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Governor's Newsletter, April 1999

Governor's Corner

I feel like the white rabbit in Alice in Wonderland, much to do and not enough time to do it. Therefore, in this edition we will cut out the philosophy and stick to what I will call an AGENDA FOR CHANGE for the Chapter. I will keep confronting those of you who read this newsletter with the new, more expansive roles that this Chapter could be taking part in over the coming years, but where our ability to participate will be dictated by the degree of member volunteerism.

This Chapter's AGENDA FOR CHANGE is rapidly evolving, and I am presenting only those issues and ideas which have arisen as a consequence of a very productive Governor's Advisory Council Meeting in February. Some are ready to go, some are just a twinkling in our collective eye, but all can be engaged within this coming year if YOU step forward. I will be adding more items as they come up and recognize those who have committed to contribute their time to their profession, their College, and their patients.

  1. Create a Chapter Website - Webmaster - Lynn Sanders, MD
    • Lynn Sanders has agreed to organize and manage a Chapter website. The intent is to have sites that provide easy access to needed information about our Chapter, our Committee agendas, evolving health policy initiatives, and our Profession. Links to guideline, patient information, and evidence-based medicine sites are planned.
    • NEEDS - Lynn will need help from any groups (medical students, Associates, women's issues, etc) that want to have their own areas on the web. Any who have an interest, and are willing to help, please contact me, or Lynn directly at 303-375-5672.
  2. Membership in the Primary Care Coalition - Robert Brettell, MD, FACP
    • Bob Brettell, has volunteered to be the Chapter's representative on the Colorado Primary Care Coalition's Board. This will reestablish Internal Medicine's input into this politically active organization.
  3. Membership in the Colorado Coalition for Guideline Development - ?
    • We have been invited to be a member of this coalition based on the ACP-ASIM's historical leadership in the area of evidence-based medicine and guideline development. The Coalition's purpose is to develop coherent clinical guidelines based on current evidence base rather than whatever an MCO finds in Milman and Robertson. We should have a seat at this table.
    • I NEED A VOLUNTEER who has an interest in clinical pathways, guidelines, and evidence-based medicine to be our representative on the Coalition. This person would be a member of the Health and Public Policy Committee, use Committee members as resources, and report their activities to that Committee.
  4. Active Participation in the College's Commitment to Bring Universal Health Insurance Back on the National Agenda - ?
    • It is fair to say that the College is the largest medical specialty group that has access to health insurance for all Americans at the top of its political agenda. We have recently proposed an incremental approach to this problem using an eighth of the budget surplus. Along with a coalition of like-minded organizations (e.g. American Academy of Pediatrics) the College has just announced an initiative to get 90% of organized medicine behind this simple tenet. THIS CHAPTER NEEDS TO BE PART OF THIS EFFORT.
    • I NEED MEDICAL STUDENT, ASSOCIATE, AND MEMBER VOLUNTEERS who have an interest in expanding access to health insurance for all Americans. THIS NEEDS TO BE A CHAPTER-WIDE, GRASSROOTS EFFORT. AS INTERNISTS WE NEED TO PUT OUR TIME WHERE OUR MOUTH'S HAVE BEEN.
    • This will not be a casual or one-time exercise. We need to build towards the 2000 election cycle, and we need to start now. I am hoping to set up a separate Access Task Force, the Chair of which would be a member of, and report to, the Health and Public Policy Committee.
  5. Participation in the College's 1999-2000 Clinical Initiative - Reducing the Inappropriate Use of Antibiotics - Forestalling Antibiotic Resistance - ?
    • As a corollary to the "Internal Medicine - Doctor's for Adults" campaign the College has decided to wade in on important public health issues affecting our patients. They have chosen an appropriate topic for the millennium. Volumes of evidence (so eloquently presented by Merle Sande, MD, MACP during our Annual Scientific Program at the Broadmoor) predict that multiple resistant bacteria, viruses, and fungi will become commonplace in the next decade. S. pneumoniae is beginning to show resistance to multiple antibiotics including penicillin. A good part of this can be traced to the indiscriminant and inappropriate use of antibiotics.
    • The College will be putting together public information brochures, written materials, op-ed pieces that can be sent to local papers (A great idea that emanated from a Colorado resolution to the Board of Governors proposed by one of our members - Karla Demby, MD, FACP of Cortez - in 1997).
    • Our Chapter has to decide how it can best participate in this important public health initiative for our patients. It will also have the nice side-light of demonstrating to the public that we are supporting their needs, as the best providers of scientific-based care for adults.
    • I WILL NEED MEDICAL STUDENT, ASSOCIATE, AND MEMBER VOLUNTEERS FOR A TASK FORCE TO ORGANIZE A STATE-WIDE CAMPAIGN TO REDUCE THE INAPPROPRIATE USE OF ANTIBIOTICS. The Chair of this Task Force would be a member of, and report to, the Health and Public Policy Committee.
  6. Making the Colorado Chapter of the ACP-ASIM a State-wide Organization that Meets the Needs of ALL of its Members.
    • Our membership is changing. Young Internists are more likely to be women, in salaried positions, or practicing in smaller communities or on the Western Slope. 40% of the Internists in Colorado are not members of the College. Our Chapter needs to recognize this diversity, and respond to the varying needs of current and potential members.
    • GEOGRAPHIC DIVERSITY - Internists on the Western Slope have not been served equitably by this Chapter. Their participation has been limited by distance, and the Chapter could not respond because of a lack of resources. This must change. In fact, this issue is so important, and so central for the effective engagement of a number of the other items on our AGENDA FOR CHANGE, that I will not wait for volunteers. I will be calling up a number of our senior members on the Western Slope to organize a teleconferenced Task Force TO DEVELOP A PLAN FOR A SECOND CHAPTER SCIENTIFIC MEETING ON THE WESTERN SLOPE. I can see no other solution to this separation, and I am committing Chapter resources to this project.
    • PRACTICE DIVERSITY - Internists who are salaried are an increasing proportion of our membership. Some work in Kaiser, some in Denver Health, some in for-profit enterprises, some in the University, and some at the VA. Some do research, others are administrators in health care systems. We need to know how this Chapter can do a better job of making the College's work relevant to these Internists. I will be creating a Task Force to examine this issue and will try to engage a number of our members in these arenas to discuss openly the impediments to greater involvement in the Chapter by these groups. ANY MEMBER WITH AN INTEREST IN THIS PROBLEM SHOULD CONTACT ME DIRECTLY.
    • GENDER DIVERSITY - I have asked Kelly O'Brien-Falls, MD, FACP to organize a Women's Issues Interest Group as a sub-committee of the Membership Committee. Her charge will be to develop a group of women Internists who will identify and discuss issues of special importance to themselves and other members, and direct recommendations for change to the Membership Committee. ANY MEMBER WITH AN INTEREST IN BEING PART OF THIS GROUP SHOULD CONTACT KELLY O'BRIEN-FALLS MD, FACP AT (303) 837-6532.
    • ALL MEMBERS WITH AN INTEREST IN PARTICIPATING IN THE 'AGENDA FOR CHANGE' CAN ALL ME AT 303-315-4649 OR USE THE ABOVE EMAIL OR FAX NUMBERS, OR PAGE ME AT 303-266-4259, OR CALL ME AT HOME AT 303-758-0791.

Chapter News

Medical Students

Eric Hester, MSII has been representing Colorado on the National Medical Student Council. When I spoke with Eric he told me that this new Council's work has focused on setting up its agenda. One of the Council's missions will be to convince Governors to incorporate medical students into the Chapter's decision making process. I told Eric NO PROBLEM IN COLORADO. In fact I will be communicating directly with the Internal Medicine Club to solicit volunteers. I have also offered to provide letters of recommendation on the College's letterhead for any students who become actively involved in the Chapter's activities.

Congrats to Karla Demby, MD, FACP for Being Awarded the Department of Medicine's Student Teaching Award!!

Debra Parsons, MD, FACP, Chair of the Medical Student Committee, has asked for a grant in aide to help further develop the Globeville Clinic for the indigent in which the medical students participate. The Globeville Clinic project has been awarded a $1500 allocation for this purpose.

Associates

Colorado had another extraordinary year in the national Associates competition. NINE residents were selected to present their research or clinical vignettes at the meeting in New Orleans. FOUR of the nine were selected as WINNERS OF $750 prizes. The nine residents and winners of prizes (*) were: Jake W. Arthur, M.D., Richard A. Birnbaum, M.D.*, Karen Chako, M.D.*, Teresa A. Cherry, M.D.*, Elizabeth Dagdigian, M.D.*, Timothy Poate, M.D., Christopher F. Rowley, M.D., Cynthia Tai, M.D., Alexander Urquhart, M.D., and Laurie A. Whittaker, M.D. All of the posters and presentations were exemplary.

Their Program Director - Bill Kaehny, M.D., FACP deserves acknowledgement for the encouragement of scholarship during training. A special thank you goes to the Chairman of the Department, Robert W. Schrier, MD, MACP, for his willingness to provide the resources that enabled ALL of the residents to go to New Orleans and represent our state and his program so well. Freeing up coverage and travel expenses for this many residents demonstrates his continuing commitment to the excellence of his training program.

PLEASE NOTE: THE ANNUAL ASSOCIATES MEETING IS SCHEDULED FOR THE EVENING OF TUESDAY MAY 25TH 1999 FROM 5-9 PM AT EXEMPLA-ST. JOSEPH'S HOSPITAL'S EDUCATION FACILITY. AS ALWAYS, MANY EXCELLENT ABSTRACTS WILL BE ON VIEW, DINNER WILL BE SERVED, AND THE CHAPTER WILL BE PROVIDING MONETARY AWARDS TO THOSE JUDGED MOST EXEMPLARY. PLEASE PLAN TO ATTEND AND SUPPORT THE FUTURE OF INTERNAL MEDICINE.

Membership and Advancement

Total membership in the Chapter has increased by 210 in the past year to 1285 with 146 medical students, 220 Associates, 611 Members, 305 Fellows, and 3 Masters. Seven members advanced to Fellowship during the past year (Linda Barbour, Laurence Chan, Barry Holcomb, Daniel Kuritzkes, Allan Prochazka, Gerard Tomasso, and Barbara Warren) and one Fellow advanced to Mastership (former Governor Herbert Rothenberg). Drs. Barbour, Holcomb, Rothenberg, and Warren joined me in the Convocation ceremony at the Annual Meeting in New Orleans. Six other members have their applications and documentation in Philadelphia awaiting the next Credentials Committee meeting.

TO BE ELIGIBLE FOR ADVANCEMENT BY THE MILLENIAL ANNUAL MEETING IN PHILADELPHIA IN APRIL 2000 THE DEADLINES FOR GETTING IN COMPLETED APPLICATIONS WITH SECONDING LETTERS FROM TWO FELLOWS IS JUNE 30th AND NOVEMBER 30th 1999. IF YOU NEED ANY HELP CALL MY OFFICE.

Annual Program

The program at the Annual Meeting again achieved its goal of providing practical information to the practicing Internist and Internist sub-specialist. I have looked over the evaluations, and they were all quite good. This reflects the time and effort that the Program Committee put into the development of the scientific portion of the meeting. I want to thank the Program Committee chaired by Robert Swaney, MD (David Abbey, MD, FACP; James Adams, MD; Jeffrey Gori, MD; Lisa Kettering, MD; Kelly O'Brien-Falls, MD, FACP; and Tom Perille, MD, FACP).

I would also like to thank the following corporations for their contributions of educational grants that help to support the annual meeting.

The Colorado Permanente Group, Group Insurance Administrators, Juice Plus, Pfizer Inc. Pharmaceuticals, Solvay Pharmaceuticals, Tap Pharmaceuticals.

We invited five speakers from outside of Colorado, led by Harold Sox, MD, MACP the President of the ACP-ASIM who spoke on preventive health measures, the College, and always made time to speak with members. Richard LeBlond MD, FACP represented the ABIM and spoke about the recertification process. Merle Sande, MD, MACP spoke on the growing problem of antibiotic resistance. William Detmer, MD, FACP VP for OVID Technologies gave a practical talk on using your computer to improve patient care. Winthrop Whitcomb MD, FACP Co-President of the National Association of In-patient Physicians spoke about the growing hospitalist movement.

Speakers from Colorado included Tanya Argo MD - Managing Chronic Patients with Chronic Pain; Karlotta Davis MD - Managing the Woman with Urinary Incontinence; Kathy Hassell, MD - Evaluation of the Hypercoagulable Patient; Margo Karsten, MSN - Joined the Hospitalist Panel; Steven Kick, MD - Managing the Patient with Anxiety; David Kroll, PhD - Herbal Medicine; Chris Lang, MD - New Modalities for Detecting Coronary Disease; and Maureen Leehey, MD - The Treatment of Parkinson's Disease.

The Annual Business Meeting had 90+ attendees (helped by the fact that we put it during lunch on Friday), lasted 1.5 hours, and I have already had a lot of good suggestions on how it could be improved. I thought for a first attempt at getting broader feedback from the membership it worked well. The process of merger was presented, including the astoundingly low total cost of $531 for legal fees and one dinner at the Holiday Inn on I-70 for the Merger Steering Committee. The new bylaws and name (Colorado Chapter of the ACP-ASIM) were approved unanimously. Steven Kroger MD, FACP and Allan Prochazka, MD, FACP were elected to the Governor's Council; Mark Levine, MD, FACP (no relation) was elected Secretary; and Joseph Matthews, MD, FACP was re-elected Treasurer. Two resolutions were discussed, approved unanimously, and forwarded for presentation at the Spring Board of Governors Meeting (see below).

Fate of Resolutions Brought to the Spring B.O.G.'S Meeting

Recommended for adoption with or without substitution:

#1-S99 - The College is to transmit to the ABIM its members concerns that Board recertification should be clinically relevant, of benefit to patients and physicians, and minimally burdensome for the candidate.

#4-S99 - The College is to develop explicit guidelines for informing the electorate about candidates nominated for elected office.

#5-S99 - The College will develop and maintain a compilation of states' CME requirements for physicians, and that local Chapter's will be encouraged to use this information in local program planning.

#6-S99 - The College urge delay in the implementation of HCFA's E and M documentation guidelines (already current policy).

#7-S99 - The College should oppose performance-based contract for HCFA PRO's that create inappropriate incentives for identification of payment errors (Colorado's resolution reworded).

#10-S99 - The College will advocate for health care policies that insure access for integrated general medical and psychiatric services.

#12-S99 - The College will encourage all medical schools to integrate geriatric education in the overall educational experience.

#13-S99 - The College will seek legislation requiring health care organizations to provide adequate advance notice of formulary changes.

#14-S99 - The College recommend to appropriate bodies that Methadone be considered no differently than any other DEA Schedule II agent.

#16-S99 - The College encourage the study of the long-term impact of genetic engineering on the food supply and human health.

#17-S99 - The College enter into discussions with the Royal College of Physicians and Surgeons of Canada to approve MKSAP as an acceptable for of study credit for Internists.

#18-S99 - The College advocate to support the requirement that all Medicare carriers include the fee schedule for office laboratory tests in the "Enrollment Package and Physician Fee Schedule" for Medicare Part B each year.

#20-S99 - The College will oppose the mandatory use of hospitalists. (Reaffirms current College policy).

Resolutions recommended for further study:

#3-S99 - The College will formally condemn the endorsement or sale for profit of non-prescription goods from physicians' offices. Colorado's and too hot to handle. Definitions of 'office' 'non-prescription goods' and 'for profit' were the main stickling points. Felt good that it was not voted down.

Resolutions not approved:

#2-S99 - The College will investigate publishing a health magazine for the public. (Unlikely to be successful, and too costly)

#8-S99 - The College will recognize the diversity of needs of Chapters. (Felt to addressed in BOG/BOR Task Force Recommendations that were approved)

#9-S99 - The College will pay for Regents to attend the BOG meetings. (Felt to be too costly of College resources and Regents time)

#11-S99 - The College will post minutes promptly on ACP-Online. (Approved as part of BOG/BOR Task Force Recommendations)

#15-S99 - The College will not create a PAC (Membership Assessment at Chapter level being undertaken - See next page)

#19-S99 - The College better educate the lay public and branches of government about the consequences of the for-profit nature of most HMOs in the United States. (Unclear mission, high cost)

Should the ACP-ASIM Have a Political Action Committee (PAC) ?

BACKGROUND: The old ASIM had a PAC, the old ACP didn't. The merger agreement ended the ASIM PAC, but left open the possibility of having a new ACP-ASIM PAC within the 501C6 part of the corporation. The BOG, at the fall 1998 meeting, had a protracted and open discussion of the issues between those who felt strongly that we should have a PAC, and those who felt strongly we should not have a PAC. Ultimately a compromise resolution was approved (overwhelmingly) that asked the Board of Regents to create an ACP-ASIM PAC that would be totally self-supporting (i.e. no dues would go to support PAC administration) from member donations. The Board of Regents felt that the issues surrounding a PAC needed broader discussion and input from the membership before they would be comfortable taking this step (They also wanted a letter from the IRS assuring that the PAC in a 501C6 would not endanger the College's 501C3 status).

What Are the Issues - As Fairly as I Can State Them?

WHAT DO PACs PROVIDE ? - Increased access to legislators. They do not buy votes.

WOULD ACP-ASIM's ADVOCACY INITIATIVES BE CRIPPLED IN THE ABSENCE OF A PAC? - No. The College would continue to effectively advocate for issues that directly affect our patients or our professionalism as it has done in the past. HOWEVER, if there are advocacy issues which involve HOW MUCH WE ARE PAID relative to other providers, relative to a fee schedule, or within a restructured health care system, not having a PAC will reduce (not eliminate) the efficacy of our advocacy. Let me be explicit. If we are successful in bringing universal health insurance back on the national agenda, and if we seriously wish to pass enabling legislation over the objections of current stakeholders (MCOs, insurance agents, malpractice lawyers, for-profit health plans, hospitals - ALL of whom have PACs), a fully funded PAC would be VERY helpful.

WOULD MY DUES BE USED TO FUND A PAC ?- No. Funding, and thus the viability of the enterprise, would be dependent on member interest and voluntary contributions.

AREN'T PACs, AND THE ORGANIZATIONS THAT FUND THEM, CONSIDERED SLEAZY? YES ... AND NO. Beauty is in the eye of beholder. Many PACs support single issue politics that many of you would find 'morally uplifting.' Other PAC's support the Trial Lawyer's Association and the Health Insurance Association of America. Until our representative democracy figures out some way to conduct the business of reelection without the business (and the $), PACs will remain an active part of the political system. At least with PACs, as opposed to soft money contributions, you can tell who is giving what to whom.