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Governor's Newsletter, September 2000

Governor's Column

Melvyn L. Sterling, MD, FACP, Southern California Region II

I was a member of both the ACP and the ASIM before the two organizations merged. I am delighted to have the opportunity to participate in the early work of the combined organization.

The Governor's Council
The merger requires changes in governance and one of the immediate effects is the need to elect a Governor's Council. The new bylaws allow a combination of elected and appointed members of the Council; I will begin with the elected members and add appointees as the need arises. Later in this newsletter, you will find a slate of candidates for the Council, all of them have agreed to serve.

In addition to the Governor's Council, I have suggested the development of a legislative advisory group. We would invite our state and national political representatives (Senators, Representatives and Assemblypersons) to participate. The purpose of such a group would be to create a forum for dialogue with these legislators. We are all keenly aware of the profound impact that the government has on our profession and I believe that such a dialogue can be of great assistance to us.

Where should we be going and how should we get there?
Our merged organization, the American College of Physicians - American Society of Internal Medicine is a work-in-progress and the role of Governor and the Governor's Council will evolve accordingly. I therefore begin my term as Governor with a request for your help.

As the ACP-ASIM addresses the scientific, academic, legislative and day-to-day practical concerns of our membership at the national level, it is my hope that our Regional activities will reflect and, where appropriate, help shape those activities.

Tell me what the College can/should do at the Regional, State, National and, in view of our international membership and our proximity to Latin America, the International level. (Note: the Los Angeles Times reported on June 27, 2000 that HMO's are now offering care to some subscribers in either the USA or Mexico.)

To PAC or not to PAC
Last year, the Board of Governors, in its advisory role to the Board of Regents, recommended the formation of a political action committee (at the national level). That was not done. Serious concerns were raised by the Regents and no action was taken. How do you feel about this? The issue is not simple; there is a real down side to forming a PAC and it has not been part of the culture of the ACP to do so. It is consistent with the culture of the ASIM. Should this issue be revisited?

Stepping on our patient's toes (and ours), non-government:
What could/should the College do about intrusions into the practice of medicine? Would it be feasible and appropriate for the College, (at the local, state or national level depending on the issue and the entity involved), to collect, analyze and respond to those intrusions? This is a really difficult and expensive thing to do. The Texas Medical Association does this and it appears to be helpful to the members of their Association.

Stepping on our patient's toes (and ours), government:
The College has analyzed the Health Care Financing Administration's Medicare Evaluation and Management Documentation Guidelines and has found them to be inappropriate. Further, the slanderous statements of the Office of the Inspector General that alleged widespread inappropriate billing were met with a request by the College for data supporting the OIG's allegations. The OIG has not provided that data.

I have been involved in the documentation controversy through the California Medical Association and the AMA and thus receive letters and calls from many physicians regarding Medicare audits. The doctors (almost exclusively internists), report the suspension of the usual standards of fairness and legal due process.

At the recent meeting of the AMA committee on E&M documentation, I asked a representative of HCFA to define "abuse." I was amazed to hear him say the term "abuse" includes "errors." I thought I must have misinterpreted what he said until he projected his Powerpoint slide, which confirmed his statement!

On September 18, 2000, Representative Patrick Toomey of Pennsylvania introduced HR 5200. This bill will (if passed in its present form) help to restore fairness in the interactions between Medicare's fiscal intermediaries and physicians. The bill addresses, among other abuses, the outrageous practice of "extrapolation." For those who are unfamiliar with this form of extortion, here is how it works:

  • The carrier audits a small number of charts (the ones that have been reported to me involve 30 charts) and decrees that the physician has overcharged by "x" percent.
  • The carrier then extrapolates this "overcharge" at "x" percent to the physician's entire Medicare billing and demands that money at that time. The money, often many tens of thousands of dollars (as the extrapolation goes back many months), is demanded at that time. Although an appeal may be initiated by the physician, the money must be paid within 30 days of the decree by the carrier.
  • When the physician wins on appeal, (which occurs in 80% of cases that come before the Administrative Law Judges that handle such cases), the physician then reclaims the money.
  • This bill, which appears to be worthy of our support, was discussed at our Statewide ACP-ASIM Health and Public Policy Committee which has recommended that we support it. Currently none of our California legislators have signed on as co-sponsors.

The AMA has taken the lead in opposing the Documentation Guidelines. Since Medicare is a huge part of most internal medicine practices, is there anything else that the College could/should be doing on this issue?

We read and hear of other serious problems confronted by our members and our patients. Where should our focus be? How can the ACP-ASIM best serve us? Let me hear from you at melvynsterling@hotmail.com.

Mel Sterling


GOVERNOR'S COUNCIL NOMINATIONS

The merger of the ACP with the ASIM requires that the Governor's Council be a combination of elected and appointed Councilors.

Listed below are nominees for the Governor's Council for ACP-ASIM Southern California Region II for a term beginning September 1, 2000 and ending August 31, 2004:

Douglas Hegstad, MD,FACP
Jeremiah Tilles, MD, MACP
Nasratolah Vaziri, MD, MACP
Phillip Gold, MD, MACP
Alpesh Amin, MD
Maher Roman, MD, FACP
Gary Stewart, MD, FACP
Arthur Silk, MD, FACP
Sam Wong, MD

Dr Hegstad is well known to our membership as the Governor whose shoes I will attempt to fill. If elected,he has consented to work with Dr Gold on Awards and Promotions.

Dr. Tilles is the Chair of the Health and Public Policy Committee and President of the Statewide Chapter.

Dr. Vaziri has served on Dr Hegstad's Governor's Council where his particular contributions have been in science and education. He has agreed to organize our Regional Educational Meeting.

Dr Gold is also a past Governor and, as noted above, would work with Dr Hegstad on Awards and Promotions.

Dr Roman has been the inspiring leader of the Associates Program. He would work with Dr Amin from UCI on the Associates and Students Program.

Dr Amin is the Assistant Program Director and Clerkship Director in Internal Medicine at UCI. He is a hospitalist and in charge of the hospitalist program as well as palliative care at UCIMC.

Dr Stewart is a member of the Health and Public Policy Committee of our Region. He is a gifted writer and would work with Dr Silk on our Communications Committee.

Dr Silk is well known as the Editor of the Orange County Medical Association and a member of the Editorial Board of the California Physician.

Dr Wong is an internist in Loma Linda. He is an inspiring teacher an skilled in computer and internet issues.

Our Bylaws permit other members of the Council to be appointed. The Council may grow as our needs and opportunities become manifest.


A TRIBUTE... To Some of the Fruits of the Outgoing Governor and His Council

Congratulations to New Fellows Elected in 1999:

Lalitha Ananth, FACP, Fountain Valley
Virginia Barrett, FACP, Newport Beach
Soo-Sang Choe, FACP, Hemet
Maher Roman, FACP, Loma Linda
Alpesh Amin, MD
Arthur Silk, FACP, Garden Grove
James Strebig, FACP, Irvine
Peter Winkle, FACP, Huntington Beach
Raymond Wong, FACP, Loma Linda

Congratulations to Masters from Southern California Region II elected in the last four years:

Thomas Cesario, MACP, Irvine
Philip Gold, MACP, Loma Linda
Sudhir Gupta, MACP, Irvine
Jeremiah Tilles, MACP, Irvine
Nasratolah Vaziri, MACP, Irvine

Congratulations to Loma Linda Student members who presented winning abstracts and posters at the Annual Session in Philadelphia:

Derek Helton Roger Seheult

Are you a Fellow of the College? Should you be? Do you know someone who deserves advancement to Fellowship? Call 1-800-523-1546, or click on www.acponline.org to start the process.

Kudos and Thank You to Dr Maher Roman
Dr Roman and his inspiring faculty presented the Second Annual Internal/Adult Medicine Update and Review Course on August 6th and 13th at the Jerry L. Pettis VA Medical Center in Loma Linda.

This course, a fast-paced review was presented on two successive Sundays following enthusiastic reviews of the same schedule/format in 1999. The course attracted participants from over 60 miles away (in spite of an 8 a.m. to 9 p.m. schedule.)


The Students And Associates' Column

January 1995 was my starting point for becoming really involved in the ACP-ASIM Southern California Region II activities at the associates' level. One day during that month Douglas R Hegstad, MD, FACP (who was then serving as the Associates' Council coordinator) asked me to be involved in the first career development workshop of our region (How to start your practice in the new millennium?). I accepted the invitation and the rest was history as they say. It has been a very rewarding experience, the experience of serving our promising future, the students and associates!

Since January 1995, our region conducted seven "career development workshops" for the associates. The workshop was also presented 3 years ago at the College's national meeting in San Diego. A "career guidance workshop" for Loma Linda medical students was also conducted last January. We also piloted a local board review course last year at Loma Linda VA Hospital to provide our associates with a locally convenient course with a nominal fee.

In region II, we genuinely believe in the mission of serving and developing our students and associates. Our experience with leading the students and associates program of all California Meeting in San Diego, October 17, 1999, reflects this belief (full report is available on the California Chapter Web site www.acponline.org/chapters/ca/10-17-99.htm.) I would like to share with you the main highlights of the meeting to recognize the achievements of our students and residents as well as the servant leadership role of many of our California Chapter leaders. The program was also a real life experience for the value of collaboration. The four regions of the California chapter united together to make the program a success!

The program included a poster session, under the leadership of Chester Choi, MD, FACP (currently serves as Region I Governor). The winners were:

Associates (4 Winners)

  • Russell Cucina MD—First Place, Clinical Vignette Category
    Stanford University, Program Director: Kelley Skeff"Cyclosporin-A encephalopathy in a cardiac transplant patient with therapeutic whole-blood cyclosporin levels"
  • Marc Arnush MD—First Place, Research Category
    Scripps - Mercy, Program Director: Stanley Amundson "IL-1 produced and released endogenously within human islets inhibits B cell function"
  • Gregory Engel MD—Second Place, Research Category
    Stanford University "Feasibility and reliability of early diagnosis of myocardial infarction"
  • David Norton MD Second Place, Clinical Vignette Category
    Travis AFB, Program Director: Kathryn Amacher "Case presentation of a 66 year old female with clinically significant respiratory alkalosis secondary to progesterone use"

Students (2 Winners)

  • Roger Seheult, Clinical Research Category (Medical Student)
    Loma Linda University, Clerkship Director: Raymond Wong "Students' perceptions regarding standardized patient (SP) exams"
  • Derek Helton, Clinical Vignette (Medical Student)
    Loma Linda University "A case of fulminate Vibrio Cholerae non-01, non-0139 primary septicemia in Southern California"

The winners were automatically accepted for the national abstract competition at the ACP-ASIM meeting in Philadelphia, April 2000. In fact the clinical vignette, presented by medical student Derek Helton was a winner at the Philadelphia meeting and he was recognized at the California chapter reception in Philadelphia, during the national meeting.

Another activity was a Panel Discussion titled "The Future of Internal Medicine: Servant or Master," the facilitator was Faith Fitzgerald, MD, MACP (Governor, Northern California) and the participants were four of California associates: Clifford Fisher, MD (Associate, University of California, Davis), Morgan Waters, MD (Associate, University of California, Davis), Lalima Hoq, MD (Associate, Loma Linda University), and Helme Silvet, MD (Associate, Loma Linda University). Active participants from the audience included Melvin Sterling, MD, FACP (Governor, Region II) and Douglas R. Hegstad (President-elect, California Chapters ACP-ASIM.)

This lively interactive panel discussion handled issues related to how young physicians view practice of medicine (and residency) in the new millennium like practice issues, employee status, academic careers, reimbursement, education and its fate, control of own destiny (balanced life, family time etc.). The discussion also handled some of the major issues of public good to which Internists should/must address themselves in the future like patients' right issues, population vs. individual patient (allocation of scarce resources), and new threats to public health. Even resident's life and in particular the sensitive issue of the long and stressful call hours.

Another activity of the program was the "Financial Planning Workshop." This workshop addressed issues related to investing, retirement planning including IRAs, 401K as well as estate planning and tax issues. Some key investment advice was emphasized like starting early (appreciating the time-value of money) and diversifying.

The final session was a "Career Planning Workshop—How to Start Your Practice in the New Millennium," by a nationally recognized career consultant, Mr. Patrick Molloy. This workshop handled issues related to career options: Is managed care the only option? How to choose the right practice? How to prepare a professional resume? How to handle the interview? Should you read the job contract? Is it negotiable?

It seems valuable to include career planning and financial planning workshops in the associates and students meetings. These are practical topics that are needed to facilitate the transition from school and residency to real life. By doing so we are filling a usual gap in the medical schools and residency training. It is intriguing that we spend between 11-15 years of school and residency to be able to practice internal medicine or one of its specialties, it seems logical to learn about how to make this important transition! It was also a fulfilling experience to enjoy the art and fun of internal medicine science via the promising research of our associates and students as reflected by the high quality posters that they presented.

Overall, the program provided a venue for including and involving the medical students and associates in the chapter's activities. It was a great opportunity to promote our profession to medical students. The students and associates had the chance to mingle with their "future" colleagues and many of the California ACP-ASIM leaders. The program again reflected the dedication of our region to the mission of serving our students and associates!

I would like to take this opportunity to introduce to you my colleague who will serve in the capacity of co-chair of the Associates' Council, Alpesh Amin, MD, the assistant residency program director at UCI. Dr. Amin and I will be working together on developing further programs to our region's students and associates for the next four years.

I would also like to invite you to participate with thoughts and ideas on how to further serve and develop our
students and associates. You can always reach me via what some call "the digital nervous system,"—the email!

Maher A. Roman, MD, FACP
Chair, Associates Council, Southern California, Region II
E-mail: DRMAR2000@AOL.COM


Governor Contact Information

Melvyn L. Sterling, MD, FACP
Governor, Southern California Region II
1310 West Stewart Drive, Suite 608 Orange, CA 92868
E-mail: melvynsterling@hotmail.com
Phone: (714) 997-7431
Fax: (714) 997-7296