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Newsletter, Summer 1998

Word from the OTSG Medicine Consultant, COL Nathan Erteschik
Membership and Senior Leader Column, MAJ Stephen Salerno
"Future for Army Internal Medicine", LTG Ron Blanck
"Medicare Subvention", COL Eric Schoomaker
"GME Application Update", COL Kris Raines
Awards and Recognition Committee, COL Les Reed
Medical Student Activities, MAJ Gilliland
Informatics Update, MAJ Kevin Abbott
Clinical Corner, CDR Sandra Kweder
Council News, Charles Bolan, FACP, LTC MC USA

Greetings from the Governor

Greetings.... As you will notice from this letterhead, the merger between the American College of Physicians and American Society of Internal Medicine has occurred: we are now members of the Army Chapter of the ACP-ASIM. This has important implications for Internal Medicine at the national level in terms of our representation in government and with other organizations such as the American Medical Association. Although there was not a corresponding Army chapter of ASIM, our new Army ACP-ASIM chapter is now part of a much larger national organization that encompasses the traditional academic, educational, legislative and political activities of both past organizations. Apart from changing letterheads and working on details of the transitional merger period, the impact of this merger is significant. For the first time, one professional organization is able to clearly speak with a single voice for Internal Medicine. We will have more information available on the impact of this merger at our meeting in Reston and in future newsletters.

The focus of the remainder of this newsletter is on our Army Chapter activities.

Word From the Internal Medicine Consultant

I'm happy to say that during last year's assignment cycle, nearly all our graduating residents were placed at locations that were high on their list of choices, albeit in some cases via a very circular route. We were fortunate to have been allowed increased fellowship slots in several subspecialty training programs last winter. COL Raines and Mrs. Pfeiffer are continuing this effort for us in the plan for next year. I cannot emphasize enough the importance of licensure, and PT/weight standards for all of you - in staff or GME positions, as well as those applying for further GME training. Additionally, anyone interested in operational or research positions needs to contact me or MAJ Cobbs-Grant at PERSCOM (703-325-2463).

Over the next few months I will be coordinating increased activities with MAJ Bill Gilliland (our medical student advisor) and others of you to promote Internal Medicine more widely at the medical student level. We need to brag about our programs and promote what we do. Graduates of our programs for the past three years have had a 90% pass rate on the ABIM examination; the national total for 1995 was 53%, for 1996 68%, and for 1997 69%. Sadly, despite an increased number of medical students nationally opting for Internal Medicine Residencies, Army numbers are slowly decreasing. All of us can play a role in reversing this.

I will also soon be addressing the disbursement of central TDY funding for our November chapteral meeting, and will provide more information in the next newsletter, as well as via cc:mail.

COL Nathan Erteschik, FACP
Army OTSG Internal Medicine Consultant
Chief, Department of Medicine
WOMACK Army Medical Center
Fort Bragg, NC
910-432-6533, 910-432-6532 (FAX)

Army ACP-ASIM Chapter Membership Column

MAJ Stephen Salerno continues his excellent work as our MEDDAC representative, and chair of our membership committee. He is presently updating our membership roster, and working with COL Erteschik and COL Phillips on general internist participation at our annual meetings. MAJ Salerno's senior leadership column this newsletter begins with a message from the Army Surgeon General, LTG Ron Blanck, a past Governor of the Army Chapter and a former Chief of Medicine at BAMC and Commander of WRAMC. Next, COL Eric Schoomaker, Commander of Fort Carson and former Chief of Medicine at Madigan AMC, discusses the impact of medicare subvention. In conclusion, COL Kris Raines, the present Head of Army Medical Education, describes the evolution and importance of standardization for GME training through the Joint Service Graduate Medical Education Board.

Army Internist Senior Leaders

"Thoughts on the Future of Army Internal Medicine"

Internal medicine training traditionally has focused on producing General Internists or on those going into Subspecialties. Recently, General Internal Medicine has further divided into "traditional" primary care and into Medical Center based academics. As primary care evolves to more and more outpatient and wellness oriented care, a need is emerging to have someone who cares for those (few) who need hospital care. So, I suggest the future of Internal Medicine will continue to be oriented to producing Generalists and Subspecialists, with the primary care focus on a specific population (longitudinal care), academics of course, and the "hospitalist". I can think of no specialty better able to produce such a broad range of physician care providers.

Ronald R. Blanck
Lieutenant General
The Surgeon General

"Medicare Subvention Coming to Colorado Springs"

In a joint statement on 12 February 1998, DoD and Health and Human Services announced plans to implement a test of Medicare Subvention at ten Military Treatment Facilities (MTF's) in eight cities. Subvention is the means by which DoD facilities receive reimbursement for care they provide "dual eligible" patients - those eligible for care in an MTF, and because they are 65 or older, are also eligible for Medicare. The test program, called TRICARE Senior, includes the city of Colorado Springs, Colorado.

Colorado Springs has two MTF's participating in TRICARE Senior, Evans Army Community Hospital (EACH) on Fort Carson, and the US Air Force Academy. EACH implemented DoD's managed care initiative, TRICARE, a year ago and transformed into a staff-model HMO. Over 40,000 of EACH's 68,000 catchment area patients are enrolled in the TRICARE Prime benefit. While the hospital command and staff are looking forward to delivering care to an additional 2,000 over-65 enrollees through TRICARE Senior, much work is to be done before the program begins.

Test sites must apply to the Health Care Financing Administration (HCFA) and become a certified HMO. This means beefing up the TRICARE Prime benefit package for seniors by offering chiropractic services, a skilled nursing benefit, and expanded home care. Additionally, test sites must follow the Medicare HMO rules regarding enrollment, using a first-come, first-served approach. All marketing and enrollment materials must be approved by DoD and HCFA. Concurrently, the EACH staff and clinics are preparing for this endeavor. The internal medicine clinic, where most patients are likely to be empaneled, requires additional staff. Some of the primary care clinics can also expect to see an influx of new over-65 patients.

We firmly believe that the test of Medicare subvention is beneficial to military medicine. It allows MTFs to deliver better health care to over-65 retirees - many of whom felt disenfranchised by the implementation of TRICARE. TIRCARE Senior also gives older military retirees full access to military medicine. In so doing, it provides internists with a much needed segment of the population to maintain critical skills. Younger, healthier populations don't always afford internal medicine physicians the challenges and complexities found in the elderly. This older population may also serve as a referral base for other specialists and sub-specialists and is essential for the success of our GME programs.

Perhaps the greatest challenge is to design high quality, accessible healthcare for the Medicare-age population which is indistinguishable from the care delivered to all current TRICARE Prime enrollees. This must be without becoming burdened by or overly concerned by concerns for the financial details of the plan. Few can claim to fully understand how the funding of the TRICARE Prime demonstration project will work for any one. Our most important goal is to provide first-class healthcare which is readily accepted by our patients. All else is of secondary importance.

Eric Schoomaker
COL USA MC
Commander, Evans Army Community Hospital

"Changes in the GME Application and Scoring Process"

Significant changes were made in the GME application and scoring process in the Department of Defense (DoD) in 1997. These changes were implemented in order to comply with directives to the Services to conduct joint selection of all trainees. A new DOD application form was introduced along with uniform requirements for supporting documents. Selection of trainees was done jointly for all specialties at the Joint Service Graduate Medical Education Selection Board (JSGMESB). The new procedures were highly successful due to the efforts of all those participating. In 1998, we expect some minor refinements to address specific suggestions by board members, but the process should remain essentially the same. The following will summarize the application and selection process.

The first step in joint selection implementation was development of a single application form. The new DoD application is a single page form that includes information on prior medical education, licensure status, and operational assignments. Applicants indicate their specialty goal as well as their program choices on the form. The supporting documents have also been standardized. All applicants are required to submit their curriculum vitae as well as a copy of their medical school dean's letter and final transcript. They need three letters of recommendation including one from their most recent residency program director.

Selection of individuals for GME is accomplished by joint panels made up of the three Service consultants and all program directors for each specialty. Program directors score the records, awarding points for performance in medical school, first year GME, residency (if applicable), operational tour (if applicable) and potential as an officer and specialist. Each application is scored by three individuals, one from each Service. The three scores are totaled, then bonus points may be awarded for prior service and research activity. The final scores are entered into a computer and an order of merit list for selection is generated for each service. Selections are made according to the ranking on the order of merit list and placements are done based on the desires of the applicant and needs of the service. Selections and placements are presented to each Service board for approval.

The joint selection process has fostered increased communication and cooperation between the Services. It also increases objectivity in the selection process and places more importance on the application itself. In order to achieve the optimal score, individuals must ensure that their application is complete and letters of recommendation should include as much information as possible. Applicants will generally not be known personally by two of the three program directors who score their records. Applicants from the field have more points available to them than current interns or residents, however the scoring system is intended to select the best qualified applicants regardless of their current assignment status.

Kris Raines
COL USA MC
Director, Army Medical Education

Army ACP-ASIM Chapter Awards and Recognition Committee

As announced in our last newsletter, COL Les Reed, Chief of Medicine at Madigan Army Medical Center, was elected to Chair a committee on awards and recognition. COL Reed's committee has added 4 new awards to our traditional Laureate, Moser and Associate Awards. These awards recognize superior performance in the following areas: operational internal medicine, teaching, research and 3rd year medical school clerkship. COL Reed's committee has made all of our awards available via the chapter web site on a standardized template. COL Reed will also chair a subcommittee to formally nominate and endorse Army Fellows of the American College of Physicians for recognition as Masters of the College. Please read his description of the Awards process carefully. Through this work, we will be able to recognize the outstanding contributions of Internists throughout the AMEDD.

I would like to take this opportunity to describe for the Army Chapter membership the process of nomination and awards selection, as well as the description of four new Army chapter awards as voted by the Governor's Council in the summer of 1998. This committee of the Governor's Council has myself as Chair and the following members as the chairs of subcommittees for the individual awards or recognition subcategories:

COL Mike Dunn (COL Robert H. Moser Award)
COL Nathan Erteschik (ACP Laureate Awards)
LTC Rick Marple (Associate Awards)
COL Lester Reed (Master Teacher Award)
MAJ Mike Tuttle (William Cosby Award for Superior Research)
MAJ Steve Salerno (Operational Internist Award)
MAJ Bill Gilliland (Medical Clerk Award)

A description of each of these awards has been formalized into a standard format, including seven categories which are reproduced for each award. These categories include: I. Establishment Date and Authority, II. Name and Purpose of the Award, III. Selection Committee, IV. Objective Selection Criteria, V. Dates of Award, Submission and Presentation, VI. Submission Instructions and VII. Recent Recipients of the Award.

The previous awards by the Army Chapter, as well as the four new awards, will all be published on the Army Chapter ACP-ASIM web site. That web site address is http://www.acponline.org/chapters/army. The award descriptions in this standardized format are also being sent to all of the ACP members who have CCMail or internet addresses. If you do not have access to this technology check with your Chief of Medicine or contact me, or one of the subcommittee chairs.

The committee is extremely excited about the expanded capability to recognize our members with these new awards, and the membership of the subcommittees which will be determining the distribution of the awards, and the standardized format for all awards. The specific timeline for submission is identified under each award with the majority being due to the Chair of the respective award by 15 September 1998. An exception to this generalized suspense date is the ACP Laureate Award which is due by August 1998 to the Chair of this award, COL Nathan Erteschik, because of the necessary processing time through the national organization. The committee sincerely hopes that the addition of these new awards will help recognize members of our chapter and encourage continued commitment to both the Army Chapter and the practice of internal medicine, as outlined in the Charter of the American College of Physicians. The committee strongly encourages all members to look closely to their peers, subordinates and superiors to nominate candidates for these various awards and recognition formats. The individual chair for each of the awards may be contacted, or I may be contacted to refer information to any of the chairs.

I may be reached at the following telephone number (253) 968-1290 , FAX number (253) 968-1168 or internet address col_lester_reed@smtplink.mamc.amedd.army.mil. Messages addressed through CCMail will reach me by using COL Lester Reed. The committee looks forward to active chapter participation in supporting these awards through nominations of some of the many worthy candidates currently in our chapter.

COL H. Lester Reed, MD, FACP
Chair, Army ACP-ASIM Chapter Awards and Recognition Committee
Chief, Department of Medicine
Madigan Army Medical Center
MCHJ-M Tacoma WA 98431

Medical Student Activities

We continue to work with Medical Students to further interest and understanding of Army Internal Medicine. Club Med, the Internal Medicine Interest Group at USUHS will be working with the Military Medical Student Association (MMSA)to increase collaboration and contact with HPSP students at other medical schools. Military Internal Medicine will be featured in an upcoming issue of the MMSA newsletter. Club Med also has rewritten its charter, and MAJ Gilliland has been selected as the new faculty advisor. We have also established the first award for outstanding performance by a 3rd year medical clerk in a military treatment facility. The award can be downloaded off the Army ACP-ASIM web site, or from cc:mail or by contacting MAJ Gilliland, the old fashioned way by telephone. There will be opportunities for students to meet with the Medical Consultant and Program Directors at the Fall Meeting in Reston, and we plan an activity similar to last year's successful career night during the Joint Service GME Selection board in December. Finally, the ACP-ASIM has established a national medical student council similar to the Associate's council, and 2LT Tom Wertin, a 3rd year student at USUHS has been elected to represent the uniformed services. Anyone with questions or ideas concerning medical student issues should contact MAJ Bill Gilliland, our ACP-ASIM medical student advisor. (202-782-5692).

Army ACP-ASIM Informatics

Perhaps no chapter or chapter of the ACP-ASIM could benefit so much from informatics as our own. Informatics could potentially address many of our needs, at least in a supplemental fashion:

  • up to date and easily accessible clinical information and tools,
  • CME and GME,
  • improved patient records,
  • automation of required clinical reporting,
  • asynchronous communications (such as the email many of use every day), and others.

However, the biggest challenge, as stressed at last year's Army Chapter Chapter ACP meeting, is to use these tools to directly improve patient care.

We are all aware of the shortcomings of many of the systems we are using today. However, we rarely give credit for how they have improved things. I can still remember back to my days as an intern when I would have killed to have a computerized laboratory reporting system. Now, in many of our hospitals, a physician can review labs and radiology reports(through CHCS and CIS), the actual patient chart (through CIS as an inpatient, and soon to come with CHCS2 for outpatients), and radiology images (through MDIS). We can communicate with referring physicians from Europe and Asia (as I just did a few minutes before starting to write this section) without worrying about "phone tag" or time changes. We can use the world wide web (for those fortunate enough to have the proper connections at work or home, and the number is increasing) to access full-text articles in Annals of Internal Medicine, Lancet, and other medical journals; clinical practice guidelines; online lecture series; and a variety of useful clinical tools. This tool provides a tremendous opportunity to give physicians and patients at the most distant clinic the same access to quality information and tools as they would have at the largest MEDCEN or academic teaching hospital. Our nephrology service recently put its service SOP's on its web home page as a service to other military nephrologists, and recently physicians at both Tripler and Madigan Army Medical Centers have taken advantage of it, saving on faxing or mailing dozens of pages of text and saving physicians precious time.

It's up to us to decide which direction to take. The national capitol area will be serving as the alpha site for CHCS2. This system will be a true computerized outpatient record in addition to lab/x-ray retrieval and order entry. Consults can be included in order sets, allowing one to have a batch order for health maintenance, for example. We believe many of the problems of the current systems come from a combination of inadequate physician/provider involvement and inadequate incorporation of their input. I have been impressed by the current approach to CHCS2 and we have a strong clinical advocate on their team in the person of Bart Harmon, WRAMC's Chief of Clinical Informatics, who has worked hard to keep components of the system simple, useful and practical. We'll have more on this system as we see how it progresses.

We had many new initiatives at last year's meeting and look forward to hosting Dr. Chris Dwyer, of the ACP-ASIM, who will be exhibiting many of the tools and initiatives the ACP-ASIM has developed nationally. The national ACP-ASIM website includes a section on informatics developments and, for subscribers to Annals of Internal Medicine, online searching a full text access to the journal. I've used this many times to give copies of articles on pertinent topics to housestaff. This excellent site is at the URL

We are pleased to announce the Army Chapter ACP-ASIM website is now operational thanks to the help of the national ACP, and available at http://www.acponline.org/chapters/army. You could also find it by going to the national site, http://www.acponline.org, and looking under "Chapters," "Army". We have copies of our chapteral newsletters, awards, and meeting information, as well as links to various MTF's and national ACP sites. We are working on building this tool and making it more useful for all of you.

Again, we realize many of you have expertise and interest in informatics, and have many good ideas. Please feel free to contact me at kabbott@vs.wramc.amedd.army.mil.

Kevin Abbott, FACP
MAJ MC USA
Staff Nephrologist
Department of Medicine Informatics Officer
Walter Reed Army Medical Center

Army ACP-ASIM Chapter: Clinical Corner

This issue of our newsletter marks the debut of the "Clinical Corner". These pieces will contain focused, referenced information in a case-based format useful for internists in clinical practice. Authors will have recognized expertise in their field and provide their phone numbers or e-mail addresses for Army Chapter ACP-ASIM members who may have future clinical questions on their own patients. The first "corner" is from Dr. Sandra Kweder, a former Chief Resident at Walter Reed who spoke at the plenary of our Fall 1997 Meeting and has completed a 2 year fellowship in Obstetrical Care and Consultation in Internal Medicine. Future topics and consultants for the clinical corner will be recruited by CPT Cecily Peterson, Chief of Medical Residents at Madigan and Chair of the Army Chapter Council of Chief Residents. If you have suggestions please contact her on cc:mail or at 253-968-1290.

Case

A 32 year old G1 pregnant woman at 29 weeks gestation presents to the Emergency Department with a one day history of mild upper respiratory symptoms and feeling poorly, followed by the onset of low-grade fever, left-sided pleuritic chest pain and dyspnea earlier today. She has no known medical problems except for longstanding obesity and marked lower extremity edema over the past month. You are consulted by the ED physician.. On examination the patient appears unwell. She is febrile, tachycardic and mildly dyspneic with respiratory excursion limited by splinting. Her obesity, large breasts and splinting severely limit her chest exam. She has a leukocytosis with a left shift and normal urinalysis. You suspect a community acquired pneumonia, but are uncomfortable making the diagnosis without more directive data regarding its extent, which is undeterminable by physical exam. You order a chest x-ray, PA and lateral views (contemplating whether a V/Q scan may be in her future). The patient asks whether the x-ray will pose a risk to her baby...making you wonder whether you should obtain the film.

Consideration

Diagnostic radiographic testing takes on new meaning for the pregnant patient. As a general rule, unnecessary radiation should be avoided for any patient, but especially for a pregnant woman. However, when her care requires a diagnostic radiographic procedure it should be obtained. The timing during gestation and extent of exposure are both determinates of actual fetal risk. Very early gestational exposures to large doses of radiation have a risk of spontaneous abortion. Most epidemiology and experimental studies have shown that a total fetal radiation dose of 10 rad is needed to induce gross congenital defects or fetal growth retardation (1). A small increase in the relative risk of childhood cancer is suggested by epidemiology literature at slightly under 5 rad of in utero exposure (2).

As can be seen from Table 1, a standard chest x-ray and even a full radiographic evaluation for pulmonary embolism can be obtained safely below the threshold of concern. It is likely that with current radiographic technique and equipment the exposure may be less. Clinically, for the case described above, a chest x-ray does appear to be warranted. The patient and her family should be informed of the risk of the procedure carefully. I usually describe the general threshold of concern for exposure being about 5 rads. Further, it is always wise to let radiologist and technician know in advance that you are sending a pregnant woman for a test and document in the chart that you have counseled her on the risks.

References

1. Brent RL: The effects of embryonic and fetal exposure to x-ray, microwave and ultrasound. Clin Obstet Gynecol 26: 484, 1983.

2. Ginsberg, JS, Hirsh J, Rainbow AJ, Coates G: Risks to the fetus of radiologic procedures used in the diagnosis of maternal venous thromboembolic disease. Thrombosis and Haemostasis 61(2): 189, 1989.

The Internist and the Pregnant Patient
Sandra L. Kweder, M.D.
E-mail: kweder@cder.fda.gov

The views expressed herein are those of the author and do not necessarily represent the views of the U.S. Food and Drug Administration or the U.S. Public Health Service.

Table 1
Risk of Diagnostic Radiation Procedures in Pregnancy
Derived from Ginsberg et al (2)

Procedure
Estimated Fetal Radiation Exposure (rads)
Chest x-ray (PA and Lateral) < 0.001
Ventilation Lung Scan 0.001-0.019 (depending on isotope used)
Perfusion Lung Scan 0.006-0.018 (depending on isotope used)
Pulmonary Angiogram - brachial route < 0.05
Pulmonary Angiogram - femoral route 0.22-0.37
Bilateral lower extremity venogram 0.6 (without abdominal shield)
Unilateral lower extremity venogram 0.3 (without abdominal shield)

Army Chapter Council News

MAJ Jeff Jackson is Program Director for the General Internal Medicine Fellowship, and along with COL Phillips and MAJ Wheeler helped design the follow up data form and CME questionnaire for the Fall 1997 meeting. He asked us to put out the following information on the Fellowship for this newsletter.

Since 1984, the Fellowship in General Internal Medicine has worked to improve patient care, teaching and research in primary care and general internal medicine. The Fellowship is a 2-year program at Walter Reed Army Medical Center which interweaves course work towards a Masters in Public Health with workshops, seminars and mentored experiences. The Fellowship is designed to produce leaders in clinical-education, clinical-research and clinician-administration, with an overall goal of promoting excellence in primary care internal medicine. For those who love the breadth of General Internal Medicine, see themselves as future leaders in clinical education or research and are interested in the academic respect that accompanies fellowship training, the General Internal Medicine Fellowship may be right for you. For further information, contact: MAJ Jeff Jackson, Dept of Medicine-EDP, 4301 Jones Bridge Rd, Bethesda, MD 20814. (202) 782-4039.

Advancement to Fellowship (FACP)

I do not yet have the official list of those Army Chapter members who have been advanced to Fellowship. (The designation, FACP, will remain in effect even though our organization is now known as ACP-ASIM.) When the full list is released, I will publish it in the newsletter. I have heard from a reliable source that congratulations are in order for COL Lou Pangaro, Head of Educational Programs for the Department of Medicine at USUHS, who has been advanced directly to Fellowship. This is a rare and well deserved honor. My thanks to all those FACP's who wrote endorsing letters for past applicants.

Members are eligible for fellowship after a minimum of two years as a full member. There are several pathways for advancement, combining different degrees of academics, patient care, and hospital and community service. Given the high quality of internists in our system, the significant extra duties performed in MEDDAC and MEDCEN settings, and our excellent graduate medical education programs, most Army Chapter members should highly consider applying for advancement to FACP at the earliest time period. I urge you all to contact me, or your colleagues if you are interested, or if you know someone who meets the criteria for FACP but has not yet applied.

I thank all those who contributed to this newsletter, and send my best wishes to those of you who have moved with the summer to new duty stations, as I have done. Everyone - check out our web site - it looks nice, is functional and has our award nomination forms on it as well as newsletters and other college activities. Have a great summer!

Charles Bolan, FACP, LTC MC USA
Governor for Army