Governor's Newsletter, Summer 2001

Eugene P. Libre, MD, FACP
Governor, District of Columbia Chapter

Governor's Message

Since my Fall 2001 Governor's Newsletter, there have been several important developments, which will affect both academic and practicing internists. Some of these are:

1) The focus on medical errors, based on the Institute of Medicine (IOM) Report. This report on safety issues has raised public awareness to a very high level. The most serious medical errors; those with a high probability of causing patient harm, are attributable to flaws in systems of care, rather than to individual physicians. There are certain situations in care of patients with disease that will continue to be associated with errors in judgment, a number which will result in mistakes potentially harmful to patients.

"No two individuals react alike and behave alike under the abnormal condition known as disease. Errors in judgment must occur in the practice of an art which consists largely in balancing probabilities." -William Osler 1892.

2) The Health Insurance Portability and Accountability Act (HIPPA). 18 months ago everyone was preparing for the arrival of the Y2K bug. Although the crisis failed to materialize, preparations for Y2K cost the health care industry an estimated $8.2 billion. Several groups are predicting that compliance with HIPPA, which will definitely materialize, could consume as much as or more than that amount.

3) The implementation of compliance programs, in association with E&M coding.

4) The thorny issue of ABIM Board Recertification and its many implications. The ABIM plan has been met with strong criticism on the part of ACP-ASIM Members, as well as by the Board of Governors. Ongoing negotiations between the College and ABIM are in progress in an effort to reconcile the differences.

Five significant events that took place with regard to our Local and National Organization were:

  1. The Board of Governors' Meeting in Seattle, Washington, in September of 2000.
  2. The Annual Regional D.C. Chapter Scientific Meeting November 3 & 4, 2000 at USUHS.
  3. The ACP-ASIM Annual Meeting in Atlanta, Georgia March 29 - April 1, 2001.
  4. Leadership Day, May 8 & 9, 2001 Washington, DC-Capitol Hill.
  5. The 8th Annual D.C. Chapter Associate' Meeting May 12, 2001 at USUHS.

Board of Governors' Meeting: September 2000

Ten Resolutions, submitted by various Chapters were reviewed and discussed. Most noteworthy were the following:

Voting Privileges for Associates submitted by the Council of Associates; after a significant period of discussion, we agreed to modify the resolution, thus allowing voting privileges for Associates with at least two years of membership.

New Mexico submitted a resolution on Medicare Reimbursement for Oximetry. This was approved by the Board of Governors and forwarded to the Board of Regents.

The Georgia delegation also submitted an important resolution for Streamlining and Simplifying the Fellowship Application Process. It was agreed that the current system is cumbersome and efforts made to simplify the procedure should be implemented.

The most interesting and provocative presentation, by far, was given by Harry Kimball, MD, MACP, President of ABIM. Dr. Kimball described in detail the necessary steps for Recertification.

All internists certified in 1990 or later must go through the Recertification Process. The Process that has been set up is arduous, expensive and requires a great deal of time. The majority of those present were not happy with the plan. A decision was made to set up a select committee comprised of Members of the ACP-ASIM and Members of the ABIM to discuss these issues and to report back at the Annual Session in Atlanta.

Regional Meeting: November 3-4, 2000

Changing the date for our Regional Meeting from January to November, resulted in our having two meetings in the Year 2000. January 14-15 and November 3-4. From the feedback, which I have received, almost everyone seems pleased with the change. Washington weather in early November is usually mild with virtually no chance of snow. We were indeed fortunate to have as our Official College Representative (OCR), Sandra A. Fryhofer, MD, MACP, President of ACP-ASIM. Dr. Fryhofer was dedicated, engaging, and full of energy, whether she was giving a talk on "Menopause in the New Millennium," giving out certificates and awards to Poster Winners, or speaking to medical students about a career in Internal Medicine. She was always 100 percent committed to the task at hand.

Highlights of the Annual Meeting

Atlanta, GA, March 29 - April 1, 2001

Sandra A. Fryhofer, MD, MACP, President ACP-ASIM 2000-2001 transferring the Office of the Presidency to our current President, William J. Hall, MD, FACP. During the Annual Convocation, Dr. Fryhofer awarded Masterships to 44 Internists and presented 15 special awards. At the top of Dr. Fryhofer's list of achievements is the Decision 2000 Campaign, which the College created to increase public awareness of the health consequences of people who lack medical insurance. She spotlighted the College's efforts to address a common clinical problem; "inappropriate antibiotic use," which has led to Emerging Antibiotic Resistance. She quoted statistics that 75 percent of antibiotics prescribed each year are for respiratory tract infections, most of which are caused by viruses for which antibiotics are ineffective.

At the opening ceremony the Keynote Address was given by Daniel Federman, MD, MACP. His topic, "Women's Health," a modest (evolutionary) proposal discussed the sexual differences that are involved in clinical manifestations of diseases throughout Internal Medicine. This talk was beautifully presented and once again, showed why Dr. Daniel Federman is recognized as a master teacher.

Clifton R. Cleaveland, MD, MACP received the Nicholas Davies Memorial Scholar Award. During his lecture he spoke of physician heroes. Dr. Cleveland profiled five physicians in his speech who influenced his commitment to the practice of medicine. These inspirational physicians were:

  • Corydon M. Wassel, MD, a Navy doctor. He defied orders to abandon his bedridden patients when Japanese forces overran the island of Java in 1942. He later received the Navy Cross and was praised in a "fireside chat" by Franklin D. Roosevelt and was later memorialized in the film, "The Story of Dr. Wassel," starring Gary Cooper.
  • William Holmes Dyer, MD, a physician who in 1918 went to France with the all black 92nd Infantry Division, where he endured demeaning treatment and racism, while treating the sick and injured of war.
  • Woodrow Bryan Dotson, DO, who practiced more than 50 years in tiny Canton, Missouri-a Mississippi town with no pharmacy and no hospital. When summoned to provide care, Woodrow Dotson would respond, no matter the time of day, weather or risk.
  • Lisa Weber, MD, who worked her way up from a nurses aide to a physician in Chattanooga, Tennessee. Her patient with Marfan's syndrome needed a heart transplant. The insurance plan was reluctant to cover his surgery and only after Dr. Weber's persistence was it covered. On her patient's behalf, Dr. Weber challenged the complex, sluggish and unfeeling bureaucracy and obtained vital care for him.
  • Janusz Korczak, MD, who founded a Jewish orphanage in Warsaw Poland that became a model across Europe. Trapped in the Warsaw Ghetto after the German invasion in 1939 he remained with the children until the Nazis ordered the removal of all Jewish children from the ghetto. On the appointed date, Dr. Korczak calmly marched along with his small charges to the train station and all were gassed the next day at Treblinka. Dr. Korczak had repeatedly refused all offers for his personal escape.

Two days later Dr. Cleaveland conducted a three hour seminar on "Insights into Literature: Images of the Physician." The seminar examined those forces that influenced the image of the physician, both in the eyes of the lay public and in the eyes of the medical profession. Also discussed was how this image may at times conflict with professional codes of ethics.

As a prerequisite for attending the seminar, he assigned a book to be read: The Cunning Man, by Robertson Davies. This fascinating novel explores physicians' rapprochement with patients and the various images constructed in the mind of both the patient and doctor with regard to these dealings. The book challenges our conceptions of social constructions of the physicians' views of medical practice, medical education, training and the role of humanism in medical science. The Cunning Man brims over with references to works of literature, drama, art and music. Taken as a whole, Davies' allusions make an impressive syllabus for an education in the Humanities. I strongly recommend this book for your enjoyment. It is available in a paperback edition published by Penguin Books; ISBN0140248307.

Board of Governors Meeting - March 2001

Resolutions-
At the BOG Annual Meeting thirty six resolutions were reviewed. Our Chapter submitted two resolutions:

1) Academic Health Centers, in particular regarding the problem of financial distress.

RESOLVED, that the Board of Regents support working with the American Association of Medical Colleges to quantify the degree of financial distress in Departments of Internal Medicine and its subspecialties in academic health centers and be it further

RESOLVED that the results of this data be used in ACP- ASIM presentations to State and local governing bodies and be it further

RESOLVED that the Board of Regents use its resources to bring this situation to the public's attention.

2) Quality of Health Care Delivery.

RESOLVED that the Board of Regents continue to support Federal legislation to study, in a scientific manner, verify and quantify the impact that pressures such as decreases in third party payments for physicians' services, managed care regulations and increased administrative and documentation demands are having on the quality of health care; and be it further

RESOLVED that the ACP-ASIM make the press and public aware of these findings.

The first resolution was adopted without amendments, the second was adopted with a few amendments. The fact that both these resolutions were adopted is a tribute to the skill and hard work of the Committee, which was spearheaded by N. Thomas Connally, MD, FACP. We are all very appreciative of his efforts.

Chapter Excellence Award-
At the Awards luncheon in Atlanta, the District of Columbia Chapter received the Chapter Excellence Award for the Year 2000. This award raises the level of achievement above the Chapter Management Award and is based on activities that took place in our Chapter during the 1999-2000 fiscal year.

Recertification Revisited: Wednesday, March 28 2001 in Atlanta-
The presentation by the joint Committee on Recertification, ABIM/ACP-ASIM was made to the BOG. Although there was evidence of some progress, most of the plans for Recertification that are being considered are still not acceptable to the BOG. With considerable testimony by numerous Members it was indicated that we do not believe Continuous Professional Development (CPD), as it is presently constituted and structured by the ABIM, is appropriate. Additionally, a proctored (secured) examination is not acceptable.

I have written a letter to Dr. Bernard Rosoff, MD, FACP, Chairman of the ACP-ASIM Committee about the problem and he indicated to me that he has once again articulated to Harry Kimball, MD, MACP that the current CPD process is unacceptable to our Membership. Dr. Rosoff also stated that while it is clear that the College does support Recertification, he also believes that specialists in Internal Medicine should be free to choose the methods that they would take to prepare for an evaluation of medical knowledge. This topic will most certainly continue to be discussed and hopefully resolved in a satisfactory manner for all parties concerned.

Advancement to Fellowship-
Eight physicians were elected to Fellowship:

Ronald S. Colson, MD, FACP
Richard T. Kenney, MD, FACP
Thomas Y. Ko, MD, FACP
Shelly McDonald-Pinkett, MD, FACP
Mahnaz Rahbar, MD, FACP
Nicholas J. Sarlis, MD, FACP
William W. Tullner, MD, FACP
Carlos M. Vasquez, MD, FACP

During the Convocation Ceremony, two new Fellows marched with me: Nicholas J. Sarlis, MB, MD from the NIH, Endocrinology Branch and Douglas J. Ward, MD in private practice, Internal Medicine and Infectious Disease.

Leadership Day - May 8 and 9, 2001

On May 8th and 9th 2001, 115 Members of the ACP-ASIM from many of the 50 States met at the J.W. Marriott Hotel for strategy planning sessions, which helped us to effectively meet with our Congressional Representatives. David B. Kessler, MD, FACP; John S. Saia, MD, FACP; Lawrence E. Klein, MD, FACP; Donald Casey, MD, FACP; Jerry Meyer, MD, FACP; and myself represented our Chapter.

Several presentations were made by members of the College Leadership, including William J. Hall, FACP, President; Lynn Ann Kirk, FACP, Chair of the BOG; and Robert Doherty, head of the Washington ACP-ASIM office, who spoke on the Washington landscape and the current political environment as they relate to ACP-ASIM issues.

A panel discussion was held on MERFA (Medicare Education and Regulatory Relief Act). S.452-H.R.868. This bill, being introduced both in the Senate and in the House would, if passed, go a long way in reducing Medicare hassles.

  • Medicare Rules, Policies and Answers to "frequently asked questions," would be made more accessible and physicians would be given advanced notice of changes in rules.
  • Medicare would be required to pay its claims without demanding more paperwork, unless there is evidence that the bill is incorrect.
  • Medicare would be required to actually examine the records, rather than using statistical samples (interpolation) to determine whether some claims were billed incorrectly.
  • Medicare's ability to investigate fraudulent claims would be preserved, as well as its role in educating providers on preventing inadvertent billing mistakes that result in over payments.

After dinner, Stuart Rothenberg author and publisher of the Rothenberg Political Report addressed our group. Mr. Rothenberg writes a bi-weekly column in the Capitol Hill's Roll Call and has been an analyst for CNN since 1996. He gave an excellent overview of the various factors, which play a role in the passage or defeat of legislation during the session.

The following morning, after breakfast, our group was briefed by Senator Bill Frist, MD, (R-TN) who is the only physician in the Senate and the first practicing physician elected to the Senate since 1928. He commented on MERFA, Patient Safety, and explained why he believes a Prescription Drug Act would be difficult if not impossible to achieve. He was followed by Shelly Berkley, (D-NV) who is married to one of our Members, Larry Lehrner, MD, a former Governor of ACP-ASIM Nevada. Her remarks covered a variety of issues and were followed by numerous questions. When asked privately about what she thought of a PAC for our organization, she stated she didn't see how we could function effectively without one. Although debated for a number of years the PAC issue has not been resolved.

At 9:30 a.m., we left for appointments with our individual Members of Congress. Harold Standiford, MD, FACP, a former Governor of the Maryland Chapter, joined our delegation. We visited the offices of current Congresswoman Constance Morella, Congressman Ben Cardin and Senators Barbara Mikulski and Paul Sarbanes. We did get a chance to speak briefly with Representatives Morella and Cardin and at length with their Legislative Aides. We only met with the Senators' Legislative Assistants. In all cases, however, we were able to make our positions known regarding the issues that had been reviewed the previous day, namely MERFA, Patients' Bill of Rights, Patient Protection, and Patient Safety. This was one of the most effective groups that has represented our area Chapter in some time. I look forward to an even stronger showing next year. Several individuals have already indicated their willingness to participate.

Associates' Meeting

May 12, 2001

The 8th Annual Associates' Meeting was held at USUHS. There were approximately 140 attendees. In addition to 8 Podium Presentations there were 75 Posters judged. All of the Podium Presenters received a monetary prize. Ten of the 75 Poster Presenters were also given a prize. Uzma Iqbal, MD, of the Washington Hospital Center, was honored as the recipient of the Linda Green, MD Award. This award is intended to acknowledge exceptional contributions to scholarly endeavor among House Staff in the Washington Area. Dr. Green, a renowned physician and well known for her tireless activities in many aspects of the delivery of health care, presented the award to Dr. Iqbal.

This year's Keynote Speaker was Eric Goosby, MD who spoke on Domestic and International Aids policy. Dr. Goosby gave an excellent talk. He pointed out that although the USA has experienced what appears to be somewhat of a respite, this is certainly not the case for "developing" countries, especially Africa.

The Jeopardy Competition was again moderated by Ray Mitchell, MD, FACP in his skillful and entertaining style. Dr. Leonard Sandler, Chief Resident at the Washington Hospital Center, provided the technical expertise for the projection of questions and answers. The winning team for the second consecutive year was Walter Reed. Last year's team from Walter Reed represented the Washington area at the National Meeting in Atlanta and won Second Place in the Competition. The overall winner was the Pennsylvania Chapter.

The Associates' Meeting continues to be very popular and we hope this will result in a number of Associates joining our ranks. Should you know of any individuals who would make suitable candidates, please ask them to submit an application which can be obtained by contacting our Philadelphia Headquarters or David G. Borenstein, MD, FACP our local Chairman of Membership and Credentials. Dr. Borenstein's phone number is: 202-293-1470 and his fax # is 202-293-9416.

In Appreciation-

Michael S. Gold, MD, FACP and his committee for again putting together an excellent program. The upcoming November meeting again appears to be first rate.

Catherine P. Lucey, MD, FACP, Program Director at the Washington Hospital Center, who served as Faculty advisor to the Washington Metropolitan Associates' Council and was responsible for arranging this very successful meeting.

Martin W. Graf, MD, FACP and Angie Lazarus, MD, FACP, Governor, Navy Chapter, who helped in the judging of posters at the National Meeting.

Robert S. Wilkinson, Jr., MD, FACP for his continuing efforts in working with the Membership Committee and now serving as Chair of the Awards Committee.

Werner F. Barth, MD, FACP for his continued support of our Chapter in so many ways.

James A. Ronan, MD, FACP and Richard B. Perry, MD, MACP (Chair of the Retired Physicians' Committee) for all their effors in providing physician leadership and support to the Mercy Volunteer Health Clinic for the uninsured in Montgomery County.

Awards

Laureate Award
During the upcoming November 2001 meeting, two individuals from our Chapter will be recognized with the highest honor our Chapter can confer: The Laureate Award.

Lawrence E. Klein, MD, FACP, a former Officer in ASIM, currently in private practice of Internal Medicine in Washington D.C. Dr. Klein has also been named Representative from ACP-ASIM to the HCFA Carrier Advisory Committee for the DC Metropolitan Area.

Stephen Ray Mitchell, MD, FACP, Division of Rheumatology, Georgetown University Hospital, Associate Dea,. Medical School and Student Affairs.

Community Based Teaching Award

Paul Schlein, MD, FACP has had a long-term interest in teaching medical students, although recently retired he continues to do this on a regular basis.

Karen Myers, MD, FACP has also participated very diligently in teaching and fostering education in medical students.

Nicholas Davies' Memorial Award

Robert J. T. Joy, M.D., FACP will receive this very prestigious, National award at the Annual Meeting in Philadelphia, 2002.

He will participate in our meeting and will also deliver a lecture on Post Traumatic Stress Syndrome. We are delighted that Dr. Joy is being recognized for all his achievements both in medical education and the history of medicine

A Note From the Vice-President

Jerry F. Meyer, MD, FACP

The ACP-ASIM is an unusual Organization, in that its leadership has always tended to be politically liberal whereas its constituency; mostly practicing physicians, tend to be more conservative. Consequently, lobbying Congress for the organization can be a bit of a schizophrenic experience. It is, therefore, very important that your local leadership provide grassroots input into this process.

ACP-ASIM Leadership Day was held on May 8 and 9. The first day included discussions of "priority issues" to being to our Congress people on the Hill the next day. There are many bills for which ACP-ASIM takes a position, but my concern is that this may dilute out the important messages that; physicians have lost control of medical treatment and are paid inadequately by Medicare for taking time with their elderly patients.

We, of course, supported the Patients' Bill of Rights, a bill increasing access to care, prescription drug benefits and patient safety funding. I had some reservations, however, about these issues. It is my belief that the only true bill of rights for patients would be the right to buy the insurance of their choice, tax free. This would be similar to what Federal Employees have. An archaic law, passed at the end of World War II, allows employers to deduct insurance premiums from their tax liability, but not individuals. Congress seems unwilling to correct this inequity. There is also a problem with supporting prescription drug benefits because its cost would almost assuredly be taken out of Medicare funds, which are already underfunded. The difficulty with supporting "patient safety" funding is the report by the Institute of Medicine citing 200,000 deaths a year caused by medical errors, a severe overstatement resulting in the fear of the medical system and a potential for increased lawsuits. Being considered is a law requiring hospitals to report to the patient and family, any errors made. However, of particular importance is the Medical Education and Regulatory Fairness Act (MERFA), which holds HCFA responsible for clarifying policies, requires payment without more paperwork, disallows statistical sampling to extrapolate billing errors and disallows withholding of payment without due process. Unfortunately, predictably, this bill is opposed by "our friend" the Office of Inspector General. I informed the Congressional representatives of my meeting with HCFA representatives who stated that HCFA itself disagrees with the Office of Inspector General on the prevalence of fraud and abuse.

Prior to our lobbying effort, we met with Senator William Frist (cardiac surgeon and family owner of an HMO), and Shelley Berkley, Congresswoman from Nevada and wife of an ACP-ASIM Member. Senator Frist was concerned about allowing HMOs to be sued. I pointed out to him that we were against lawsuits, if they could be equally limited against physicians. Senator Frist said, "They would consider it." I doubt that they will. I later discussed this idea with Congressman Tom Davis, whose wife is a physician. Representative Davis agreed wholeheartedly, but thought implementation on a national level would be difficult since such lawsuits are governed by State law(s). Dr. Eugene Libre, our DC Chapter Governor asked Representative Berkley if she thought an ACP-ASIM PAC would be advisable. She indicated, "You are not even in the game without a PAC." This will have to be revisited at the Board of Governors meetings.

Overall, the experience was positive and we found the Congressional staff to be knowledgeable and receptive. I would encourage you to get your congressional representatives to support MERFA. Without it, Medicare patients will find it more difficult for their physicians to treat them. In the meantime, we will continue to lobby our own Organization to concentrate on issues important to the practicing physician.

Mark Your Calendars

November 9-10, 2001
District of Columbia Chapter
Annual Scientific Meeting
Uniformed Services of the
Health Sciences
Bethesda

April 11-14, 2002
ACP-ASIM Annual Session
Philadelphia, Pennsylvania