One signature is all it took to ignite a fiery debate that has spread through the Texas Capitol and around the nation. On Friday, Feb. 2, 2007, Gov. Rick Perry signed an executive order mandating that all girls entering 6 th grade in Texas receive a vaccination for Human Papillomavirus unless her parents submit a written statement of objection. Since then, lawmakers have filed bills, requested attorney general opinions, written letters to the governor asking him to rescind the order, and challenged the legality of executive orders by governors in any circumstance.

All the while, the media have reported each action and statement made for or against the mandate and, in one family physician’s opinion, missed the main points of the vaccine: HPV infection is common, cervical cancer is a bad disease, and the vaccine is safe and effective.

Through two presentations to the media and legislative staff on Monday, Feb. 12, TAFP member Janet Realini, M.D., M.P.H., of San Antonio, asked lawmakers to return to the core of the debate and take another look at the science behind the HPV vaccine. “I do think that the furor over the executive order mandating the vaccine for middle school entry has obscured the main message—that the vaccine is a tremendous advance and is recommended routinely for girls 11-12 and for all females 9-26,” Realini says.

As a family physician, Realini is concerned that the governor’s action took lawmakers and the public by surprise and will cause a backlash against an important public health measure, possibly prohibiting required HPV vaccination permanently. Realini also took time in the presentation to contradict one worry, that HPV vaccination will encourage young people to be sexually active. “Young people don’t even know about HPV and cervical cancer,” she says. “Young people’s decisions about abstinence and having sex are made for other reasons—and we can help them make healthy decisions.”

The American Academy of Family Physicians recently published an official policy on HPV vaccine mandates and cited several issues to consider: questions about providing an adequate supply, the high cost for state public health budgets and physician implementation, and that HPV does not adhere to the traditional public health model for the control of infectious disease in a school setting. “The AAFP feels it is premature to consider school entry mandates for HPV vaccine until such time as the long term safety with widespread use, stability of supply, and economic issues have been clarified,” according to the policy.

The House Public Health Committee will hear several bills on the HPV vaccine, for, against and as a complement to Perry’s executive order. Bills to rescind Perry’s Executive order include House Bill 1098 by Rep. Dennis Bonnen, R-Angleton, House Bill 1115 by Rep. Charlie Howard, R-Sugar Land, and House Bill 1215 by Rep. Bryan Hughes, R-Mineola. House Bill 146 by Rep. Joseph Deshotel, D-Beaumont, would require educational materials about FDA-approved HPV vaccines be distributed to the public and House Bill 215 by Rep. Jessica Farrar, D-Houston, would enforce the mandate through legislation.

Bill to extend end-of-life care indefinitely

Texas physicians should continue to treat patients on life support even after they determine the patient’s treatment to be “futile” according to identical bills filed in the Texas House and Senate this week. Through Senate Bill 439 and House Bill 1094, Sen. Bob Deuell, R-Greenville, and Rep. Bryan Hughes, R-Mineola, would allow patients or their families to choose or reject life-sustaining treatment. Physicians who refuse to provide this care would have to treat the patient until he is transferred to another willing provider. The bill would be cited as the Patient and Family Treatment Choice Rights Act of 2007.

Ten years ago the Texas Legislature adopted the Texas Advance Directive Act, which put in place three types of advance directives: the directive to physicians or living will, the medical power of attorney and the out-of-hospital do-not-resuscitate order. TADA also standardized the process of right-to-die and medical futility disputes, allowing physicians to end a terminal patient’s treatment within 10 days if they can’t be transferred to another facility.

The Texas Medical Association cited three major successes of TADA over the past few years, including improved communication and patient choice at the end of life, decreased suffering for patients and their families near the end of life and the ability for physicians to provide “medically appropriate and compassionate treatment at the end of life without fear of legal intrusion by outside parties,” according to TMA’s statement on advance directives.

Deuell, who is also a family physician, told the Dallas Morning News that 10 days isn’t enough time for families and physicians to make the tough decision. “I understand the cost of health care; I’m not insensitive to that,” Deuell said in a Dallas Morning News article. “But our medical system is so complicated now that I don’t think that 10 days is enough. If we’re going to err, let’s err on the side of life and give families a chance to get loved ones transferred without a 10-day window.”

Other health groups and advocates stress the great cost of life-sustaining treatment for patients in a vegetative state, estimated in the Dallas Morning News to be between $60,000 and $80,000 a year, and recommend extending the 10-day period, not eliminating it.

Tell legislators to put their money where the need is

The Senate Finance Committee workgroups and the House Committee on Appropriations subcommittees have begun budget deliberations, to conclude mid-March. These will sculpt the final funding decisions, which will ultimately affect support for graduate medical education and public assistance programs like Medicaid and CHIP, among other issues.

Tell your legislators where you stand on the topics important to your practice and your patients. Contact information for each legislator can be found through the “Who Represents Me?” feature on the Texas Legislature Web site.

TAFP has developed talking points about Medicaid and CHIP and physician workforce and graduate medical education in the first two of several Issue Briefs published during the 80 th Legislative Session. Each Issue Brief educates lawmakers on statistics and goals surrounding medical policy. Access these one-page Issue Briefs on the policy initiatives page of the TAFP Web site.

Join other white coats to lobby at the Capitol

Mark your calendars for Tuesday, March 6, 2007, to join the Primary Care Coalition and the Texas Medical Association at TMA’s second First Tuesdays at the Capitol, a gathering of physicians, medical students and others to lobby on behalf of medicine. Hundreds of white coats in the Capitol make a bold statement to lawmakers who said the same efforts in 2003 helped encourage the passing of tort reform legislation. This session, TAFP aims to improve CHIP and Medicaid funding, graduate medical education and contracting with managed care companies.

The first Tuesday of the 80 th Legislative Session on Feb. 6, 2007, drew more than 200 members of the medical community from around the state for the day’s events, which included a welcome from TMA President-elect William Hinchey, M.D., and a legislative briefing from TMA’s public affairs staff. The group then filled the House gallery to hear Gov. Rick Perry’s state of the state address.

TAFP encourages all members to come to Austin to rally for issues that affect family physicians’ practices and patients. Find more information on how to register, special events and other information on TMA’s First Tuesdays Web site.

Spots still open for Physician of the Day, dates listed below

Thanks to the physicians who volunteered their time this week to serve at the Capitol as Physician of the Day. This week’s physicians were Richard Young, M.D., of Fort Worth; Mitchell Finnie, M.D., of San Antonio; Jimmy C. Burns, M.D., of West Columbia; and Victor Peralta, M.D., of Arlington.

Many spots remain in the Physician of the Day calendar. Open dates in March include March 9 and 13, and open dates in April include April 3, 9, 10, 12, 16, 23, 24, 25, 26 and 30. For May’s available spots, to volunteer for March or April, or for more information on the program for family physicians or family medicine residents and students, contact Kate McCann at TAFP.