the medical community is going to ask insurers and other payers to offer financial incentives in this area, said David Kindig, M.D., chair of the Institute of Medicine Committee on Health Literacy, which issued a report on the topic earlier this year.

WASHINGTON — Physicians are experimenting with better ways to communicate with patients with low health literacy, Joanne Schwartzberg, M.D., said at a conference on health literacy sponsored by the American College of Physicians.

"It's right in the lap of every physician," said Dr. Schwartzberg, director of aging and community health at the American Medical Association. "Physicians can't say it's someone else's problem."

Using simple language, distributing patient education materials, speaking slowly, reading instructions aloud, asking patients how they follow instructions at home, using teach-back techniques, and drawing pictures are some of the ways health care providers say they are trying to do a better job of reaching out to patients with low health literacy, Dr. Schwartzberg said.

The AMA has developed a health literacy kit with a video and manual for clinicians. The group has also started a train-the-trainer program. To date, the group has trained 11 teams from state and specialty societies. In 6 months, the first 5 teams have conducted 57 trainings and reached more than 1,500 physicians, she said.

Preliminary results show that after the training, a majority of the physicians changed their communication with patients. For example, many reported that they were more often asking patients to repeat back instructions. "People are trying this," noted Dr. Schwartzberg.

Reaching out to patients with low health literacy is especially important in managing chronic disease because there is a "mismatch" between the capabilities of individuals and the demands of their diseases, said Dean Schillinger, M.D., associate professor of medicine at the University of California, San Francisco.

For example, in examining the interactions between physicians and patients with type 2 diabetes, Dr. Schillinger found that physicians used a lot of medical jargon when providing recommendations or education to patients.

Patients with low health literacy were confused by terms that physicians might expect a person with chronic diabetes to know, such as "glucometer," or by hearing that their weight is "stable."

But simply raising awareness among physicians may not be enough, Dr. Schillinger said. Physicians say they need more systemic support, such as more appropriate educational materials and improved labeling of pill bottles.

More research is still needed on what interventions work, especially if the medical community is going to ask insurers and other payers to offer financial incentives in this area, said David Kindig, M.D., chair of the Institute of Medicine Committee on Health Literacy, which issued a report on the topic earlier this year.

WASHINGTON — Physicians are experimenting with better ways to communicate with patients with low health literacy, Joanne Schwartzberg, M.D., said at a conference on health literacy sponsored by the American College of Physicians.

"It's right in the lap of every physician," said Dr. Schwartzberg, director of aging and community health at the American Medical Association. "Physicians can't say it's someone else's problem."

Using simple language, distributing patient education materials, speaking slowly, reading instructions aloud, asking patients how they follow instructions at home, using teach-back techniques, and drawing pictures are some of the ways health care providers say they are trying to do a better job of reaching out to patients with low health literacy, Dr. Schwartzberg said.

The AMA has developed a health literacy kit with a video and manual for clinicians. The group has also started a train-the-trainer program. To date, the group has trained 11 teams from state and specialty societies. In 6 months, the first 5 teams have conducted 57 trainings and reached more than 1,500 physicians, she said.

Preliminary results show that after the training, a majority of the physicians changed their communication with patients. For example, many reported that they were more often asking patients to repeat back instructions. "People are trying this," noted Dr. Schwartzberg.

Reaching out to patients with low health literacy is especially important in managing chronic disease because there is a "mismatch" between the capabilities of individuals and the demands of their diseases, said Dean Schillinger, M.D., associate professor of medicine at the University of California, San Francisco.

For example, in examining the interactions between physicians and patients with type 2 diabetes, Dr. Schillinger found that physicians used a lot of medical jargon when providing recommendations or education to patients.

Patients with low health literacy were confused by terms that physicians might expect a person with chronic diabetes to know, such as "glucometer," or by hearing that their weight is "stable."

But simply raising awareness among physicians may not be enough, Dr. Schillinger said. Physicians say they need more systemic support, such as more appropriate educational materials and improved labeling of pill bottles.

More research is still needed on what interventions work, especially if the medical community is going to ask insurers and other payers to offer financial incentives in this area, said David Kindig, M.D., chair of the Institute of Medicine Committee on Health Literacy, which issued a report on the topic earlier this year.

Actinic Keratoses Screening

Elderly patients with actinic keratoses (AK) are six times more likely to develop skin cancer than are those without AK, according to study (Dermatol. Surg. 2005;31:43-7). The research demonstrates that patients who have experienced a lot of sun exposure should be evaluated for AK at the first sign of any suspicious skin abnormality, said Rhoda S. Narins, M.D., president of the American Society for Dermatologic Surgery. Researchers examined more than 25,000 subjects using Medicare survey and claims data. The sample was 88% white and 60% female with a mean age of 78 years. "Although individual AK lesions do not uniformly develop into skin cancer, the presence of AK significantly increases the risk of skin cancer, including melanoma," Phillip M. Williford, M.D., coauthor of the study and a dermatologic surgeon at Wake Forest University, Winston-Salem, N.C., said in a statement. "This elevated risk was unmatched by any other variable we analyzed and, overall, older white males with AK seem to be at very high risk," according to Dr. Williford.

Psoriasis Advocacy

A newly formed advocacy group is calling on Congress to increase federal research for psoriasis and psoriatic arthritis. "Psoriasis Cure Now!" aims to educate lawmakers, opinion leaders, and the general public about the need for more research and the importance of patient access to the full range of treatments for the disease. Michael Paranzino, a psoriasis patient for more than 20 years, launched the group. "Congress will be disturbed to learn that for a full decade, 6.5 million of its constituents with psoriasis and psoriatic arthritis have been shortchanged in federally funded research," Mr. Paranzino said in a statement. "It is unconscionable that psoriasis research has languished throughout the biggest increase in biomedical research funding in world history." Psoriasis research at the National Institute of Arthritis and Musculoskeletal and Skin Diseases has declined from $4.7 million in 1995 to $4.1 million in 2004, even as funding for other diseases has increased, according to the group. The group launched a Web-based petition to Congress that is available online at

www.psorcurenow.org

MedPAC: Give Doctors a 2.7% Hike

Medicare should increase physician payments by 2.7% in 2006 to keep pace with the cost of providing care, the Medicare Payment Advisory Commission recommended. Such an increase will help physicians continue to treat Medicare patients, John C. Nelson, M.D., president of the American Medical Association, said in a statement. "Unless Medicare payments keep up with the cost of providing care, there is a real concern that some physicians will be forced to stop taking new Medicare patients," he said. However, unless Congress fixes a flaw in Medicare's physician payment formula, doctors face a 5% cut next year and cumulative cuts of 30% thru 2012. Several MedPAC commissioners supported the idea of taking outpatient or Part B drugs from the formula, although the Government Accountability Office has warned that this solution would not prevent several years of declines in physician payments.

Fatigue and Driving Don't Mix

Tired residents on the road are more likely have automobile accidents, according to a Web-based survey of 2,737 residents in their first postgraduate year (N. Engl. J. Med. 2005;352:125-34). Investigators found that in any month, each extended work shift increased the risk of any motor vehicle crash by 9% and increased the risk of a crash on the way home from work by more than 16%. Those who worked five or more extended shifts in a month were also more likely to fall asleep behind the wheel. "These results have implications for medical residency programs, which routinely schedule physicians to work more than 24 consecutive hours," the researchers said. The respondents had completed more than 17,000 monthly reports that provided detailed information about work hours, work shifts of an extended duration, documented motor vehicle crashes, near-miss accidents, and incidents involving involuntary sleeping.

Compensation for Vaccine Injuries

The National Vaccine Injury Compensation Program (VICP) will now cover injuries related to the hepatitis A vaccine. Those who believe they've been injured by the vaccine must file a claim within 3 years of the first symptom of the vaccine injury or within 2 years of the vaccine-related death, but not more than 4 years after the start of the first symptom of the vaccine-related injury from which the death occurred. Administered by the Health Resources and Services Administration, VICP provides financial compensation to eligible individuals thought to be injured by vaccines.

Actinic Keratoses Screening

Elderly patients with actinic keratoses (AK) are six times more likely to develop skin cancer than are those without AK, according to study (Dermatol. Surg. 2005;31:43-7). The research demonstrates that patients who have experienced a lot of sun exposure should be evaluated for AK at the first sign of any suspicious skin abnormality, said Rhoda S. Narins, M.D., president of the American Society for Dermatologic Surgery. Researchers examined more than 25,000 subjects using Medicare survey and claims data. The sample was 88% white and 60% female with a mean age of 78 years. "Although individual AK lesions do not uniformly develop into skin cancer, the presence of AK significantly increases the risk of skin cancer, including melanoma," Phillip M. Williford, M.D., coauthor of the study and a dermatologic surgeon at Wake Forest University, Winston-Salem, N.C., said in a statement. "This elevated risk was unmatched by any other variable we analyzed and, overall, older white males with AK seem to be at very high risk," according to Dr. Williford.

Psoriasis Advocacy

A newly formed advocacy group is calling on Congress to increase federal research for psoriasis and psoriatic arthritis. "Psoriasis Cure Now!" aims to educate lawmakers, opinion leaders, and the general public about the need for more research and the importance of patient access to the full range of treatments for the disease. Michael Paranzino, a psoriasis patient for more than 20 years, launched the group. "Congress will be disturbed to learn that for a full decade, 6.5 million of its constituents with psoriasis and psoriatic arthritis have been shortchanged in federally funded research," Mr. Paranzino said in a statement. "It is unconscionable that psoriasis research has languished throughout the biggest increase in biomedical research funding in world history." Psoriasis research at the National Institute of Arthritis and Musculoskeletal and Skin Diseases has declined from $4.7 million in 1995 to $4.1 million in 2004, even as funding for other diseases has increased, according to the group. The group launched a Web-based petition to Congress that is available online at

www.psorcurenow.org

MedPAC: Give Doctors a 2.7% Hike

Medicare should increase physician payments by 2.7% in 2006 to keep pace with the cost of providing care, the Medicare Payment Advisory Commission recommended. Such an increase will help physicians continue to treat Medicare patients, John C. Nelson, M.D., president of the American Medical Association, said in a statement. "Unless Medicare payments keep up with the cost of providing care, there is a real concern that some physicians will be forced to stop taking new Medicare patients," he said. However, unless Congress fixes a flaw in Medicare's physician payment formula, doctors face a 5% cut next year and cumulative cuts of 30% thru 2012. Several MedPAC commissioners supported the idea of taking outpatient or Part B drugs from the formula, although the Government Accountability Office has warned that this solution would not prevent several years of declines in physician payments.

Fatigue and Driving Don't Mix

Tired residents on the road are more likely have automobile accidents, according to a Web-based survey of 2,737 residents in their first postgraduate year (N. Engl. J. Med. 2005;352:125-34). Investigators found that in any month, each extended work shift increased the risk of any motor vehicle crash by 9% and increased the risk of a crash on the way home from work by more than 16%. Those who worked five or more extended shifts in a month were also more likely to fall asleep behind the wheel. "These results have implications for medical residency programs, which routinely schedule physicians to work more than 24 consecutive hours," the researchers said. The respondents had completed more than 17,000 monthly reports that provided detailed information about work hours, work shifts of an extended duration, documented motor vehicle crashes, near-miss accidents, and incidents involving involuntary sleeping.

Compensation for Vaccine Injuries

The National Vaccine Injury Compensation Program (VICP) will now cover injuries related to the hepatitis A vaccine. Those who believe they've been injured by the vaccine must file a claim within 3 years of the first symptom of the vaccine injury or within 2 years of the vaccine-related death, but not more than 4 years after the start of the first symptom of the vaccine-related injury from which the death occurred. Administered by the Health Resources and Services Administration, VICP provides financial compensation to eligible individuals thought to be injured by vaccines.

Actinic Keratoses Screening

Elderly patients with actinic keratoses (AK) are six times more likely to develop skin cancer than are those without AK, according to study (Dermatol. Surg. 2005;31:43-7). The research demonstrates that patients who have experienced a lot of sun exposure should be evaluated for AK at the first sign of any suspicious skin abnormality, said Rhoda S. Narins, M.D., president of the American Society for Dermatologic Surgery. Researchers examined more than 25,000 subjects using Medicare survey and claims data. The sample was 88% white and 60% female with a mean age of 78 years. "Although individual AK lesions do not uniformly develop into skin cancer, the presence of AK significantly increases the risk of skin cancer, including melanoma," Phillip M. Williford, M.D., coauthor of the study and a dermatologic surgeon at Wake Forest University, Winston-Salem, N.C., said in a statement. "This elevated risk was unmatched by any other variable we analyzed and, overall, older white males with AK seem to be at very high risk," according to Dr. Williford.

Psoriasis Advocacy

A newly formed advocacy group is calling on Congress to increase federal research for psoriasis and psoriatic arthritis. "Psoriasis Cure Now!" aims to educate lawmakers, opinion leaders, and the general public about the need for more research and the importance of patient access to the full range of treatments for the disease. Michael Paranzino, a psoriasis patient for more than 20 years, launched the group. "Congress will be disturbed to learn that for a full decade, 6.5 million of its constituents with psoriasis and psoriatic arthritis have been shortchanged in federally funded research," Mr. Paranzino said in a statement. "It is unconscionable that psoriasis research has languished throughout the biggest increase in biomedical research funding in world history." Psoriasis research at the National Institute of Arthritis and Musculoskeletal and Skin Diseases has declined from $4.7 million in 1995 to $4.1 million in 2004, even as funding for other diseases has increased, according to the group. The group launched a Web-based petition to Congress that is available online at

www.psorcurenow.org

MedPAC: Give Doctors a 2.7% Hike

Medicare should increase physician payments by 2.7% in 2006 to keep pace with the cost of providing care, the Medicare Payment Advisory Commission recommended. Such an increase will help physicians continue to treat Medicare patients, John C. Nelson, M.D., president of the American Medical Association, said in a statement. "Unless Medicare payments keep up with the cost of providing care, there is a real concern that some physicians will be forced to stop taking new Medicare patients," he said. However, unless Congress fixes a flaw in Medicare's physician payment formula, doctors face a 5% cut next year and cumulative cuts of 30% thru 2012. Several MedPAC commissioners supported the idea of taking outpatient or Part B drugs from the formula, although the Government Accountability Office has warned that this solution would not prevent several years of declines in physician payments.

Fatigue and Driving Don't Mix

Tired residents on the road are more likely have automobile accidents, according to a Web-based survey of 2,737 residents in their first postgraduate year (N. Engl. J. Med. 2005;352:125-34). Investigators found that in any month, each extended work shift increased the risk of any motor vehicle crash by 9% and increased the risk of a crash on the way home from work by more than 16%. Those who worked five or more extended shifts in a month were also more likely to fall asleep behind the wheel. "These results have implications for medical residency programs, which routinely schedule physicians to work more than 24 consecutive hours," the researchers said. The respondents had completed more than 17,000 monthly reports that provided detailed information about work hours, work shifts of an extended duration, documented motor vehicle crashes, near-miss accidents, and incidents involving involuntary sleeping.

Compensation for Vaccine Injuries

The National Vaccine Injury Compensation Program (VICP) will now cover injuries related to the hepatitis A vaccine. Those who believe they've been injured by the vaccine must file a claim within 3 years of the first symptom of the vaccine injury or within 2 years of the vaccine-related death, but not more than 4 years after the start of the first symptom of the vaccine-related injury from which the death occurred. Administered by the Health Resources and Services Administration, VICP provides financial compensation to eligible individuals thought to be injured by vaccines.

Funding Stem Cell Research

Some states are looking to follow in California's footsteps by attracting scientists to their states to conduct research on human embryonic stem cells. The governors of New Jersey and Connecticut have already announced their proposals to spend millions to entice stem cell researchers to their states, and a New York state senator wants to ask the state's voters for approval of a $1 billion stem cell research initiative. California voters recently approved a measure to spend nearly $3 billion on embryonic stem cell research over the next 10 years. Sean Tipton, spokesman for the Coalition for the Advancement of Medical Research said these activities are good news, given the federal policy on stem cell research; however, his organization questions whether a state-by-state approach makes sense. Researchers will have to figure out the different rules for grants in each state and could waste time and money on these administrative hurdles, he said.

Contaminated Stem Cells Lines

The currently available lines of human embryonic stem cells are contaminated with a nonhuman molecule that compromises their potential use in humans, according to a new study from researchers at the University of California, San Diego, and the Salk Institute in La Jolla, Calif. The study was published in the online Jan. 23 issue of the journal Nature Medicine. Supporters of expanding the federal policy on stem cell research touted the research as evidence that the current policy isn't working. In August 2001, President Bush announced a policy allowing federal funding for human embryonic stem cell research but only on a limited number of stem cell lines that were derived before Aug. 9, 2001. “Stem cell policy in 2005 should not be based on 2001 policy,” Rep. Mike Castle (R-Del.), said in a statement. “An expansion of this policy is critical to our scientists and researchers who need access to the best stem cell lines available and who want the important ethical guidance of the National Institutes of Health.” Rep. Castle, along with Rep. Diana DeGette (D., Colo.), has been pushing for an easing of the 2001 federal policy.

The State of Cervical Cancer

Most U.S. states are falling behind when it comes to cervical cancer screening rates, coverage of routine screening tests in public insurance programs, and legislation on cervical cancer, according to a new report from Women in Government. In the best-performing states, at least 80% of women in the appropriate age range have been screened in the last 3 years, and Medicaid programs cover both Pap testing and HPV tests in routine screening of women aged 30 and older. However, while 46 states and the District of Columbia cover HPV testing through Medicaid when medically necessary, many physicians are not routinely offering it, said J. Thomas Cox, M.D., director of the Women's Clinic at the University of California, Santa Barbara. “Therefore, it is imperative to inform doctors and women about HPV, and to ensure access to HPV testing and to the vaccine for HPV when it become available,” he said in a statement. A copy of the report is available online at

www.womeningovernment.org

Focus on Folic Acid

Women of childbearing age with a family history that puts their potential children at high risk for neural tube defects should supplement their diets with 4 mg of folic acid each day, according to the U.S. Surgeon General. But the increased folic acid should be taken through folic acid supplements, not by increasing the number of multivitamins, the Surgeon General said, because of the risk of vitamin A poisoning. The Surgeon General made these recommendations while announcing his agenda for 2005. Women of childbearing age without family history of neural tube defects should supplement their diets with 400 mcg of folic acid each day, said Surgeon General Richard H. Carmona, M.D.

MedPAC: Give Doctors a 2% Hike

Medicare should increase physician payments by 2.7% in 2006 to keep pace with the cost of providing care, the Medicare Payment Advisory Commission recommended. Such an increase will help physicians continue to treat Medicare patients, John Nelson, M.D., president of the American Medical Association, said in a statement. “Unless Medicare payments keep up with the cost of providing care, there is a real concern that some physicians will be forced to stop taking new Medicare patients,” he said. However, unless Congress fixes a flaw in Medicare's physician payment formula, doctors face a 5% cut next year and cumulative cuts of 30% through 2012. Several MedPAC commissioners supported the idea of taking outpatient or Part B drugs from the formula, although the Government Accountability Office has warned that this solution would not prevent several years of declines in physician payments.

Funding Stem Cell Research

Some states are looking to follow in California's footsteps by attracting scientists to their states to conduct research on human embryonic stem cells. The governors of New Jersey and Connecticut have already announced their proposals to spend millions to entice stem cell researchers to their states, and a New York state senator wants to ask the state's voters for approval of a $1 billion stem cell research initiative. California voters recently approved a measure to spend nearly $3 billion on embryonic stem cell research over the next 10 years. Sean Tipton, spokesman for the Coalition for the Advancement of Medical Research said these activities are good news, given the federal policy on stem cell research; however, his organization questions whether a state-by-state approach makes sense. Researchers will have to figure out the different rules for grants in each state and could waste time and money on these administrative hurdles, he said.

Contaminated Stem Cells Lines

The currently available lines of human embryonic stem cells are contaminated with a nonhuman molecule that compromises their potential use in humans, according to a new study from researchers at the University of California, San Diego, and the Salk Institute in La Jolla, Calif. The study was published in the online Jan. 23 issue of the journal Nature Medicine. Supporters of expanding the federal policy on stem cell research touted the research as evidence that the current policy isn't working. In August 2001, President Bush announced a policy allowing federal funding for human embryonic stem cell research but only on a limited number of stem cell lines that were derived before Aug. 9, 2001. “Stem cell policy in 2005 should not be based on 2001 policy,” Rep. Mike Castle (R-Del.), said in a statement. “An expansion of this policy is critical to our scientists and researchers who need access to the best stem cell lines available and who want the important ethical guidance of the National Institutes of Health.” Rep. Castle, along with Rep. Diana DeGette (D., Colo.), has been pushing for an easing of the 2001 federal policy.

The State of Cervical Cancer

Most U.S. states are falling behind when it comes to cervical cancer screening rates, coverage of routine screening tests in public insurance programs, and legislation on cervical cancer, according to a new report from Women in Government. In the best-performing states, at least 80% of women in the appropriate age range have been screened in the last 3 years, and Medicaid programs cover both Pap testing and HPV tests in routine screening of women aged 30 and older. However, while 46 states and the District of Columbia cover HPV testing through Medicaid when medically necessary, many physicians are not routinely offering it, said J. Thomas Cox, M.D., director of the Women's Clinic at the University of California, Santa Barbara. “Therefore, it is imperative to inform doctors and women about HPV, and to ensure access to HPV testing and to the vaccine for HPV when it become available,” he said in a statement. A copy of the report is available online at

www.womeningovernment.org

Focus on Folic Acid

Women of childbearing age with a family history that puts their potential children at high risk for neural tube defects should supplement their diets with 4 mg of folic acid each day, according to the U.S. Surgeon General. But the increased folic acid should be taken through folic acid supplements, not by increasing the number of multivitamins, the Surgeon General said, because of the risk of vitamin A poisoning. The Surgeon General made these recommendations while announcing his agenda for 2005. Women of childbearing age without family history of neural tube defects should supplement their diets with 400 mcg of folic acid each day, said Surgeon General Richard H. Carmona, M.D.

MedPAC: Give Doctors a 2% Hike

Medicare should increase physician payments by 2.7% in 2006 to keep pace with the cost of providing care, the Medicare Payment Advisory Commission recommended. Such an increase will help physicians continue to treat Medicare patients, John Nelson, M.D., president of the American Medical Association, said in a statement. “Unless Medicare payments keep up with the cost of providing care, there is a real concern that some physicians will be forced to stop taking new Medicare patients,” he said. However, unless Congress fixes a flaw in Medicare's physician payment formula, doctors face a 5% cut next year and cumulative cuts of 30% through 2012. Several MedPAC commissioners supported the idea of taking outpatient or Part B drugs from the formula, although the Government Accountability Office has warned that this solution would not prevent several years of declines in physician payments.

Funding Stem Cell Research

Some states are looking to follow in California's footsteps by attracting scientists to their states to conduct research on human embryonic stem cells. The governors of New Jersey and Connecticut have already announced their proposals to spend millions to entice stem cell researchers to their states, and a New York state senator wants to ask the state's voters for approval of a $1 billion stem cell research initiative. California voters recently approved a measure to spend nearly $3 billion on embryonic stem cell research over the next 10 years. Sean Tipton, spokesman for the Coalition for the Advancement of Medical Research said these activities are good news, given the federal policy on stem cell research; however, his organization questions whether a state-by-state approach makes sense. Researchers will have to figure out the different rules for grants in each state and could waste time and money on these administrative hurdles, he said.

Contaminated Stem Cells Lines

The currently available lines of human embryonic stem cells are contaminated with a nonhuman molecule that compromises their potential use in humans, according to a new study from researchers at the University of California, San Diego, and the Salk Institute in La Jolla, Calif. The study was published in the online Jan. 23 issue of the journal Nature Medicine. Supporters of expanding the federal policy on stem cell research touted the research as evidence that the current policy isn't working. In August 2001, President Bush announced a policy allowing federal funding for human embryonic stem cell research but only on a limited number of stem cell lines that were derived before Aug. 9, 2001. “Stem cell policy in 2005 should not be based on 2001 policy,” Rep. Mike Castle (R-Del.), said in a statement. “An expansion of this policy is critical to our scientists and researchers who need access to the best stem cell lines available and who want the important ethical guidance of the National Institutes of Health.” Rep. Castle, along with Rep. Diana DeGette (D., Colo.), has been pushing for an easing of the 2001 federal policy.

The State of Cervical Cancer

Most U.S. states are falling behind when it comes to cervical cancer screening rates, coverage of routine screening tests in public insurance programs, and legislation on cervical cancer, according to a new report from Women in Government. In the best-performing states, at least 80% of women in the appropriate age range have been screened in the last 3 years, and Medicaid programs cover both Pap testing and HPV tests in routine screening of women aged 30 and older. However, while 46 states and the District of Columbia cover HPV testing through Medicaid when medically necessary, many physicians are not routinely offering it, said J. Thomas Cox, M.D., director of the Women's Clinic at the University of California, Santa Barbara. “Therefore, it is imperative to inform doctors and women about HPV, and to ensure access to HPV testing and to the vaccine for HPV when it become available,” he said in a statement. A copy of the report is available online at

www.womeningovernment.org

Focus on Folic Acid

Women of childbearing age with a family history that puts their potential children at high risk for neural tube defects should supplement their diets with 4 mg of folic acid each day, according to the U.S. Surgeon General. But the increased folic acid should be taken through folic acid supplements, not by increasing the number of multivitamins, the Surgeon General said, because of the risk of vitamin A poisoning. The Surgeon General made these recommendations while announcing his agenda for 2005. Women of childbearing age without family history of neural tube defects should supplement their diets with 400 mcg of folic acid each day, said Surgeon General Richard H. Carmona, M.D.

MedPAC: Give Doctors a 2% Hike

Medicare should increase physician payments by 2.7% in 2006 to keep pace with the cost of providing care, the Medicare Payment Advisory Commission recommended. Such an increase will help physicians continue to treat Medicare patients, John Nelson, M.D., president of the American Medical Association, said in a statement. “Unless Medicare payments keep up with the cost of providing care, there is a real concern that some physicians will be forced to stop taking new Medicare patients,” he said. However, unless Congress fixes a flaw in Medicare's physician payment formula, doctors face a 5% cut next year and cumulative cuts of 30% through 2012. Several MedPAC commissioners supported the idea of taking outpatient or Part B drugs from the formula, although the Government Accountability Office has warned that this solution would not prevent several years of declines in physician payments.

Laws that require parental notification for teens to receive prescription contraception at family planning clinics could increase the risk of teen pregnancy, according to a study by Rachel Jones, Ph.D., and her colleagues.

“Family planning clinics need to be supported in the work that they are doing with teens,” said Dr. Jones, senior research associate at the Alan Guttmacher Institute (JAMA 2005;293:340–8).

The study found that if a law required clinics to inform parents in writing when their teenagers got prescription birth control, 18% of teens would have sex using no contraceptive method or would rely on rhythm or withdrawal.

About 1% of teens surveyed said their only reaction to such a law would be to stop having sex, the study said.

Most teens said they would continue to use the services at the clinic even if parental notification was required or would use over-the-counter contraceptives, such as condoms.

The implications are that mandated parental notification laws would discourage few teens from having sex and likely would increase rates of adolescent pregnancy and sexually transmitted diseases, the study authors concluded.

The study was based on a nationwide survey of 1,526 adolescent females under age 18 years who were seeking sexual health services, excluding abortion and prenatal and postnatal care, at publicly funded family planning clinics in 33 states.

About 60% of respondents said their parents were aware that they were using a clinic for sexual health services. In most cases, the teens had either voluntarily told their parents or they had come to the clinic at the suggestion of a parent.

About one-third of teens surveyed said their parent or guardian was unaware that they were obtaining sexual health services at the clinic. About 4% said they were unsure if their parents knew.

Reasons respondents gave for not informing their parents include:

▸ Not wanting parents to know of the teen's sexual activity.

▸ Not wanting parents to be disappointed by the teen's sexual activity.

▸ Not feeling comfortable with discussing sex with their parents.

▸ Not wanting parents to know the reason for the teen's clinic visit.

▸ Wanting to take responsibility for their own health.

Concerned Women for America (CWA), a group that supports abstinence-only education, discounted the study. CWA said the study is biased because its authors are researchers associated with the Alan Guttmacher Institute, which is affiliated with Planned Parenthood. CWA claims that Planned Parenthood is concerned that greater parental involvement will mean less business for them.

“Policymakers need to stop treating parents as a suspect class, presumed not to have their own kids' best interests at heart,” Wendy Wright, CWA's senior policy director, said in a statement. “Adolescents benefit when their parents are involved in their lives, and policymakers shouldn't forbid their involvement in their daughters' and sons' most important decisions.”

Texas and Utah currently require parental consent for teenage use of state-funded family planning services, and a similar restriction exists in one county in Illinois. Last year, lawmakers in Kentucky, Minnesota, and Virginia introduced bills to impose parental consent requirements on teens seeking contraception.

On the federal level, lawmakers have introduced plans in recent years to require parental involvement in teens seeking contraceptives at federally funded clinics; none has become law.

Laws that require parental notification for teens to receive prescription contraception at family planning clinics could increase the risk of teen pregnancy, according to a study by Rachel Jones, Ph.D., and her colleagues.

“Family planning clinics need to be supported in the work that they are doing with teens,” said Dr. Jones, senior research associate at the Alan Guttmacher Institute (JAMA 2005;293:340–8).

The study found that if a law required clinics to inform parents in writing when their teenagers got prescription birth control, 18% of teens would have sex using no contraceptive method or would rely on rhythm or withdrawal.

About 1% of teens surveyed said their only reaction to such a law would be to stop having sex, the study said.

Most teens said they would continue to use the services at the clinic even if parental notification was required or would use over-the-counter contraceptives, such as condoms.

The implications are that mandated parental notification laws would discourage few teens from having sex and likely would increase rates of adolescent pregnancy and sexually transmitted diseases, the study authors concluded.

The study was based on a nationwide survey of 1,526 adolescent females under age 18 years who were seeking sexual health services, excluding abortion and prenatal and postnatal care, at publicly funded family planning clinics in 33 states.

About 60% of respondents said their parents were aware that they were using a clinic for sexual health services. In most cases, the teens had either voluntarily told their parents or they had come to the clinic at the suggestion of a parent.

About one-third of teens surveyed said their parent or guardian was unaware that they were obtaining sexual health services at the clinic. About 4% said they were unsure if their parents knew.

Reasons respondents gave for not informing their parents include:

▸ Not wanting parents to know of the teen's sexual activity.

▸ Not wanting parents to be disappointed by the teen's sexual activity.

▸ Not feeling comfortable with discussing sex with their parents.

▸ Not wanting parents to know the reason for the teen's clinic visit.

▸ Wanting to take responsibility for their own health.

Concerned Women for America (CWA), a group that supports abstinence-only education, discounted the study. CWA said the study is biased because its authors are researchers associated with the Alan Guttmacher Institute, which is affiliated with Planned Parenthood. CWA claims that Planned Parenthood is concerned that greater parental involvement will mean less business for them.

“Policymakers need to stop treating parents as a suspect class, presumed not to have their own kids' best interests at heart,” Wendy Wright, CWA's senior policy director, said in a statement. “Adolescents benefit when their parents are involved in their lives, and policymakers shouldn't forbid their involvement in their daughters' and sons' most important decisions.”

Texas and Utah currently require parental consent for teenage use of state-funded family planning services, and a similar restriction exists in one county in Illinois. Last year, lawmakers in Kentucky, Minnesota, and Virginia introduced bills to impose parental consent requirements on teens seeking contraception.

On the federal level, lawmakers have introduced plans in recent years to require parental involvement in teens seeking contraceptives at federally funded clinics; none has become law.

Laws that require parental notification for teens to receive prescription contraception at family planning clinics could increase the risk of teen pregnancy, according to a study by Rachel Jones, Ph.D., and her colleagues.

“Family planning clinics need to be supported in the work that they are doing with teens,” said Dr. Jones, senior research associate at the Alan Guttmacher Institute (JAMA 2005;293:340–8).

The study found that if a law required clinics to inform parents in writing when their teenagers got prescription birth control, 18% of teens would have sex using no contraceptive method or would rely on rhythm or withdrawal.

About 1% of teens surveyed said their only reaction to such a law would be to stop having sex, the study said.

Most teens said they would continue to use the services at the clinic even if parental notification was required or would use over-the-counter contraceptives, such as condoms.

The implications are that mandated parental notification laws would discourage few teens from having sex and likely would increase rates of adolescent pregnancy and sexually transmitted diseases, the study authors concluded.

The study was based on a nationwide survey of 1,526 adolescent females under age 18 years who were seeking sexual health services, excluding abortion and prenatal and postnatal care, at publicly funded family planning clinics in 33 states.

About 60% of respondents said their parents were aware that they were using a clinic for sexual health services. In most cases, the teens had either voluntarily told their parents or they had come to the clinic at the suggestion of a parent.

About one-third of teens surveyed said their parent or guardian was unaware that they were obtaining sexual health services at the clinic. About 4% said they were unsure if their parents knew.

Reasons respondents gave for not informing their parents include:

▸ Not wanting parents to know of the teen's sexual activity.

▸ Not wanting parents to be disappointed by the teen's sexual activity.

▸ Not feeling comfortable with discussing sex with their parents.

▸ Not wanting parents to know the reason for the teen's clinic visit.

▸ Wanting to take responsibility for their own health.

Concerned Women for America (CWA), a group that supports abstinence-only education, discounted the study. CWA said the study is biased because its authors are researchers associated with the Alan Guttmacher Institute, which is affiliated with Planned Parenthood. CWA claims that Planned Parenthood is concerned that greater parental involvement will mean less business for them.

“Policymakers need to stop treating parents as a suspect class, presumed not to have their own kids' best interests at heart,” Wendy Wright, CWA's senior policy director, said in a statement. “Adolescents benefit when their parents are involved in their lives, and policymakers shouldn't forbid their involvement in their daughters' and sons' most important decisions.”

Texas and Utah currently require parental consent for teenage use of state-funded family planning services, and a similar restriction exists in one county in Illinois. Last year, lawmakers in Kentucky, Minnesota, and Virginia introduced bills to impose parental consent requirements on teens seeking contraception.

On the federal level, lawmakers have introduced plans in recent years to require parental involvement in teens seeking contraceptives at federally funded clinics; none has become law.

WASHINGTON — Physicians are experimenting with better ways to communicate with patients who have limited health literacy, Joanne Schwartzberg, M.D., said at a conference on health literacy sponsored by the American College of Physicians.

“It's right in the lap of every physician,” said Dr. Schwartzberg, director of aging and community health at the American Medical Association.

The AMA has developed a health literacy kit with a video and manual for clinicians, and has started a train-the-trainer program, she said.

Preliminary results show that after the training, a majority of the physicians changed their communication with patients.

For example, many reported that they were more often asking patients to repeat back instructions.

Reaching out to patients with low health literacy is especially important in managing chronic disease because there is a “mismatch” between the capabilities of individuals and the demands of their diseases, said Dean Schillinger, M.D., associate professor of medicine at the University of California, San Francisco.

For example, in examining the interactions between physicians and patients with type 2 diabetes, Dr. Schillinger found that physicians used a lot of medical jargon when providing recommendations or education to patients.

Patients with low health literacy were confused by terms that physicians might expect a person with chronic diabetes to know, such as “glucometer,” or by hearing that their weight is “stable.”

But simply raising awareness among physicians may not be enough, Dr. Schillinger said.

Physicians say they need more systemic support, such as more appropriate educational materials and improved labeling of pill bottles.

WASHINGTON — Physicians are experimenting with better ways to communicate with patients who have limited health literacy, Joanne Schwartzberg, M.D., said at a conference on health literacy sponsored by the American College of Physicians.

“It's right in the lap of every physician,” said Dr. Schwartzberg, director of aging and community health at the American Medical Association.

The AMA has developed a health literacy kit with a video and manual for clinicians, and has started a train-the-trainer program, she said.

Preliminary results show that after the training, a majority of the physicians changed their communication with patients.

For example, many reported that they were more often asking patients to repeat back instructions.

Reaching out to patients with low health literacy is especially important in managing chronic disease because there is a “mismatch” between the capabilities of individuals and the demands of their diseases, said Dean Schillinger, M.D., associate professor of medicine at the University of California, San Francisco.

For example, in examining the interactions between physicians and patients with type 2 diabetes, Dr. Schillinger found that physicians used a lot of medical jargon when providing recommendations or education to patients.

Patients with low health literacy were confused by terms that physicians might expect a person with chronic diabetes to know, such as “glucometer,” or by hearing that their weight is “stable.”

But simply raising awareness among physicians may not be enough, Dr. Schillinger said.

Physicians say they need more systemic support, such as more appropriate educational materials and improved labeling of pill bottles.

WASHINGTON — Physicians are experimenting with better ways to communicate with patients who have limited health literacy, Joanne Schwartzberg, M.D., said at a conference on health literacy sponsored by the American College of Physicians.

“It's right in the lap of every physician,” said Dr. Schwartzberg, director of aging and community health at the American Medical Association.

The AMA has developed a health literacy kit with a video and manual for clinicians, and has started a train-the-trainer program, she said.

Preliminary results show that after the training, a majority of the physicians changed their communication with patients.

For example, many reported that they were more often asking patients to repeat back instructions.

Reaching out to patients with low health literacy is especially important in managing chronic disease because there is a “mismatch” between the capabilities of individuals and the demands of their diseases, said Dean Schillinger, M.D., associate professor of medicine at the University of California, San Francisco.

For example, in examining the interactions between physicians and patients with type 2 diabetes, Dr. Schillinger found that physicians used a lot of medical jargon when providing recommendations or education to patients.

Patients with low health literacy were confused by terms that physicians might expect a person with chronic diabetes to know, such as “glucometer,” or by hearing that their weight is “stable.”

But simply raising awareness among physicians may not be enough, Dr. Schillinger said.

Physicians say they need more systemic support, such as more appropriate educational materials and improved labeling of pill bottles.

WASHINGTON — Physicians should continue to control access to outpatient physical therapy for Medicare beneficiaries, according to the Medicare Payment Advisory Commission.

In a report to Congress, MedPAC recommended that Medicare keep in place its current policy of using physicians as gatekeepers to accessing physical therapy.

Under current law, Medicare beneficiaries must be referred by a physician to receive physical therapy services; the physician must review a written plan of care every 30 days. The Medicare Modernization Act required MedPAC to examine the idea of allowing beneficiaries direct access to these services.

But MedPAC commissioners were reluctant to recommend removing the restrictions because so many Medicare beneficiaries have multiple and chronic health conditions.

“Without these physician requirements, the medical appropriateness of starting or continuing physical therapy services would be more uncertain,” the MedPAC commissioners said in their report. “Under Medicare, physical therapists are not allowed to order the diagnostic services that may be critical to identifying the patient's underlying medical conditions.”

And current requirements do not appear to impair access for most beneficiaries. In 2003, 85% of beneficiaries reported no problem in getting physical therapy services, commission consultant Carol Carter said at a MedPAC meeting last November.

But MedPAC recommended that additional steps should be taken to make the current restrictions more effective. For example, there should be increased provider education about Medicare coverage rules both for physicians making the referrals and for physical therapists.

The Office of Inspector General has repeatedly recommended that Medicare claims contractors, the facilities where physical therapists practice, and the professional associations step up their efforts in increasing provider knowledge about Medicare's coverage rules, Ms. Carter said.

Better data are needed about the efficacy of physical therapy for older patients, the report said. This evidence could help establish guidelines to educate physical therapists and physicians about which therapy services are likely to be effective for beneficiaries.

WASHINGTON — Physicians should continue to control access to outpatient physical therapy for Medicare beneficiaries, according to the Medicare Payment Advisory Commission.

In a report to Congress, MedPAC recommended that Medicare keep in place its current policy of using physicians as gatekeepers to accessing physical therapy.

Under current law, Medicare beneficiaries must be referred by a physician to receive physical therapy services; the physician must review a written plan of care every 30 days. The Medicare Modernization Act required MedPAC to examine the idea of allowing beneficiaries direct access to these services.

But MedPAC commissioners were reluctant to recommend removing the restrictions because so many Medicare beneficiaries have multiple and chronic health conditions.

“Without these physician requirements, the medical appropriateness of starting or continuing physical therapy services would be more uncertain,” the MedPAC commissioners said in their report. “Under Medicare, physical therapists are not allowed to order the diagnostic services that may be critical to identifying the patient's underlying medical conditions.”

And current requirements do not appear to impair access for most beneficiaries. In 2003, 85% of beneficiaries reported no problem in getting physical therapy services, commission consultant Carol Carter said at a MedPAC meeting last November.

But MedPAC recommended that additional steps should be taken to make the current restrictions more effective. For example, there should be increased provider education about Medicare coverage rules both for physicians making the referrals and for physical therapists.

The Office of Inspector General has repeatedly recommended that Medicare claims contractors, the facilities where physical therapists practice, and the professional associations step up their efforts in increasing provider knowledge about Medicare's coverage rules, Ms. Carter said.

Better data are needed about the efficacy of physical therapy for older patients, the report said. This evidence could help establish guidelines to educate physical therapists and physicians about which therapy services are likely to be effective for beneficiaries.

WASHINGTON — Physicians should continue to control access to outpatient physical therapy for Medicare beneficiaries, according to the Medicare Payment Advisory Commission.

In a report to Congress, MedPAC recommended that Medicare keep in place its current policy of using physicians as gatekeepers to accessing physical therapy.

Under current law, Medicare beneficiaries must be referred by a physician to receive physical therapy services; the physician must review a written plan of care every 30 days. The Medicare Modernization Act required MedPAC to examine the idea of allowing beneficiaries direct access to these services.

But MedPAC commissioners were reluctant to recommend removing the restrictions because so many Medicare beneficiaries have multiple and chronic health conditions.

“Without these physician requirements, the medical appropriateness of starting or continuing physical therapy services would be more uncertain,” the MedPAC commissioners said in their report. “Under Medicare, physical therapists are not allowed to order the diagnostic services that may be critical to identifying the patient's underlying medical conditions.”

And current requirements do not appear to impair access for most beneficiaries. In 2003, 85% of beneficiaries reported no problem in getting physical therapy services, commission consultant Carol Carter said at a MedPAC meeting last November.

But MedPAC recommended that additional steps should be taken to make the current restrictions more effective. For example, there should be increased provider education about Medicare coverage rules both for physicians making the referrals and for physical therapists.

The Office of Inspector General has repeatedly recommended that Medicare claims contractors, the facilities where physical therapists practice, and the professional associations step up their efforts in increasing provider knowledge about Medicare's coverage rules, Ms. Carter said.

Better data are needed about the efficacy of physical therapy for older patients, the report said. This evidence could help establish guidelines to educate physical therapists and physicians about which therapy services are likely to be effective for beneficiaries.

Leaders in medicine are trying to figure out how to make primary care attractive to students and residents once again.

“We've got to change the way students see primary care,” said Michael Whitcomb, M.D., senior vice president of the division of medical education at the Association of American Medical Colleges.

Over the last few years, students have been choosing internal medicine subspecialties over primary care, causing groups like the AAMC, the American College of Physicians, and the American Academy of Family Medicine to reevaluate how to sell primary care to students.

Part of the problem is how students and residents are trained, said Holly Humphrey, M.D., dean for medical education at the University of Chicago. For example, students don't usually get a chance to see the multidisciplinary team approach that works best in primary care, Dr. Humphrey said.

Students training in the hospital see chronic disease management as “overwhelming” and don't see the infrastructure that could make it workable, she said.

But showing the proper management of chronic care patients could be a way to attract more medical students into primary care, said Dr. Whitcomb of the AAMC.

AAMC has formed a group to consider broad issues around improving chronic care, including how a change in emphasis could be one way to attract more students into primary care. This group started its work last fall and is expected to produce a proposal sometime this year, Dr. Whitcomb said.

Trainees and students often don't recognize the gratification of building relationships over many years, said Steven Weinberger, M.D., senior vice president for medical knowledge and education at the ACP.

Dr. Weinberger said he hopes that by redesigning student and resident training, medical school faculty can demonstrate to students that primary care offers the potential for long-lasting relationships with patients.

“We haven't been able to get residents to recognize that because they haven't been exposed to it,” he said.

One way that the AAFP is looking to increase student interest is by providing students access to competent role models in family medicine. One of the academy's efforts in this area includes piloting an online mentoring system. The concept began in Ohio where the Ohio Academy of Family Physicians and students from Ohio State University in Columbus have been using the Internet to connect medical students with practicing physicians in the community.

This year, AAFP is testing out the concept of an online mentoring program through similar projects in three states, said Jay Fetter, AAFP's student interest manager.

These organizations are also working on revitalizing primary care at the practice level.

Repairing the payment system, reducing administrative hassles, articulating the value of internal medicine, and redesigning training to better meet the scope of practice, are all important steps, Dr. Weinberger said.

In fact, improving practice issues may be more important to attracting students than making educational changes, said Tod Ibrahim, executive vice president for the Alliance for Academic Internal Medicine.

“I think the generational issues are bigger than anyone realizes,” Mr. Ibrahim said.

The federal government could help by offering economic incentives, such as repayment of medical school loans, said Richard Lang, M.D., chairman of the department of general internal medicine at the Cleveland Clinic. Everyone is medicine is working hard, he said, but the salaries for primary care are much lower than other areas of medicine.

The key is to bring back job satisfaction for practicing primary care physicians, said Lawrence Smith, M.D., dean of medical education at the Mount Sinai School of Medicine, New York.

Dr. Smith predicts that electronic health records could make practice easier in the future. New practice models that revolve around a team of caregivers in a single office, could also help.

Physicians need to be reimbursed for how they spend their time, including phone calls and e-mail consultations with patients, he said.

If this problem isn't addressed, the United States could end up with a system without primary care physicians, Dr. Smith said. While that might be workable for smart, enfranchised patients, most others would be lost in the health care system without a primary care doctor to help them navigate it, he said.

Leaders in medicine are trying to figure out how to make primary care attractive to students and residents once again.

“We've got to change the way students see primary care,” said Michael Whitcomb, M.D., senior vice president of the division of medical education at the Association of American Medical Colleges.

Over the last few years, students have been choosing internal medicine subspecialties over primary care, causing groups like the AAMC, the American College of Physicians, and the American Academy of Family Medicine to reevaluate how to sell primary care to students.

Part of the problem is how students and residents are trained, said Holly Humphrey, M.D., dean for medical education at the University of Chicago. For example, students don't usually get a chance to see the multidisciplinary team approach that works best in primary care, Dr. Humphrey said.

Students training in the hospital see chronic disease management as “overwhelming” and don't see the infrastructure that could make it workable, she said.

But showing the proper management of chronic care patients could be a way to attract more medical students into primary care, said Dr. Whitcomb of the AAMC.

AAMC has formed a group to consider broad issues around improving chronic care, including how a change in emphasis could be one way to attract more students into primary care. This group started its work last fall and is expected to produce a proposal sometime this year, Dr. Whitcomb said.

Trainees and students often don't recognize the gratification of building relationships over many years, said Steven Weinberger, M.D., senior vice president for medical knowledge and education at the ACP.

Dr. Weinberger said he hopes that by redesigning student and resident training, medical school faculty can demonstrate to students that primary care offers the potential for long-lasting relationships with patients.

“We haven't been able to get residents to recognize that because they haven't been exposed to it,” he said.

One way that the AAFP is looking to increase student interest is by providing students access to competent role models in family medicine. One of the academy's efforts in this area includes piloting an online mentoring system. The concept began in Ohio where the Ohio Academy of Family Physicians and students from Ohio State University in Columbus have been using the Internet to connect medical students with practicing physicians in the community.

This year, AAFP is testing out the concept of an online mentoring program through similar projects in three states, said Jay Fetter, AAFP's student interest manager.

These organizations are also working on revitalizing primary care at the practice level.

Repairing the payment system, reducing administrative hassles, articulating the value of internal medicine, and redesigning training to better meet the scope of practice, are all important steps, Dr. Weinberger said.

In fact, improving practice issues may be more important to attracting students than making educational changes, said Tod Ibrahim, executive vice president for the Alliance for Academic Internal Medicine.

“I think the generational issues are bigger than anyone realizes,” Mr. Ibrahim said.

The federal government could help by offering economic incentives, such as repayment of medical school loans, said Richard Lang, M.D., chairman of the department of general internal medicine at the Cleveland Clinic. Everyone is medicine is working hard, he said, but the salaries for primary care are much lower than other areas of medicine.

The key is to bring back job satisfaction for practicing primary care physicians, said Lawrence Smith, M.D., dean of medical education at the Mount Sinai School of Medicine, New York.

Dr. Smith predicts that electronic health records could make practice easier in the future. New practice models that revolve around a team of caregivers in a single office, could also help.

Physicians need to be reimbursed for how they spend their time, including phone calls and e-mail consultations with patients, he said.

If this problem isn't addressed, the United States could end up with a system without primary care physicians, Dr. Smith said. While that might be workable for smart, enfranchised patients, most others would be lost in the health care system without a primary care doctor to help them navigate it, he said.

Leaders in medicine are trying to figure out how to make primary care attractive to students and residents once again.

“We've got to change the way students see primary care,” said Michael Whitcomb, M.D., senior vice president of the division of medical education at the Association of American Medical Colleges.

Over the last few years, students have been choosing internal medicine subspecialties over primary care, causing groups like the AAMC, the American College of Physicians, and the American Academy of Family Medicine to reevaluate how to sell primary care to students.

Part of the problem is how students and residents are trained, said Holly Humphrey, M.D., dean for medical education at the University of Chicago. For example, students don't usually get a chance to see the multidisciplinary team approach that works best in primary care, Dr. Humphrey said.

Students training in the hospital see chronic disease management as “overwhelming” and don't see the infrastructure that could make it workable, she said.

But showing the proper management of chronic care patients could be a way to attract more medical students into primary care, said Dr. Whitcomb of the AAMC.

AAMC has formed a group to consider broad issues around improving chronic care, including how a change in emphasis could be one way to attract more students into primary care. This group started its work last fall and is expected to produce a proposal sometime this year, Dr. Whitcomb said.

Trainees and students often don't recognize the gratification of building relationships over many years, said Steven Weinberger, M.D., senior vice president for medical knowledge and education at the ACP.

Dr. Weinberger said he hopes that by redesigning student and resident training, medical school faculty can demonstrate to students that primary care offers the potential for long-lasting relationships with patients.

“We haven't been able to get residents to recognize that because they haven't been exposed to it,” he said.

One way that the AAFP is looking to increase student interest is by providing students access to competent role models in family medicine. One of the academy's efforts in this area includes piloting an online mentoring system. The concept began in Ohio where the Ohio Academy of Family Physicians and students from Ohio State University in Columbus have been using the Internet to connect medical students with practicing physicians in the community.

This year, AAFP is testing out the concept of an online mentoring program through similar projects in three states, said Jay Fetter, AAFP's student interest manager.

These organizations are also working on revitalizing primary care at the practice level.

Repairing the payment system, reducing administrative hassles, articulating the value of internal medicine, and redesigning training to better meet the scope of practice, are all important steps, Dr. Weinberger said.

In fact, improving practice issues may be more important to attracting students than making educational changes, said Tod Ibrahim, executive vice president for the Alliance for Academic Internal Medicine.

“I think the generational issues are bigger than anyone realizes,” Mr. Ibrahim said.

The federal government could help by offering economic incentives, such as repayment of medical school loans, said Richard Lang, M.D., chairman of the department of general internal medicine at the Cleveland Clinic. Everyone is medicine is working hard, he said, but the salaries for primary care are much lower than other areas of medicine.

The key is to bring back job satisfaction for practicing primary care physicians, said Lawrence Smith, M.D., dean of medical education at the Mount Sinai School of Medicine, New York.

Dr. Smith predicts that electronic health records could make practice easier in the future. New practice models that revolve around a team of caregivers in a single office, could also help.

Physicians need to be reimbursed for how they spend their time, including phone calls and e-mail consultations with patients, he said.

If this problem isn't addressed, the United States could end up with a system without primary care physicians, Dr. Smith said. While that might be workable for smart, enfranchised patients, most others would be lost in the health care system without a primary care doctor to help them navigate it, he said.

WASHINGTON — The National Institutes of Health should increase its support for research into chronic fatigue syndrome in children to match the burden and impact of the illness, Peter Rowe, M.D., said at a meeting of the Health and Human Services Department's Chronic Fatigue Advisory Committee.

More philanthropic support is needed to advance the care of children and adults with chronic fatigue syndrome (CFS), said Dr. Rowe, a professor at Johns Hopkins Children's Center, Baltimore, and director of the center's chronic fatigue clinic.

Currently, few hospital- or university-affiliated clinical centers and no university research centers are treating children with CFS, and only $1 million annually in NIH funds are targeted at children with CFS, he said.

“This isn't enough to create a critical level of interest in bringing good people into the field, and it does not make CFS seem like a viable option to the new pediatric researcher,” Dr. Rowe said.

As a result, it's difficult for CFS patients to find physicians to care for them, Dr. Rowe said. CFS specialists are usually overburdened, and patients are so eager for a timely evaluation that they are willing to pay a premium, he said.

Dr. Rowe said he knows of one place where a patient can be evaluated fairly quickly—but at a price tag of $5,800. “I think we have a responsibility to protect children and young families from this kind of economic risk,” he said.

To be diagnosed with CFS, patients generally must have severe chronic fatigue for 6 months or longer with other known medical conditions excluded by clinical diagnosis, and they must concurrently have four or more of the following symptoms: substantial impairment in short-term memory or concentration; sore throat; tender lymph nodes; muscle pain; multijoint pain without swelling or redness; headaches of a new type, pattern, or severity; unrefreshing sleep; and postexertional malaise lasting more than 24 hours, according to the Centers for Disease Control and Prevention. The symptoms must have persisted or recurred during 6 or more consecutive months of illness and must not have predated the fatigue.

The heterogeneous nature of the illness itself also makes it difficult to recognize and treat the disease. For example, how CFS affects individual children depends on the child's developmental status, the duration of the illness, as well as the severity of the illness, Dr. Rowe said. And the patient's response to the illness is affected by the quality of support provided by family, friends, and the medical profession, he said.

The heterogeneity also impacts research and many of the current studies are underpowered and much larger studies are needed to detect efficacy from other changes caused by comorbid conditions, he said. It's also difficult to control for just one variable in a randomized clinical trial on CFS because of the many overlapping and interacting pathophysiologic dysfunctions associated with the condition, he said. Dr. Rowe proposes conducting randomized trials by withdrawing ostensibly effective therapies. For example, in an otherwise well-managed and clinically stable patient with CFS, the patient would be randomized to receive either a placebo or the active medication.

Another option would be to incorporate a “run-in period” for studies during which other influences to symptoms are brought under good clinical control before examining the efficacy of a single agent.

For example, Dr. Rowe said he had good results treating one patient with midodrine, but he might not have noticed its dramatic effect on the patient if he had started it before treating her pelvic congestion syndrome, since that condition appeared to have an independent effect on her orthostatic tolerance.

WASHINGTON — The National Institutes of Health should increase its support for research into chronic fatigue syndrome in children to match the burden and impact of the illness, Peter Rowe, M.D., said at a meeting of the Health and Human Services Department's Chronic Fatigue Advisory Committee.

More philanthropic support is needed to advance the care of children and adults with chronic fatigue syndrome (CFS), said Dr. Rowe, a professor at Johns Hopkins Children's Center, Baltimore, and director of the center's chronic fatigue clinic.

Currently, few hospital- or university-affiliated clinical centers and no university research centers are treating children with CFS, and only $1 million annually in NIH funds are targeted at children with CFS, he said.

“This isn't enough to create a critical level of interest in bringing good people into the field, and it does not make CFS seem like a viable option to the new pediatric researcher,” Dr. Rowe said.

As a result, it's difficult for CFS patients to find physicians to care for them, Dr. Rowe said. CFS specialists are usually overburdened, and patients are so eager for a timely evaluation that they are willing to pay a premium, he said.

Dr. Rowe said he knows of one place where a patient can be evaluated fairly quickly—but at a price tag of $5,800. “I think we have a responsibility to protect children and young families from this kind of economic risk,” he said.

To be diagnosed with CFS, patients generally must have severe chronic fatigue for 6 months or longer with other known medical conditions excluded by clinical diagnosis, and they must concurrently have four or more of the following symptoms: substantial impairment in short-term memory or concentration; sore throat; tender lymph nodes; muscle pain; multijoint pain without swelling or redness; headaches of a new type, pattern, or severity; unrefreshing sleep; and postexertional malaise lasting more than 24 hours, according to the Centers for Disease Control and Prevention. The symptoms must have persisted or recurred during 6 or more consecutive months of illness and must not have predated the fatigue.

The heterogeneous nature of the illness itself also makes it difficult to recognize and treat the disease. For example, how CFS affects individual children depends on the child's developmental status, the duration of the illness, as well as the severity of the illness, Dr. Rowe said. And the patient's response to the illness is affected by the quality of support provided by family, friends, and the medical profession, he said.

The heterogeneity also impacts research and many of the current studies are underpowered and much larger studies are needed to detect efficacy from other changes caused by comorbid conditions, he said. It's also difficult to control for just one variable in a randomized clinical trial on CFS because of the many overlapping and interacting pathophysiologic dysfunctions associated with the condition, he said. Dr. Rowe proposes conducting randomized trials by withdrawing ostensibly effective therapies. For example, in an otherwise well-managed and clinically stable patient with CFS, the patient would be randomized to receive either a placebo or the active medication.

Another option would be to incorporate a “run-in period” for studies during which other influences to symptoms are brought under good clinical control before examining the efficacy of a single agent.

For example, Dr. Rowe said he had good results treating one patient with midodrine, but he might not have noticed its dramatic effect on the patient if he had started it before treating her pelvic congestion syndrome, since that condition appeared to have an independent effect on her orthostatic tolerance.

WASHINGTON — The National Institutes of Health should increase its support for research into chronic fatigue syndrome in children to match the burden and impact of the illness, Peter Rowe, M.D., said at a meeting of the Health and Human Services Department's Chronic Fatigue Advisory Committee.

More philanthropic support is needed to advance the care of children and adults with chronic fatigue syndrome (CFS), said Dr. Rowe, a professor at Johns Hopkins Children's Center, Baltimore, and director of the center's chronic fatigue clinic.

Currently, few hospital- or university-affiliated clinical centers and no university research centers are treating children with CFS, and only $1 million annually in NIH funds are targeted at children with CFS, he said.

“This isn't enough to create a critical level of interest in bringing good people into the field, and it does not make CFS seem like a viable option to the new pediatric researcher,” Dr. Rowe said.

As a result, it's difficult for CFS patients to find physicians to care for them, Dr. Rowe said. CFS specialists are usually overburdened, and patients are so eager for a timely evaluation that they are willing to pay a premium, he said.

Dr. Rowe said he knows of one place where a patient can be evaluated fairly quickly—but at a price tag of $5,800. “I think we have a responsibility to protect children and young families from this kind of economic risk,” he said.

To be diagnosed with CFS, patients generally must have severe chronic fatigue for 6 months or longer with other known medical conditions excluded by clinical diagnosis, and they must concurrently have four or more of the following symptoms: substantial impairment in short-term memory or concentration; sore throat; tender lymph nodes; muscle pain; multijoint pain without swelling or redness; headaches of a new type, pattern, or severity; unrefreshing sleep; and postexertional malaise lasting more than 24 hours, according to the Centers for Disease Control and Prevention. The symptoms must have persisted or recurred during 6 or more consecutive months of illness and must not have predated the fatigue.

The heterogeneous nature of the illness itself also makes it difficult to recognize and treat the disease. For example, how CFS affects individual children depends on the child's developmental status, the duration of the illness, as well as the severity of the illness, Dr. Rowe said. And the patient's response to the illness is affected by the quality of support provided by family, friends, and the medical profession, he said.

The heterogeneity also impacts research and many of the current studies are underpowered and much larger studies are needed to detect efficacy from other changes caused by comorbid conditions, he said. It's also difficult to control for just one variable in a randomized clinical trial on CFS because of the many overlapping and interacting pathophysiologic dysfunctions associated with the condition, he said. Dr. Rowe proposes conducting randomized trials by withdrawing ostensibly effective therapies. For example, in an otherwise well-managed and clinically stable patient with CFS, the patient would be randomized to receive either a placebo or the active medication.

Another option would be to incorporate a “run-in period” for studies during which other influences to symptoms are brought under good clinical control before examining the efficacy of a single agent.

For example, Dr. Rowe said he had good results treating one patient with midodrine, but he might not have noticed its dramatic effect on the patient if he had started it before treating her pelvic congestion syndrome, since that condition appeared to have an independent effect on her orthostatic tolerance.

The malpractice insurance crisis is prompting a small number of professional liability insurers to institute strict standards for performing vaginal birth after cesarean section.

And an Oklahoma insurer last month has gone as far as excluding coverage for the procedure, citing a high number of claims associated with allegations of failure to perform a timely cesarean.

For its part, Northwest Physicians Mutual Insurance Company in Oregon still covers vaginal birth after cesarean section (VBAC), but it instituted a requirement in late 2003 that physicians and nurse-midwives who provide obstetric care must submit verification that the hospital where they practice is able to meet specific criteria. To continue to be covered to perform VBAC, physicians and the facilities in which they perform VBAC have to demonstrate that a physician capable of monitoring and performing an emergency cesarean delivery is present in the hospital or on the hospital's campus throughout active labor.

The insurer bases its certification on a practice bulletin issued by the American College of Obstetricians and Gynecologists (ACOG), which recommends that a physician capable of monitoring labor and performing an emergency cesarean be “immediately available” throughout active labor.

“Given the associated risks and elective nature of performing this procedure, coverage for the performance of VBACs will only be offered under specific criteria,” William Gallagher, M.D., president and chair of Northwest Physicians Mutual, said in a letter to physicians.

For N. Michelle Sang, M.D., an ob.gyn. in Portland, Ore., who is insured through Northwest Physicians Mutual, this change means she and her colleagues are a lot more selective about providing VBAC.

Since she is affiliated with two hospitals, it's not practical to expect to be in one hospital for a patient's labor and delivery, she said. As a result, Dr. Sang and her colleagues in the practice have their patients sign a contract acknowledging that they might not be able to undergo VBAC.

“We tell our patients that we cannot guarantee a trial of labor if their physician is not available—regardless of the call schedule—or if there are multiple patients in labor at more than one hospital for our office,” Dr. Sang said.

Although some physicians in her group are offering VBAC to any patient who is a good candidate, most of them only offer VBAC to patients who have already had a successful VBAC.

For Northwest Physicians Mutual, the decision to require adherence to the ACOG practice bulletin was primarily a patient-safety issue, Dr. Gallagher said. The company's board had considered instituting a full exclusion of VBAC but decided against it. “We're not really in the business to tell doctors what they can do and can't do,” he said.

Northwest Physicians Mutual isn't the only company asking physicians to certify that they will follow the recommendations laid out in the ACOG bulletin.

ProAssurance, a professional liability insurer that operates in a number of southern states, has a similar policy that requires physicians to sign endorsements saying they will follow the ACOG recommendations.

The company recently phased in this policy in Georgia, Virginia, North Carolina, Texas, and Tennessee. The change in policy is part of the company's ongoing evaluation of medical liability, said Frank O'Neil, a spokesman for ProAssurance.

The Utah Medical Insurance Association has developed its own guidelines that physicians must adhere to as part of their policy. VBAC is subject to special guidelines, along with other high-risk obstetric procedures, because it is a huge area of litigation and loss around the country, said Steven L. Clark, M.D., a Salt Lake City-based perinatal advisor for the Utah Medical Insurance Association and medical director of perinatal medicine for the Hospital Corporation of America.

Physicians are covered to perform VBAC only if they follow certain conditions such as not using prostaglandin agents, performing continuous electronic fetal heart rate monitoring, being within 5 minutes of the operating room throughout the patient's labor, and providing informed consent to the patient. In addition, VBAC for twin gestations is prohibited.

Dr. Clark said his company's guidelines aren't particularly strict and are similar to requirements in place by hospitals. “Our view of this … that this is basically a tertiary hospital procedure,” he said.

In Oklahoma, the Physicians Liability Insurance Corp. (PLICO) has taken its policy a step further by excluding from its malpractice coverage all VBAC procedures except in the case of an emergency. The new policy went into effect on Jan. 1.

The decision was based on a number of factors, said PLICO President and CEO Carl Hook, M.D., including ACOG's practice bulletin on VBAC, which was issued in 1999 and revised last year, and statistics showing an increased risk of uterine rupture when women undergoing VBAC receive uterine muscle contraction medications to assist labor.

Claims were also a factor. In 2003, about half of PLICO's losses were paid on claims in which failure to perform a timely cesarean was alleged, Dr. Hook said.

But Dana Stone, M.D., an ob.gyn. in Oklahoma City, said she is concerned that coverage is being denied for a reasonable medical procedure.

Dr. Stone said she doesn't believe she can continue to offer VBAC in light of this restriction. To date, Dr. Stone said she hasn't had a patient ask to change doctors because she can't perform VBAC, but she says her colleagues have had patients who are seeking new physicians as a result.

These types of restrictions imposed by insurers aren't widespread, said Albert L. Strunk, M.D., vice president of ACOG's fellowship activities. In many cases, companies recommend adherence to practice guidelines, but the process is informal, he said.

Although the educational efforts for improving patient safety and care can be helpful, Dr. Strunk said, practice parameters that have as their primary goal the protection of the insurance company are inappropriate. It's also inappropriate for the insurer to impose practice requirements that would impair physicians in exercising their judgment in terms of patient safety, Dr. Strunk said.

The malpractice insurance crisis is prompting a small number of professional liability insurers to institute strict standards for performing vaginal birth after cesarean section.

And an Oklahoma insurer last month has gone as far as excluding coverage for the procedure, citing a high number of claims associated with allegations of failure to perform a timely cesarean.

For its part, Northwest Physicians Mutual Insurance Company in Oregon still covers vaginal birth after cesarean section (VBAC), but it instituted a requirement in late 2003 that physicians and nurse-midwives who provide obstetric care must submit verification that the hospital where they practice is able to meet specific criteria. To continue to be covered to perform VBAC, physicians and the facilities in which they perform VBAC have to demonstrate that a physician capable of monitoring and performing an emergency cesarean delivery is present in the hospital or on the hospital's campus throughout active labor.

The insurer bases its certification on a practice bulletin issued by the American College of Obstetricians and Gynecologists (ACOG), which recommends that a physician capable of monitoring labor and performing an emergency cesarean be “immediately available” throughout active labor.

“Given the associated risks and elective nature of performing this procedure, coverage for the performance of VBACs will only be offered under specific criteria,” William Gallagher, M.D., president and chair of Northwest Physicians Mutual, said in a letter to physicians.

For N. Michelle Sang, M.D., an ob.gyn. in Portland, Ore., who is insured through Northwest Physicians Mutual, this change means she and her colleagues are a lot more selective about providing VBAC.

Since she is affiliated with two hospitals, it's not practical to expect to be in one hospital for a patient's labor and delivery, she said. As a result, Dr. Sang and her colleagues in the practice have their patients sign a contract acknowledging that they might not be able to undergo VBAC.

“We tell our patients that we cannot guarantee a trial of labor if their physician is not available—regardless of the call schedule—or if there are multiple patients in labor at more than one hospital for our office,” Dr. Sang said.

Although some physicians in her group are offering VBAC to any patient who is a good candidate, most of them only offer VBAC to patients who have already had a successful VBAC.

For Northwest Physicians Mutual, the decision to require adherence to the ACOG practice bulletin was primarily a patient-safety issue, Dr. Gallagher said. The company's board had considered instituting a full exclusion of VBAC but decided against it. “We're not really in the business to tell doctors what they can do and can't do,” he said.

Northwest Physicians Mutual isn't the only company asking physicians to certify that they will follow the recommendations laid out in the ACOG bulletin.

ProAssurance, a professional liability insurer that operates in a number of southern states, has a similar policy that requires physicians to sign endorsements saying they will follow the ACOG recommendations.

The company recently phased in this policy in Georgia, Virginia, North Carolina, Texas, and Tennessee. The change in policy is part of the company's ongoing evaluation of medical liability, said Frank O'Neil, a spokesman for ProAssurance.

The Utah Medical Insurance Association has developed its own guidelines that physicians must adhere to as part of their policy. VBAC is subject to special guidelines, along with other high-risk obstetric procedures, because it is a huge area of litigation and loss around the country, said Steven L. Clark, M.D., a Salt Lake City-based perinatal advisor for the Utah Medical Insurance Association and medical director of perinatal medicine for the Hospital Corporation of America.

Physicians are covered to perform VBAC only if they follow certain conditions such as not using prostaglandin agents, performing continuous electronic fetal heart rate monitoring, being within 5 minutes of the operating room throughout the patient's labor, and providing informed consent to the patient. In addition, VBAC for twin gestations is prohibited.

Dr. Clark said his company's guidelines aren't particularly strict and are similar to requirements in place by hospitals. “Our view of this … that this is basically a tertiary hospital procedure,” he said.

In Oklahoma, the Physicians Liability Insurance Corp. (PLICO) has taken its policy a step further by excluding from its malpractice coverage all VBAC procedures except in the case of an emergency. The new policy went into effect on Jan. 1.

The decision was based on a number of factors, said PLICO President and CEO Carl Hook, M.D., including ACOG's practice bulletin on VBAC, which was issued in 1999 and revised last year, and statistics showing an increased risk of uterine rupture when women undergoing VBAC receive uterine muscle contraction medications to assist labor.

Claims were also a factor. In 2003, about half of PLICO's losses were paid on claims in which failure to perform a timely cesarean was alleged, Dr. Hook said.

But Dana Stone, M.D., an ob.gyn. in Oklahoma City, said she is concerned that coverage is being denied for a reasonable medical procedure.

Dr. Stone said she doesn't believe she can continue to offer VBAC in light of this restriction. To date, Dr. Stone said she hasn't had a patient ask to change doctors because she can't perform VBAC, but she says her colleagues have had patients who are seeking new physicians as a result.

These types of restrictions imposed by insurers aren't widespread, said Albert L. Strunk, M.D., vice president of ACOG's fellowship activities. In many cases, companies recommend adherence to practice guidelines, but the process is informal, he said.

Although the educational efforts for improving patient safety and care can be helpful, Dr. Strunk said, practice parameters that have as their primary goal the protection of the insurance company are inappropriate. It's also inappropriate for the insurer to impose practice requirements that would impair physicians in exercising their judgment in terms of patient safety, Dr. Strunk said.

The malpractice insurance crisis is prompting a small number of professional liability insurers to institute strict standards for performing vaginal birth after cesarean section.

And an Oklahoma insurer last month has gone as far as excluding coverage for the procedure, citing a high number of claims associated with allegations of failure to perform a timely cesarean.

For its part, Northwest Physicians Mutual Insurance Company in Oregon still covers vaginal birth after cesarean section (VBAC), but it instituted a requirement in late 2003 that physicians and nurse-midwives who provide obstetric care must submit verification that the hospital where they practice is able to meet specific criteria. To continue to be covered to perform VBAC, physicians and the facilities in which they perform VBAC have to demonstrate that a physician capable of monitoring and performing an emergency cesarean delivery is present in the hospital or on the hospital's campus throughout active labor.

The insurer bases its certification on a practice bulletin issued by the American College of Obstetricians and Gynecologists (ACOG), which recommends that a physician capable of monitoring labor and performing an emergency cesarean be “immediately available” throughout active labor.

“Given the associated risks and elective nature of performing this procedure, coverage for the performance of VBACs will only be offered under specific criteria,” William Gallagher, M.D., president and chair of Northwest Physicians Mutual, said in a letter to physicians.

For N. Michelle Sang, M.D., an ob.gyn. in Portland, Ore., who is insured through Northwest Physicians Mutual, this change means she and her colleagues are a lot more selective about providing VBAC.

Since she is affiliated with two hospitals, it's not practical to expect to be in one hospital for a patient's labor and delivery, she said. As a result, Dr. Sang and her colleagues in the practice have their patients sign a contract acknowledging that they might not be able to undergo VBAC.

“We tell our patients that we cannot guarantee a trial of labor if their physician is not available—regardless of the call schedule—or if there are multiple patients in labor at more than one hospital for our office,” Dr. Sang said.

Although some physicians in her group are offering VBAC to any patient who is a good candidate, most of them only offer VBAC to patients who have already had a successful VBAC.

For Northwest Physicians Mutual, the decision to require adherence to the ACOG practice bulletin was primarily a patient-safety issue, Dr. Gallagher said. The company's board had considered instituting a full exclusion of VBAC but decided against it. “We're not really in the business to tell doctors what they can do and can't do,” he said.

Northwest Physicians Mutual isn't the only company asking physicians to certify that they will follow the recommendations laid out in the ACOG bulletin.

ProAssurance, a professional liability insurer that operates in a number of southern states, has a similar policy that requires physicians to sign endorsements saying they will follow the ACOG recommendations.

The company recently phased in this policy in Georgia, Virginia, North Carolina, Texas, and Tennessee. The change in policy is part of the company's ongoing evaluation of medical liability, said Frank O'Neil, a spokesman for ProAssurance.

The Utah Medical Insurance Association has developed its own guidelines that physicians must adhere to as part of their policy. VBAC is subject to special guidelines, along with other high-risk obstetric procedures, because it is a huge area of litigation and loss around the country, said Steven L. Clark, M.D., a Salt Lake City-based perinatal advisor for the Utah Medical Insurance Association and medical director of perinatal medicine for the Hospital Corporation of America.

Physicians are covered to perform VBAC only if they follow certain conditions such as not using prostaglandin agents, performing continuous electronic fetal heart rate monitoring, being within 5 minutes of the operating room throughout the patient's labor, and providing informed consent to the patient. In addition, VBAC for twin gestations is prohibited.

Dr. Clark said his company's guidelines aren't particularly strict and are similar to requirements in place by hospitals. “Our view of this … that this is basically a tertiary hospital procedure,” he said.

In Oklahoma, the Physicians Liability Insurance Corp. (PLICO) has taken its policy a step further by excluding from its malpractice coverage all VBAC procedures except in the case of an emergency. The new policy went into effect on Jan. 1.

The decision was based on a number of factors, said PLICO President and CEO Carl Hook, M.D., including ACOG's practice bulletin on VBAC, which was issued in 1999 and revised last year, and statistics showing an increased risk of uterine rupture when women undergoing VBAC receive uterine muscle contraction medications to assist labor.

Claims were also a factor. In 2003, about half of PLICO's losses were paid on claims in which failure to perform a timely cesarean was alleged, Dr. Hook said.

But Dana Stone, M.D., an ob.gyn. in Oklahoma City, said she is concerned that coverage is being denied for a reasonable medical procedure.

Dr. Stone said she doesn't believe she can continue to offer VBAC in light of this restriction. To date, Dr. Stone said she hasn't had a patient ask to change doctors because she can't perform VBAC, but she says her colleagues have had patients who are seeking new physicians as a result.

These types of restrictions imposed by insurers aren't widespread, said Albert L. Strunk, M.D., vice president of ACOG's fellowship activities. In many cases, companies recommend adherence to practice guidelines, but the process is informal, he said.

Although the educational efforts for improving patient safety and care can be helpful, Dr. Strunk said, practice parameters that have as their primary goal the protection of the insurance company are inappropriate. It's also inappropriate for the insurer to impose practice requirements that would impair physicians in exercising their judgment in terms of patient safety, Dr. Strunk said.