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Governor's Newsletter, Summer 2001

Col. Nathan Erteschik, MD, FACP
Governor, U.S. Army Chapter

Governor's Column

Greetings: It is with a great sense of pride that I have the opportunity to serve as your new Governor for the Army Chapter of the ACP-ASIM. The learning curve has been quite steep already, and I wish to personally thank Dr. Bolan for both his energetic leadership for the past four years and for mentoring and orienting me within the College itself.

I thought it would be important and useful in my first newsletter to reiterate some information about the College, which not all of you may be familiar with. The ACP was founded in 1915, the ASIM in 1956, and the merger has been completed over the past few years.; it represents the largest medical specialty society with over 115,000 members. The College's mission is to enhance the quality and effectiveness of health care by fostering excellence and professionalism in the practice of medicine. Its primary goals include: establishing and promoting the highest clinical and ethical standards; providing the foremost comprehensive education and information resource for all internists; advocating responsible positions on public policy relating to health care; and serving the professional needs of the membership and advancing internal medicine as a career.

The College includes the Board of Governors, which serves to advise the Board of Regents, the policy-making body. I represent our chapter with several specific goals and tasks: encouraging wide medical student interest in our specialty as well as the College, encouraging input for resolutions on local and national issues, encouraging member participation and advancement to Fellowship, and hosting our chapter's local scientific meeting each November. The College is extremely active and highly respected within Congress and is currently involved with many issues, including: access to care and a patient's bill of rights, women's health issues, antibiotic over-usage and resistance, Medicare drug coverage, clinical guidelines, HCFA hassles, GME funding, influences from industry, and the entire arena of the mechanisms to be used by the ABIM for recertification for generalists and subspecialists alike.

The 2001-2002 ACP-ASIM leadership includes: Dr. Walter McDonald, Exec. VP (who, sadly for us, will be retiring next year); Dr. William Hall, President; Dr. Bernard Rosof, Chair, Board of Regents, and Dr. Lynn Kirk, Chair, Board of Governors. Dr. Sandra Fryhofer, Immediate Past President, will be the College Representative at our November 2001 Army Chapter meeting in San Antonio. The Army is further represented by: Col(Ret) Robert Gibbons, and BG(Army Reserve) Jamie Barkin on the Board of Regents, and MG(Army Reserve) Ken Herbst, who is also a member of the Board of Governors. Dr. Herbst is from San Diego, and was recently named the new Deputy Surgeon General for the US Army Reserve.

I would like to also make all of you aware of several new key players in Army Internal Medicine: LTC Lisa Zachar is the new Residency Director at William Beaumont Army MEDCEN; Two new OTSG subspecialty Consultants at BAMC are Col. Dooley in ID, and Col. Mong in Endocrinology; and the new GI Consultant is Col. Holtzmuller at Walter Reed. Col. Engler (Allergy), Col. Vernalis (Cardiology), and I were reappointed as Consultants in our respective specialties.

Congratulations also to all those who were selected to Fellowship in the College during the past year. I would be happy to answer any questions related to advancement to Fellow (PS ≠ I am also a member of the Credentials Subcommittee that decides these selections.) Our Army Chapter website is currently under much revision, but I would urge all of you to explore www.acponline.org at length, which has a great deal on advancement to Fellowship, information for student members, CME, etc. I will detail more on this next time. Our next newsletter will also have more on our upcoming fall meeting in San Antonio, and I look forward to seeing many of you there, as well as potentially in Philadelphia next April for the ACP-ASIM Annual Session. In the remainder of this letter, you will hear about the highlights from our last chapteral meeting, as well as some insightful comments by Dr. Bolan. Please feel free to contact me with questions, comments, and suggestions at 910-907-6359, or on e-mail either via outlook, or at nathan.erteschik@amedd.army.mil.

Immediate Past Governor's Farewell

Greetings - it has been my great pleasure and privilege to serve as Army Governor. I look forward to seeing as many of you as possible in the future, in particular at Army and National ACP-ASIM meetings. Please keep in touch.

Sincerely, Charles Bolan, LTC, MC
E-mail: Cbolan@mail.cc.nih.gov

"On Being a Doctor"

At the March 2001 ACP-ASIM Board of Governors meeting, Dr. Bolan was invited to participate in a session "On Being A Doctor." Here follows a synopsis of those remarks.

The American College of Physicians-American Society of Internal Medicine maintains a focus on the patient. There is also an emphasis on teaching care of the patient in the patient's environment. This talk is about the care of patients in war and other military settings.

Physicians in the American Army experience many things in common with those occurring in everyday civilian practice. Internists in both settings must articulate the value of their skills to a system that may not always fully grasp or appreciate expertise in Internal Medicine. Despite an emphasis on adult medicine and a long history of military contributions in fields such as Infectious Disease, Nephrology, Critical Care, and Hematology, and despite the impact of traditional as well as chemical, biological, nuclear and other medically-based weapons strategies, the military Internal Medicine community must be constantly vigilant to maintain the ability of their system to treat optimally adult patients in the military environment. Health care systems may not always understand the factors required for excellence in adult medicine, and may not appreciate ≠ in advance ≠ the consequences of omitting this expertise from the system.

Other similarities may be found in Army and ACP-ASIM core values.

Army Values

ACP-ASIM Values

Respect

Respect

Duty

Leadership

Honor

Professionalism

Loyalty

Excellence

Integrity

Compassion

Selfless Service

 

Personal Courage

 

 

These Army values have special focus as guides for young soldiers, their leaders and their physicians who serve in hostile, isolated settings thousands of miles from the United States.

A famous scientist noted at the close of the nineteenth century that there seemed "to be two forces at work in the world... one a force of death and destruction, with societies developing ever more deadly weapons and technology for killing, the other a force of light and healing, with societies trying to prevent and treat disease and the destruction brought by war." It was not known then, nor is it known today, which of these forces will prevail.

The patients and practice environment of military medicine are found in the intersection of the forces of death and destruction with the forces of light and healing. Within the pain, suffering and injury that occurs in this environment, there is potential to provide comfort and healing. The special challenge faced by military physicians who practice in this environment is to meet the needs of the patients and at the same time, those of the Army.

The Army ACP-ASIM chapter has established several awards to recognize excellence in military settings. One is the Award for Excellence in Operational Internal Medicine. Another is the Crosby Award for Research, named for COL (retired) William Crosby. Crosby served with forward units during WW2 in Europe and Africa. He later served as an Army hematologist in a MASH unit during the Korea War, and published the first comprehensive studies of massive transfusion with group O blood, establishing efficacy when civilian practice was unfamiliar with this therapy. He also noted that the suffering of the patients before and after these large surgeries was more intense for him than when he cared for wounded as a regimental surgeon and triage officer during intense battles in Italy in World War 2.

At the time of Dr Crosby, everyone served in the military, and learned about the care of patients in these settings as part of ordinary medical education. That strategy for delivering care to patients in war time no longer exists, and care today is largely performed by physicians trained and practicing in the military hospital system. Augmentation by reserve units also occurs, but via different mechanisms than those previously utilized. While there may be, or there may not be, volunteer physicians in war-torn areas, when military forces from this country deploy, they doctrinally do so with military physicians as integral members of their unit.

Medical decisions evoke emotional reactions, in both military as well as in civilian medical practice settings. These reactions may have significant consequences for subsequent patient care. One emotional reaction was recently illustrated artistically in an episode from the Star Trek television series, in which the crew is deployed on a prolonged mission deep in space during the 24th century. After the medical officer is killed, care for the crew is provided by a computer-generated emergency medical hologram, possessing the extensive medical knowledge database of 3,000 species. However, his programming breaks down after improvising a brilliant emergency surgical procedure to save the life of one of two crew members attacked on patrol. The memories of his comrades injuries and his inability to save both of the crew induce his ethical subroutines to ruminate constantly and uncontrollably. Obsessing and ruminating over these events interferes so greatly with his capability that the crew deletes his memory of the attack ≠ and with it the knowledge of the procedure which saved the life of one person.

Military medicine also has memory problems. Lessons about the operational environment and treatment of disease learned in prior wars tend to be forgotten. Concurrently, the application of newly developed medical technologies to treat injuries in traditional or future operational settings may also be difficult to anticipate, especially if one is unfamiliar with the patient and the patient's environment. Not all these lessons seem forgotten simply by the passage of time; memory loss also appears to be influenced by the nature of military conflict. Emotions, colored by the relationship of the people in society with their Army and government, deeply color the fabric of what is learned and available for the care of future patients in these settings.

During the Viet Nam war, soldiers who had been drafted into military service often were spit upon after returning to this country. Physicians, nurses, and medics who cared for the soldiers and other patients during this conflict were also spit upon during their return home. It is unfortunate, but likely, that the emotional reaction of our country to this war was extended to the perception of the needs and suffering of those injured. Perhaps because of this reaction, medical personnel from this country often chose not to participate in the care of patients injured during this conflict.

The infantry brigade clearing station with which I deployed as a medical officer in Desert Storm often encountered inconsistencies between what was known and available, and what was possible, for patient care in that environment. Many medical units had Viet Nam era technology, however many medical personnel did not have extensive military medical experience as was learned in that conflict. It was especially frustrating not to find a cohesive guideline for the use of blood as our clearing station could be augmented with a forward surgical team and had responsibility for stabilizing casualties from forward aid stations.

After the ground offensive, our division remained in place to screen the northwest corner of occupied Iraq during the time of the cease-fire negotiations. In this area, local civilian populations were regularly attacked by surviving Republican Guard troops, and casualties sought out American units for care. As larger line units were withdrawn for redeployment to the United States, they were replaced by smaller units to maintain security. Thus, a battalion from our brigade was assigned to replace in sector the area previously occupied by a full brigade, in an tactically secure area with heavy casualties. Although the brigade operations officer saw little advantage to deploying additional medical assets beyond those normally utilized for support of a battalion, the brigade commander agreed to deploy the majority of medical assets to the area. He knew that his soldiers were not going to turn away wounded civilians.

Driving to the new area, the highway remained littered with the wreckage of equipment and bodies of an Army whose earlier defeat had led to the end of the war and helped ensure the safety of our unit. On arrival, we cared for civilian casualties wounded by the same weapons and the same Army that had previously deployed against our own soldiers. Casualties usually came in the morning in groups of 10 or 20 after overnight shelling. One afternoon, a young boy in hemorrhagic shock was carried in by his father after stepping on a land mine; he recovered quickly after transfusion of a single unit of group O blood. Many other patients later arrived during a mass casualty that occurred when an armored column attacked a town in daylight. Some of these casualties, such as a young girl with a burned face who had lost her eye, elicited no reaction except numbness.

Physicians have protective mechanisms to shield emotions. During patient rounds, it is difficult to make complex medical decisions and at the same time feel the pain and suffering of patients on ventilators or with invasive monitoring devices. This emotional distance appears reflexively and remains in place daily upon entering an intensive care unit or ward. Similarly, societies distanced geographically from war activities may be further distanced emotionally when visual images of missiles and bombs hitting buildings are processed without a sense of the human suffering that is involved. Death, injury and misery due to starvation, disease and direct weapons fire remain widespread throughout the world, brought about by conscious decisions of societies in conflict with each other.

Scholars point to relationships between three elements of society, the People, Government, and Army, as critical for the success of military operations. Operations conducted without the contribution and involvement of all three groups generally fare poorly. Such an analysis may be especially applicable regarding the care of patients in operational and war-time settings. Participation of military physicians in medical organizations can increase the appreciation by society of the patients and patient care environment, and provide an opportunity for improved patient care when the soldiers of their Army are deployed on future missions.

Army ACP-ASIM Chapter Awards Activity

The Awards Committee continues to successfully sponsor Army Internists for national awards. In addition, COL Vincent is presently working with the committee to update criteria for the awards which are presented at our Chapter meeting. These will be available for review on the Army Chapter Web site (www.acponline.org/chapters/army/) before the nominations deadline for the Fall 2001 meeting.

Endowments to support these and other Army ACP-ASIM awards are maintained with the Henry M. Jackson Foundation. Persons interested in more information may contact Dr. Bryce Redington at bredington@hjf.org, or at 301-294-1226

Fall 2000 Meeting

Fall 2000 marked a return to the Reston VA meeting site and the first shared meeting with the Navy Chapter of ACP-ASIM. There were several shared activities including a combined plenary session with speakers on Military Medicine from the Uniformed Services University of the Health Sciences and on the clinical implications of the National Human Genome Research Project from the National Institutes of Health. Due to costs of producing a meeting and mutual educational interests, shared meetings are frequent in other ACP-ASIM chapters that have common geographic boundaries. The 2000 Reston meeting was the first to capitalize on the similarities in Army and Navy Internal Medicine. With the many shared clinical and graduate medical education functions between Walter Reed Army and Bethesda National Naval Medical Centers this was logical for local internists. I commend the meeting planners and chairs, especially LTC Greg Argyros and CPT Lance Sullenberger from Walter Reed, for their dedication in sponsoring this excellent meeting.

Sara Walker, MD, MACP, President-Elect for ACP-ASIM, was the College Representative for both the Army and Navy portions of the meeting. Dr. Walker also assisted in conducting a breakfast for Women in Army Internal Medicine, and in initiating the formation of an Army ACP-ASIM Women's Physician Council. The Henry M. Jackson Foundation, with Dr Bryce Reddington and John Rosenquist, again provided administrative and structural support. The 2001 meeting returns to San Antonio.

Award winners for 2000 included the following:

Army ACP-ASIM Chapter Laureates

  • LTG (retired) Ronald Blanck, MACP
  • BG (retired) Michael Kussman, FACP
  • COL (retired) Yancy Phillips, MACP

Robert Moser Award

  • MAJ Alice Pugh - Walter Reed Army Medical Center

William Crosby Award for Superiority in Research

  • MAJ John C Byrd - Walter Reed Army Medical Center

Master Teacher Award

  • COL (retired) Ronald Cooper - Madigan Army Medical Center

Award for Excellence in Operational Medicine

  • COL Stephen Gouge - US Army War College

The Laureate Awards are presented to Fellows of the Army Chapter who have made long standing and lasting contributions to Internal Medicine and the Army Chapter. Lieutenant General (retired) Blanck served as a battalion surgeon in Viet Nam and in key Internal Medicine positions throughout the Army such as Assistant Chief of Medicine at Walter Reed and Chief of Medicine at Brooke before assuming multiple leadership roles in Military Medicine such as Commander of Walter Reed Army Medical Center and eventually Surgeon General of the Army. He was also deeply committed to medical education at the Uniformed Services University of the Health Sciences. LTG Blanck served as Governor for the Army Chapter, American College of Physicians, and was awarded a Mastership by ACP-ASIM in 2000. LTG Blanck has retired from the Army and serves as President, University of North Texas Health Science Center, Fort Worth, Texas.

Brigadier General (retired) Kussman also served as an ACP Governor for the Army Chapter. He maintained a leadership role in Internal Medicine as Chief of Medicine at Brooke Army Medical Center and as the Internal Medicine Consultant to the Surgeon General. BG Kussman's military medical leadership positions included early service as a battalion surgeon with the 25th Infantry Division and later assignments as Commander Fort Benning MEDDAC, Commander Walter Reed Health Care System, Commander European Chapter Medical Command and 7th Army Command Surgeon. BG Kussman is retired from the Army and serves as Deputy Medical Inspector for Investigations for the Veterans Administration.

Colonel (retired) Phillips served as the Army Chapter ACP-ASIM Meeting Program Chair for many years, as well as in multiple leadership positions at Walter Reed Army Medical Center and Walter Reed Army Institute of Research. He is the recipient of a Mastership from ACP-ASIM in 2001 (see page 7 for more information on COL Phillips.)

The Moser Award is presented in honor of Robert Moser, COL (retired) USA MC, who served as Chief of Medicine at multiple Army Medical Centers, then as editor of JAMA and later as the Executive Vice President of the ACP. The award recognizes an AMEDD medical officer at the rank of Major or below for service as a general internist. Major Pugh first served in this capacity starting in 1998 as Chief of Medical Residents at Walter Reed Army Medical Center. She helped integrate formal Field Operational Training into the Medicine Residency at Walter Reed Army Medical Center, and has been awarded the Outstanding Staff Teaching Award and the Outstanding General Medicine Attending Award by house staff and medical students respectively. She presently serves as the Chief of the General Internal Medicine Clinic at Walter Reed Army Medical Center.

The Crosby Award recognizes superiority in research, and is presented in honor of William Crosby, COL (retired) USA MC, for his many accomplishments in Hematology and Transfusion Medicine. Major Byrd has achieved an International reputation for translational research into disease mechanisms and development of novel therapies for hematologic malignancies. MAJ Byrd has authored more than 45 publications in less than four years time as a staff physician and serves on multiple editorial boards and educational committees in Hematology and Oncology related areas. He is an outstanding clinician and teacher, and serves as the Director of Research for the Hematology Oncology Service, Walter Reed Army Medical Center.

The Master Teacher Award recognizes members of the Army ACP-ASIM chapter who have excelled as a master mentor and teacher. Colonel (retired) Cooper was awarded the Outstanding Teaching Award six times at Letterman and

Madigan Army Medical Centers, and the Department of Medicine Outstanding Teaching Award at Madigan has been named the "Cooper Faculty Mentor Award" in honor of his contributions. COL Cooper has published in leading medical and Internal Medicine journals, and structured the Department of Medicine Morning Report at Madigan into an outstanding educational format. He is widely acknowledged as a superb Infectious Disease specialist and as an excellent general internist who inspires excitement in learning and sets up an environment which thrives on a quest for knowledge. COL Cooper is presently a hospitalist and Assistant Director of the Internal Medicine Residency at Madigan Army Medical Center.

The Award for Excellence in Operational Medicine.

Colonel Gouge has served as Division Surgeon 3rd ID, Commander 46th CSH Fort Campbell KY, Commander 212th MASH 7th MEDCOM, and as the clinical operations officer, Directorate of Combat and Doctrine Development AMEDD Center and School. He is an astute clinician and received the Outstanding Staff Teaching Award as a staff nephrologist at Walter Reed. When serving as Chief of Nephrology at Brooke, he was assigned to the 41st CSH in Operation Desert Storm. He is currently enrolled in the US Army War College at Carlisle Barracks, PA.

Associate Activities

More than 60 Associates attended activities at the Reston meeting, coordinated by CPT Lance Sullenberger, Chief of Medical Residents at Walter Reed. This meeting included the second annual Army Associates Jeopardy competition as well as podium and poster research presentations. CPT Harrison commissioned the formation of an "Army Associates Jeopardy Competition Cup" which is presented to and maintained by the winning team at their respective MEDCEN. The winners are listed below.

Poster Presentations

  • CPT Mark Happe, BAMC

Podium Presentations

  • CPT Lori Sweeney, DDEAMC

Jeopardy Competition

  • Dwight D. Eisenhower Army Medical Center

In addition to these events, Army Associates have been winners in competitions at the 2001 National ACP-ASIM Annual Scientific Meeting and have competed in the National ACP-ASIM Associates Jeopardy.

Research Presentation Poster Winners - National ACP-ASIM Meeting

  • CAPT Scott Hartronft ≠ BAMC
  • CPT Eric Rupard ≠ WRAMC

National ACP-ASIM Associates Jeopardy Competition Participants

  • Dwight D. Eisenhower Medical Center (representing US Army Chapter)
  • Walter Reed Army Medical Center (representing District of Columbia)

Army ACP-ASIM Chapter Women Physicians Council

At the recent meeting in Reston sponsored by Walter Reed, LTC Argyros established a breakfast meeting attended by Army female internists from across the chapter. Dr Walker, President-Elect of ACP-ASIM, served as a facilitator.

COL Alice Mascette, Deputy Director of Army GME is working with COL Erteschik and COL Marple on topics which will expand the impact of the council at the 2001 San Antonio meeting. COL Mascette can be reached by
e-mail at alice.mascette@otsg.amedd.army.mil.

Please contact her if you have any interest or suggestions for the council.

2001 National Award Recipients

College Mastership

COL (retired) Yancy Phillips was awarded a Mastership by the American College of Physicians-American Society of Internal Medicine at the April 2001 Annual Session in Atlanta, Georgia. He was an All American football player at the University of Delaware before graduating cum laude from the University of Alabama School of Medicine. COL Phillips completed an internship and residency in Internal Medicine at Tripler Army Medical Center, a tour as a staff internist at DeWitt Army Community Hospital, Fort Belvoir, and a fellowship in Pulmonary Medicine and Critical Care at Walter Reed Army Medical Center. He subsequently served as Chief, Department of Respiratory Research at Walter Reed Army Institute of Research where he elucidated the pathophysiology of blast injury. COL Phillips served in many high level Clinical leadership positions at Walter Reed Army Medical Center including Chief, Pulmonary Medicine Service, Chief of the Department of Medicine, and Deputy Commander for Clinical Services. His academic appointments have included Program Director of the Pulmonary Medicine Fellowship and of the Internal Medicine Residency at Walter Reed, and Professor of Medicine at the Uniformed Services University of the Health Sciences. He received the 1993 WRAMC Chennault Award for Outstanding Teaching and the 1998 Mologne Award for Excellence in Academic Military Medicine. COL Phillips is especially remembered for his clinical leadership and teaching at Walter Reed.

He served for many years as Program Chair of the Army ACP-ASIM Chapter Scientific Meetings where he expanded a tradition of organizational educational excellence that is recognized throughout ACP-ASIM. COL Phillips is the author more than 50 scientific papers and book chapters, and received the Army A designator for excellence in Pulmonary Medicine and Critical Care. He joins COL (ret) Leonard Wartofsky, COL (ret) Barbara Alving, and LTG (ret) Ronald Blanck as recent Army Internists to be awarded a Mastership in the ACP-ASIM. COL Phillips retired from the Army in the year 2000 and serves as Associate Medical Director for Clinical Affairs at the Southeastern Permanente Medical Group in Atlanta, Georgia

Nicholas E. Davies Memorial Award for Scholarly Activities in the Humanities and History of Medicine

Colonel (retired) Robert Joy, Professor Emeritus of Medical History at USUHS, is the most recent awardee of the Nicholas Davies Memorial Award, and will receive his award at the 2002 ACP-ASIM meeting in Philadelphia PA. COL Joy received his medical degree from Yale in 1954, and completed an internship in Internal Medicine at Walter Reed in 1955. He then served as a Battalion Surgeon and Medical Platoon Leader for the 714th Tank Battalion during the Korean War before returning to complete his Internal Medicine Residency at Walter Reed. COL Joy later completed the Medical Research Fellowship at WRAIR as well as a Masters Degree in Physiology at Harvard. COL Joy attained a distinguished career at WRAIR, and was the Director and Commandant from 1975-76.

COL Joy is best known for his scholarly activity in medical history at USUHS where he established the Department of Medical History after first serving as Chairman of the Department of Military Medicine and Commandant. He has spoken before countless audiences on subjects related to medicine and military medicine, and has been an invited speaker and visiting Professor at multiple academic institutions. He remains an active lecturer at USUHS and throughout the world on matters related to medical and military medical history.