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Governor's Newsletter, Summer 2002

David N. Podell, MD, PhD, FACP
Governor, Connecticut Chapter

Governor's Message

It is a pleasure once again to address all of you in the Governor's Newsletter. Much has happened since the fall. The Chapter is extremely busy with many activities, which continue to thrive.

We are busy putting the finishing touches on our fall meeting, which will be held on Friday, October 4, 2002 at the Aqua Turf in Southington, Connecticut. Dr. Eric Mazur and his committee are putting together an exciting and challenging program, which I know you will enjoy and feel worthy of making the trip to attend. This year we are combining the Associates meeting with the full state meeting to allow continued interaction and camaraderie among the members of our Chapter, as well as a chance for mentoring and discussion of important issues by both our newest and oldest members. Dr. David Dale, Chair of the Board of Governors, will be our College Representative and I know that the day will be meaningful and well worth the trip. I look forward to seeing all of you there. We are thrilled that Dr. David Kessler, Dean of Yale University School of Medicine, will be our keynote speaker.

April 2002 Board of Governors Meeting Report:

There were many important topics that the Board of Governors addressed at our April Board of Governors Meeting in Philadelphia. An important topic revolved around recertification. As you know, for those who have not been grandfathered, the American Board of Internal Medicine requires recertification before the tenth anniversary of your initial certification. This has involved a costly, as well as timeconsuming process. After many discussions between the College and the American Board of Internal Medicine, a new effective dialogue and plan has been proposed to allow members to better meet the needs of recertification. It is hoped that this will lead to a more meaningful and successful way to recertify and to continue in professional development.

At the time of the merger of the ACP, it was agreed that for three years the College name would be ACP. Top choices for an official name that is not cumbersome and would be easily recognized was brought forth by a special committee. Two top choices included the American College of Physicians and the American College of Internal Medicine. A motion was made to move back to the name American College of Physicians, which would occur gradually.

Dr. Walt McDonald, FACP is retiring in June as Executive Vice President and CEO of the College. The new CEO of the ACP, Dr. John Tooker, FACP, was announced after a nationwide search. Dr. Tooker has been the Chief Operating Officer of the College. He has been enthusiastically welcomed and the College is delighted to have him on board as CEO. We are sure that he will lead the College wonderfully during his tenure.

I continue to enjoy visiting the Departments of Medicine within the state. I recently had an enjoyable visit at Bridgeport Hospital and look forward to seeing many of you in the future. In this newsletter you will read about the many activities within the College, including those involving medical students led by Dr. Barry Wu, at our exciting Associates Program and recent May 10, 2002 meeting for Associates chaired by Dr. Scott Wolf. The busy work of the Health and Public Policy meeting, chaired by Dr. Rob McLean, and plans for our upcoming visit to Washington during Leadership Day. Dr. Anna Reisman has provided us with the results of her bioterrorism survey. I thank all of you who have participated in this study.

In closing, I would like to tell you how privileged I am to be your Governor and look forward to continued hard work within the College. Wishing you and your families all the best.

Dr. David Kessler, Dean, Yale University School of Medicine- Fall Annual Meeting Keynote Speaker

Eric Mazur, MD, Program Chair

Scheduled for Friday, October 4, 2002, the ACP statewide meeting will have an exciting new look this year. Dr. David Kessler, Dean of the Yale University School of Medicine will be the keynote speaker and discuss his pioneering work as FDA Commissioner that defined nicotine as an addictive drug and resulted in the first Federal regulations governing tobacco advertising and sales. Complimenting the keynote address will be poster and oral scientific presentations by internal medical residents from throughout the State culminating in awards for the most outstanding research work. During the buffet lunch, attendees will be updated by ACP leaders on political and educational initiatives of the College and the Annual Chapter Awards will be presented. The afternoon will feature four simultaneous clinical workshops led by nationally recognized faculty. Two of these workshops, cardiac auscultation and the musculoskeletal examination, will use a "hands-on" approach to teach residents and seasoned clinicians how to improve these important clinical skills. The third workshop will adapt the "Multiple Small Feedings of the Mind" format so popular at the national ACP meeting to address, using an evidence-based approach, salient and practical clinical questions on Women's Health, diabetes and dementia. The fourth workshop will focus on the hot clinical and political issue of how we physicians can reduce medical error. The "hands-on" workshop spaces are limited. Sign up early to assure yourself a spot. The Meeting will be held at the Aqua Turf in Southington, CT, a beautiful setting and easy access from everywhere in the State.

Report from the Health & Public Policy Committee

Robert Mclean, MD, FACP

Several Health & Public Policy issues are hot legislative topics at the national level but the short legislative session in Hartford this year kept health care topics very low on the priority list. The HPP Committee has tried to make more effective contact with state legislators through several breakfast meetings, the last one being held Tuesday April 16 in Hartford. Drs. David Podell, Paul Dolinsky, and Robert McLean met with 8-10 legislators and expressed our hopes that the Legislature will address medical liability reform, support legislation allowing municipalities to pass more stringent laws regulating smoking, and restore funding for Medicaid co-payments to physicians for Medicare/Medicaid dually eligible patients. The legislative session in Hartford finished in May.

Many health-related legislative topics at the national level were discussed in various forums at the Annual Session in Philadelphia. Dr. Robert McLean represented our Chapter at the Annual Session State Health Policy Networking Session. It was a wonderful opportunity to learn about legislative issues facing other chapters. There was a specific focus on several topics:

State Tort Reform - Malpractice insurance rates are rising precipitously across the country. California's MICRA legislation in place since 1975 proves that effective tort reform works, and tort reform to be effective must have a reasonable cap on non- economic damages ($250.000). While MICRA-like legislation will be introduced in the House, it is felt that Congress won't pass sweeping tort reform with caps. Muchof the action will have to come at the state level.

In Connecticut, CSMS identified medical liability insurance reform a priority item. Malpractice rates for internists are much lower in CT than in other parts of the country. While CT malpractice law does not have a cap on non-economic damages, it has very effective statute of limitations provisions. There is concern that re-working of CT malpractice law will bring all aspects of it up for review (and subject to legislative battle with the ever-powerful trial lawyers' lobby) and lead to malpractice law, which is worse for doctors.

State Bioterrorism Preparedness - The events of 2001 have led to legislation passed by both the Senate and the House (not yet reconciled with mild differences) to direct funds enacting bioterrorism emergency programs at state levels. The CDC drafted a "Model State Emergency Powers Act" which ACP's HPP Dept. reviewed extensively with some great concerns including language that effectively allows for conscription of physicians. The Act focuses on terrorist threats when it is recognized that our entire public health infrastructure needs help, and what is needed is more comprehensive disaster planning of any type.

State Prescription Drug Initiatives - Connecticut's ConnPACE to help elderly pay for prescription drugs has made progress by increasing the income ceiling for eligibility as of April 1, 2002. We heard details of the more comprehensive EPIC Program in New York, which has an income ceiling of $50,000 and which used some tobacco settlement money towards the program thus allowing it to double funding in 2001. Other important national legislative issues are listed in the column "What has the ACP Done For You Lately?" Drs. David Podell and Robert McLean travelled to Washington, DC in late May for the College's Leadership Day to meet with legislators and their health policy staffers to try to convey the Connecticut physicians' perspectives on these many issues. Those contacts are just part of our ongoing efforts to be effective with legislators.

There are many parties trying to influence legislators, and while we think we have a voice of reason, we are frequently a quiet and infrequently heard voice. Internists need to realize that their ability to practice medicine as they hope to continue to do depends on many factors, which different types of legislation can significantly affect. It is not the time to ignore political realities. I welcome others to join our advocacy efforts.

Connecticut Chapter, ACP Annual Associates Educational Meeting

Scott Wolf, MD, Chair

It was a beautiful Friday at Hartford Hospital as they played host to the revitalized ACP Annual Associates Educational Meeting held on May 10, 2002. House staff from Internal Medicine programs around the state participated in what turned out to be an informative and enlightening conference. Following the opening remarks and welcome from conference chair Scott Wolf DO, MPH, FACP; Dr Thomas Duffy, Professor of Medicine, Yale University, delivered an insightful presentation on Medical Ethics. His dissertation brought us all back to why we became physicians and reminded us all the true joy of medicine stems from our relationships we develop with them and the privilege we have in caring for them. A very practical approach to managing resident debt followed. Mr. John Joyce, financial representative from Northwestern Mutual Financial Network, walked the audience through a practical approach to managing their current medical school debt and some useful tidbits for beginning their investment careers.

Closing the morning was a panel of three women physicians addressing various aspects of finding professional satisfaction after residency. Drs Pamela Charney, Janet Henrich and Stephanie Arlis Mayor, shared their own personal experience regarding their career choices and the options that the future internists may encounter. Dr. David Podell, Governor, Connecticut Chapter offered a brief welcome over lunch followed by an informative presentation from Dr Joe Lim, President Elect of the National Associates Council. He provided an update on the activities of the National Associates Council and encouraged all to get involved at both the national and local levels. For those who resisted the sunny day and remained for the afternoon, they were treated to an outstanding keynote address from Mr. Ford Koles, from the Health Care Advisory Board in Washington DC. Ford presented a very eye opening state of the union address on health care in the United States and what we can all expect in the future. The reviews of the conference were extremely positive and all are looking forward to next year.

Congratulations! Newly Inducted Fellows

Adler-Klein, Debra - Stamford
Apaloo, Catherine E. - New Haven
Cohen, Neil S. - Stamford
Dulipsingh, Latha - West Hartford
D'Avella, John F. - Farmington
Dunne, Dana W. - Old Saybrook
Freitag, Anna C. - Norwalk
Hassanein, Eihab O. - Plainville
Keltner, Robert J. - New London
Magaldi, John A. - Torrington
Neiditz, Charles A. - Fairfield
Quentzel, Howard L. - Derby
Regenbogen, Howard M. - Litchfield
Rohr, Richard E. - West Haven
Rosenberg, Eric L. - Glastonbury
Sack, David M. - Meriden
Schwartz, Marlene - Colchester
Soukas, Peter A. - Hamden
Tarkhan, Ismail I. - Milford
Vargas, Socorro J. - West Hartford
Weiser, Jeffrey S. - Trumbull
Zlotoff, Ronald A. - Waterbury

Medical Student Committee

Barry Wu, MD, Chair

Despite national trends, internal medicine remains strong in Connecticut. This year 33 of 109 graduating students from Yale Univ. and 20 of 76 from the Univ. of Connecticut are entering internal medicine residencies. This is the 4th year we awarded the Connecticut ACP Internal Medicine Award to a graduating senior entering an internal medicine residency in Connecticut. The recipient is chosen based on academic achievement and community service. This year's winners are Joyce Oen-Hsiao from Yale Univ. and Rebecca Andrews from the Univ. of Connecticut. Joyce will join the Categorical Program at the Hospital of Saint Raphael and Rebecca the Categorical Program at the Univ. of Connecticut.

The Fourth Annual Medical School Jeopardy Tournament will be held in September at the Hospital of Saint Raphael. Last year, six medical schools from the Northeast region participated. Previous winners include: 1999 New Jersey Medical School, 2000 New York Medical School, and 2001 SUNY Downstate. We look forward to continued support of this activity, promoting student participation and exposure to the ACP. I am thankful for the support and dedicated efforts of Dean Nancy Angoff (Yale), Dr. Ellen Nestler (Univ. of Connecticut), and Rina Reyes (Yale third year medical student). If you are interested in serving on this committee, please contact me at (bwu@srhs.org).

What Has the ACP Done For You Lately?

The ACP continues to work diligently on behalf of internists regarding important legislative and reimbursement issues. Out of necessity, ACP's Department of Government Affairs & Public Policy has set an ambitious agenda to advocate for internists by convincing legislators to halt Medicare fee cuts, expand and protect access to care, prepare for terrorism, pass a patients' bill of rights, ease Medicare red tape, and give Medicare beneficiaries prescription drug coverage. So if these are the goals, what's actually been accomplished? Here's a list of Congressional victories:

• Regulatory Relief is closer to reality with bills introduced in the House and Senate to provide a fairer Medicare appeals process, clearer and consistent policies, and a single source for all regulations.

• Patients' rights legislation moved closer to law after legislation was passed in the House and Senate with compromises on key issues including the patients' right to outside review. The bill has moved to a conference committee to reach a compromise on medical liability.

• Recently introduced legislation to allow physicians to engage in joint negotiations with health plans is the result of the College and other medical associations' efforts to level the playing field between physicians and managed care companies. The Health Care Antitrust Improvement Act of 2002 would allow courts to consider not only the issue of competition when evaluating group negotiating efforts, but also the effect of the joint negotiations on patient access to care and quality of care.

• Language in the V.A. appropriation bill allowing chiropractors to be classified as primary care physicians was removed after objections from the ACP and other medical associations. The ACP warned that chiropractors' limited diagnostic training and inability to prescribe medications meant that veterans would not receive adequate care for common ailments.

And most currently,

• Efforts to minimize Medicare's excessive cuts to the physicians' fee schedule are continuing in the House and Senate. Over 213 of Senators and Representatives currently support legislation to alleviate the current physician payment update formulas that resulted in a 5.4% cut this year and will result in Medicare payments falling nearly 30% behind the rising cost of providing medical services through 2005.

We need your help. Legislators listen to constituents. We must make our concerns heard. I urge you to address the current Medicare fee cuts with letters to Senators Dodd and Lieberman and your local Representative. ACP's website makes it very easy to compose such a letter, that you can print on your letterhead and fax to either the legislators' local district or DC office. An estimated mere 10 letters on a subject will put any issue dramatically higher on a legislator's priority list. Please visit the Key Contact Program and proceed through very easy directions.

Black Box Warning

Do you have any idea what is going on in Washington, DC? There's a lot of talk about a Medicare prescription plan and trying to make true improvements to Medicare…but there's a real possibility that nothing substantial will pass this year. Drs. Robert McLean and David Podell, FACP, Governor, Connecticut Chapter traveled to DC on May 22 to speak with Connecticut's legislators about these health issues.

Much of the Medicare related legislation is in development as of late May, but unfortunately budget constraints may lead to less-than-perfect legislation (in the eyes of many legislators) that may not proceed through both the House and Senate. So what can the physicians of Connecticut do? ... Make noise!! As we talked around the Capitol, we saw many other advocacy groups of all types: surgeons, disabled individuals, AARP, the ambulance industry, the insurance industry, all just on one random day. If physicians don't speak up, no one else will speak for us. We need you to contact your representative on several specific issues, which affect your daily practice.

1. Medicare fee cuts - Explain how fee schedule cuts this year based on a flawed reimbursement formula are affecting your ability to care for Medicare patients

2. Liability reform - Ask for support of H.R. 4200 "HEALTH Act of 2002" to safeguard patient access to care through common sense malpractice reform. Discuss the impact on you of rising malpractice insurance premiums.

3. Anti-trust legislation - Ask for support of H.R. 3897 "Health Care Anti-trust Improvements Act of 2002" to allow physicians to group together and negotiate with health plans on a level playing field.

Please write something on letterhead and fax to legislators, or put together something online through the College Legislative Action Center. Act now. Legislators are working on these issues in the coming months. All listed are fax numbers.

Senator Joseph Lieberman 202-224-9750
Rep. Nancy Johnson 202-225-4488
Senator Chris Dodd 202-224-1083
Rep. James Maloney 202-225-5746
Rep. Chris Shays 202-225-9629
Rep. John Larson 202-225-1031
Rep. Rosa DeLauro 202-225-4890
Rep. Rob Simmons 202-225-4977

Connecticut Chapter Contact Information

ACP CT Chapter
Nancy Sullivan, Executive Director
30 Dwight Drive
Middlefield, CT 06455

Phone: 860-349-8995
Fax: 860-349-3004
Email: 76032.660@compuserve.com

ACP - Keeping You Connected

Help us keep you up-to-date on the latest College news and important happenings in internal medicine! Please take a moment to provide ACP with your email address. ACP will not sell or share your e-mail address.

New Member Benefit: Online CME Transcripts

The College is pleased to announce a new member benefit: online CME transcripts. Members may view/print a transcript of CME credit earned for participation in activities sponsored by the College. The transcript provides a six year listing and includes credit earned for: Annual Session, Postgraduate Courses, Chapter/Regional Meetings Accredited by the College (Starting November 1999), MKSAP and Related MKSAP Enhancements, MKSAP Audio Companion, Clinical Problem Solving Cases, Audio and Video Products.

Members can also print documentation of their participation in sessions related to state specific CME requirements. If you have any questions, please contact ACP's Customer Service Department at (800-523-1546, ext. 2600), or (custserv@acponline.org).

CT Chapter Annual Meeting

Aqua Turf Club, Southington, CT
Friday, October 4, 2002, Agenda

Survey Results

Thanks to those who sent back the questionnaire on biological warfare (BW) in the Winter 2001-02 Newsletter. Our response rate was low—only 22 members—but the answers were nonetheless interesting and useful for future planning of education in BW. The mean percent of correct answers overall was 68%. Questions on anthrax drew the most correct responses; respondents did less well with questions on smallpox vaccine and plague prophylaxis.

The answers to the true or false questions were as follows. Inhalation anthrax—not transmissible from person to person; onset of symptoms CAN occur as late as 8 weeks after spores are inhaled; ciprofloxacin is not the only antibiotic shown to be effective against it; patients do not require respiratory isolation. Cutaneous anthrax—the classic lesion of full—blown disease is not tender and dark red in color (it is a black eschar). Plague: IS transmissible from person-to-person; requires respiratory isolation; does not typically cause enlarged, tender lymph nodes in the pneumonic form; should warrant prophylactic antibiotics in cases of close contact for 7 days; typically presents as a rapidly progressive pneumonia with hemoptysis. Smallpox: requires respiratory isolation in all cases; patients with cough are especially infectious; the rash usually develops first on the face, not the chest and back; the rash usually consists of macules/papules/vesicles/pustules together; vaccine wil1 not necessarily protect completely from developing the disease, and it is potentially still useful in a person already exposed.

More practices and/or hospitals had guidelines for caring for patients exposed to biological warfare agents. lists of internal/external contacts, and CME on biological warfare. Fewer had masks in the outpatient setting, negative pressure rooms, or a policy on requests for dealing with requests for prophylactic antibiotics. 9% of respondents had prescribed prophylactic antibiotics, and these were to patients perceived to be at high risk.

There was some variety in the responses regarding respondents' sense of preparation for treating patients with possible exposure to agents of biological warfare. More than half felt they were somewhat prepared for treating anthrax victims. Most felt somewhat prepared to treat pneumonic plague or smallpox victims. Almost half of respondents reported that their affiliated hospitals were somewhat prepared for treating victims of biological warfare in general. About half of respondents would continue to treat plague victims in an epidemic. If vaccinated, half would treat smallpox victims, and 65% would treat anthrax victims.

Finally, respondents learned the most about anthrax from medical journal articles and conferences (61%). For future learning sources, respondents preferred these plus the CDC website.

In summary, respondents were most knowledgeable about and comfortable with the idea of treating patients with anthrax, compared with smallpox and pneumonic plague. The favoured sources of learning about BW—journal articles, conferences, and the CDC website—should be taken into consideration when planning future education on BW for internists.

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