As a member of a rapidly dying breed of physicians who practice general internal medicine and take care of patients in skilled-nursing facilities, I was disappointed to read that the physician freedom to practice the art of managing the many medications needed to control pain and suffering will be restricted [1].

The medications are approved by the Food and Drug Administration, and the term "inappropriate" is misleading. Several of the medications listed by Beers and colleagues [1] are useful in the elderly patients I treat. What do the authors consider medications that are "appropriate" for the indications they listed?

We physicians try to limit medications, but our backs are pushed against the wall by telephone calls from nursing staff or families of patients concerned that their relative's problems are not being treated. This can lead to polypharmacy. Many patients have multiple problems such as:

1. Degenerative disk disease requiring nonsteroidal inflammatory agents

2. Esophageal reflux requiring antacids and histamine-blocking agents

3. Chronic depression for which antidepressants are indicated

4. Sleep and mood disorders requiring medication

5. Recurrent bladder infections requiring long-term antibiotic suppression

6. Dementia leading to agitated states in the evening, which put the patients at risk and cause the nurses to request medications

7. Smoking-related pulmonary problems requiring medication to prevent bronchospasm

8. Cardiovascular problems requiring multiple medications.

It was pointed out that medications prescribed on an as-needed basis are used frequently. Nurses in most skilled-nursing facilities have more than enough to do without giving unnecessary medications.

Young doctors are not interested in primary care because they see our struggle with complex patients, confusing Medicare regulations, inappropriate expectations of care, family members who lean on the physician, and poor reimbursement. I typically see my patients in skilled-nursing facilities one time per month and receive daily phone calls from these facilities about management problems. For this I receive less than $50 per month in reimbursement. The increased liability in prescribing the medications that Beers and colleagues have listed as "inappropriate" is another disservice to those of us on the front line trying to provide quality care in trying times.