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The Florida Internist

Summer 2002

2002 Scientific Session Highlights

In addition to a state-of-the-art scientific program chaired by Dr. Mark A. Gelbard and utilizing the faculty of the University of Miami, the scientific program will provide 13.5 Category 1 CME hours at no cost to those who have paid chapter dues. The Regional Meeting also allows the Chapter the opportunity to recognize some of "our own". At Saturday evening's awards dinner, Dr. Yank D. Coble, Jr., MACP, President of the AMA, will receive a Laureate award and Dr. Kenneth R. Ratzan, immediate past ACP-ASIM Governor for Florida will receive the other. The Laureate Award honors those Fellows & Masters of the College who have demonstrated by their example and conduct an abiding commitment to excellence in medical care, education, or research, and in service to their community and the ACP-ASIM. Dr. H. Frank Farmer, President of the FMA Medical Association, will accept the Charles K. Donegan Memorial Award for community service.

Dr. Yank Coble
Yank D. Coble, Jr., MD,
MACP		 Dr. Kenneth Ratzan
Kenneth R. Ratzan, MD,
FACP
   
Dr. Frank Farmer
H. Frank Farmer, MD		  

 

Mandatory CME Courses Offered at the Regional Meeting

  • Patient Safety
  • Update in HIV
  • Risk Management

H. Frank Farmer, MD, President of the FMA is the featured speaker at the Friday lunch and Cecil B. Wilson, MD, FACP, Chair of the ACP-ASIM Board of Regents and AMA Trustee, will address the Saturday luncheon participants.

Be sure to join us for an outstanding meeting. If you have misplaced the brochure, information can be downloaded from the chapter website (see above) or call Alice at 800-542-8461 Ext 1. Registrations can be faxed to 863-983-6556.

Florida Internists in AMA Leadership Positions

Yank D. Coble, Jr., MD, MACP was inducted as President of the American Medical Association June 19th, 2002 in Chicago.

Cecil B. Wilson, MD, FACP, Chair of the Board of Regents, was elected to serve a four-year term on the AMA Board of Trustees.

James L. Borland, Jr., MD, MACP, was elected Chair of the AMA Council on Medical Education.

Roy D. Altman, MD, FACP won re-election to the AMA Council on Scientific Affairs.

Upcoming Election for Governor

Drs. Daniel M. Lichtstein and Kay M. Mitchell will face each other in an election for Governor. Our members will have a difficult time deciding between these two prominent physicians who have distinguished careers in both private practice and academia. The College will be sending your ballots out in the fall. For the first time, Associates for two years will participate in the election process.

The Veterans Health Administration … The Rodney Dangerfield of American Medicine?

Craig S. Kitchens, MD, FACP, Governor, Florida Chapter

What I tried to communicate to my residents over the last 20 years, the movie Saving Private Ryan did in the first 20 minutes. I have spent the vast majority of my professional life at the Gainesville Veterans Affairs Medical Center (VAMC) directly connected with Shands Hospital at the University of Florida. I started as a Clinical Investigator for six years, and then returned to clinical medicine, serving the unusual concurrent combination of hematologist with a sub-sub-specialty and interest in coagulation and thrombosis, and also as a primary care internist as Program Director for a 60-70 resident training program and Chief of the Medical Service at VAMC.

I have been constantly queried about my vocational choices. First, my parents asked when or if I would ever "get out of medical school" (they perceived I was still a medical student in his 38th year, i.e., MS38.) Second, various institutions across the country from time to time have invited me to interview for various positions. For some of these offers I interviewed while others I didn't, but I subsequently rejected all of these opportunities, either initially or after a first visit; for some reason for which I have had difficulty in articulating, I was most happy at the VAMC. Finally, my internal medicine residents and hematology/oncology fellows, while devising their future professional plans, would seek my counsel on why I remained at the VAMC.

My father's life was interrupted by World War II. He never got to finish college. He participated in Third Army (Patton) activities in North Africa, moving up through Italy, and finally into Germany. He witnessed the freeing of German concentration camps first-hand. I soon learned that it was a family taboo to mention these. I recall as a six-year old, one day in 1950, finding a scrapbook filled with clippings and photos of the just-liberated camps and inquired about the meaning of such grotesque horror. He didn't say a thing - it was the only time I saw fear, hate, and tears expressed simultaneously by my father. After the war he returned to civilian life, while his three brothers opted to stay in military service, completing highly successful careers. My mother's two brothers suffered horribly as consequences of being captured by Japanese while they tried valiantly to defend Corregidor. The "March to Hell" for them proved why it was so named.

From time to time I would try to convey such feelings to my trainees. While most were not aware of the military history of their veteran-patients, some had been imprinted, mostly negatively, by the smaller number of patients who never saw combat or overseas service, while some patients succumbed to self-abuse with alcohol and cigarettes. Others had been euphemistically labeled "service-connected" for a variety of ailments, some of which taxed the credulity of the notion of service-connection.

On the other hand, on rounds sometimes I would steer the bedside interview and examination to the patient's military service. Being a novice student of US military history, I was frequently rewarded by the nearly instantaneous bond that could be secured with an often heretofore-reticent patient by simply knowing or asking about several campaigns that they may have been in. Some of these included various European conflicts, island-hopping in the Pacific (one could always get a lively debate going regarding whether the Army under MacArthur or the Navy under Nimitz did the better job), or nearly getting pushed literally into the sea at Pusan in Korea, only to be rescued by this nation's greatest military coup, MacArthur's invasion at Inchon. Tales from POWs always brought the stark reality and suffering accrued from service to one's country to even the most jaded resident. Some residents would question the relevancy of all this to their patient's medical problems. All this is relevant; it's the reason for the VA!

The VA was the initial and remains the largest "HMO" in this country. We have long managed under restricted resources, personnel, and now especially, pharmaceutical budgeting. We have been making difficult but fair decisions for decades in such an environment. Studies comparing care of patients in the VA to the private sector has shown that the average VA patient is older, sicker, and more likely to be homeless and/or psychiatrically ill compared to the nation's non-VA patients. Still, we get along offering quality medical, surgical and psychiatric services, again leading in primary care and preventive measures. VA has spearheaded clinical research with the groundbreaking work on hypertension, being the first to prove the efficacy of treatment of hypertension to decrease sequelae of untreated hypertension. VA researchers were among the pioneers in the development of the CT scan and MRI as well as cardiac pacemakers and renal dialysis. VA group studies on TB remain the best in that field. Most recently, VA researchers have identified the first gene implicated in schizophrenia, a discovery that may well change the entire thrust of psychiatric research and care. VA grew a nascent notion of geriatrics into a highly-respected and useful clinical specialty. The VA has broken ground in medicolegal matters with early up-front disclosure for untoward events involving patients, giving esteem to the idea of clinical honesty while decreasing punitive aspects of tort claims. VA's Surgical Services have developed the National Surgical Quality Improvement Program (NSQIP), which has been so successful that it will soon be expanded into a program for surgery nationwide. Recently, VA outperformed the private sector in 16 of 18 indicators for quality of healthcare delivery by meeting or exceeding goals for the use of beta-blockers following myocardial infarction, hypercholesterolemia treatment following myocardial infarction, hemoglobin A1C levels for outpatient diabetes mellitus, JNC6 goals for outpatient treated hypertension, and goals for pneumococcal immunization. The VA was only 2% below the best competitor's results for influenza immunization and annual eye examination for diabetics.

The VA system is huge and we at VA facilities in Florida bear the consequences of the nation's veteran pool retiring and moving to the South. For the past several years, the Gainesville VA's budget growth has averaged 5% per year, while our patient population has grown 10-20% per year. The largest VA system in the entire nation is centered in Tampa, and is closely followed by the system grounded in Gainesville.

So why do I lament the "we get no respect" attitude? Clearly, VA is caring for a very ill, very deserving population and doing it at least as well as other methods and arguably with less resources. Still, too often, patients are dumped into our system unprofessionally. Rarely do we get a referral call, even from the same physician who the next day will respectfully call me for a consult or referral in my limited non-VA consultative practice at the university. Biopsies, records, and CT scans and MRIs far too infrequently accompany the patient when one is transferred hospital-to-hospital. I invite you, in your next referral to a VA facility, to use the same professionalism as would any physician in discussing the care and management of a mutual patient. After all, the veteran has earned this respect.

The Soldier
By Charles M. Province, a veteran patient

It is the soldier, not the reporter, who has given us freedom of the press.

It is the soldier, not the poet, who has given us freedom of speech.

It is the soldier, not the campus organizer, who has given us the freedom to demonstrate.

It is the soldier, not the lawyer, who has given us the right to a fair trial.

It is the soldier, who salutes the flag, who serves under the flag, and whose coffin is draped by the flag, who allows the protester to burn the flag.

2002 Legislative Session

N. H. Tucker, III, MD, FACP, Chair, Legislative Committee

The Florida Legislature was pre-occupied with re-apportionment and therefore the 2002 legislative session was more difficult than most. We were unable to pass our prompt pay bill during the regular session, but fortunately, Governor Jeb Bush included it during the special session where it was acted upon favorably.

The new prompt pay law expands the previous prompt pay language to include not only HMOs but also PPOs and indemnity insurance plans. The concept of "clean claim" is eliminated and insurers have a specific time frame (from receipt of the claim) to either pay or deny it. Also, the loophole allowing HMOs to avoid payment by contracting with third parties is closed and the overdue claim interest rate rises from 10 to 12%.

Several allied health scope of practice expansion attempts were defeated. If they had passed, they would have: allowed ARNPs to prescribe controlled substances; allowed acupuncturists to use the term physician; allowed chiropractors to be "school physicians"; and allowed pharmacists to be paid for convincing Medicaid patients that the drug prescribed by their physician needed to be switched to a cheaper one.

The overwhelming problem in Florida and the nation is the constant escalation of medical liability insurance premiums. Liability insurance is becoming increasingly unaffordable and at times unavailable at any price. As a result physicians are curtailing their practices and in some instances retiring early or leaving the state. In addition, young physicians think twice before entering a practice in Florida and an untold number of talented potential medical school applicants almost certainly are opting out of a medical career and pursuing other avenues.

There is only one known solution to this crisis--- a $250,000 cap on non-economic damages. The Florida Supreme Court previously ruled that such a cap was unconstitutional and therefore a constitutional amendment will be required. See the CITIZENS FOR TORT REFORM article under the MEDICAL LIABILITY INSURANCE CRISIS in this newsletter.

Our legislative tort reform package will not solve the problem but will be part of the solution. We were unable to pass the tort package this year but, although it faces an uphill battle, it will be at the top of our agenda in 2003. It includes requiring that an expert witness be actively practicing in the same specialty as the defendant physician and hold either a Florida license or for out-of-staters, a Florida Expert Witness Certificate. This Witness Certificate will help to ensure truthful testimony by placing the witness under the purview of the Florida Board of Medicine. The package also includes: equal access for plaintiff and defendant attorneys to all subsequent treating physicians; allowing the jury to receive evidence of all collateral source payments; allowing for periodic as opposed to lump sum payment of awards; and creating a medical review panel whose opinion would be admissible at trial. We would also like to see a sliding scale for attorney contingency fees as well as monetary penalties for attorneys that file frivolous lawsuits.

I want to thank those physicians that took time out of their busy medical practices to visit our legislators in Tallahassee this past session. They are: Elias Amador, Fred Carter, Manning Hanline, Saeed Khan, Cornel Lupu, Ken Ratzan, Fred Turton, and Michael Zimmer. I also want to thank those physicians that made contacts through our key contact program. They are: Fred Carter, Gene Davidson, Cornel Lupu, Clay Molstad, Margaret Rank, Ken Ratzan, Fred Turton, Norm Vickers, Cecil Wilson, and Michael Zimmer. Thank you all. Your efforts are deeply appreciated. And of course, thanks to our lobbyist Gene Mcgee as well as Dawn Moerings and Chris Nuland for their excellent efforts on our behalf. If you have legislative issues you would like for us to address or if you would like to participate in our legislative program, please contact Dawn at 800-542-8461 Ext 2.

Medical Liability Insurance Crisis

There is no tooth fairy; there is no white knight; there is no easy way. If we are to solve this crisis, it will take a lot of hard work and a lot of money. The only known solution is a $250,000 cap on non-economic damages. The Florida Supreme Court would declare any legislation to this effect unconstitutional, and therefore a constitutional amendment is needed.

We would not be successful if we did not have the funds to rebut the negative media advertising from the trial bar. It would require $15- 20 million to successfully wage a constitutional initiative and although others might potentially help, we cannot count on anyone but ourselves to raise these funds. It is recommended that each physician donate at least $500 to the escrow account of the CITIZENS FOR TORT REFORM and send your check to: 6675 WEEPING WILLOW WAY, TALLAHASSEE, FLORIDA, 32311. If $15 million cannot be raised, this money will be returned.

Even if the public becomes outraged because of an access crisis, there is little they can do to solve this problem long term other than help with this constitutional amendment.

Remember a wise man once said: " If not you, who? If not now, when?" - N. H. Tucker, III, MD, FACP, Chair, Legislative Committee

Business Plans for Physicians

Corey L. Howard, MD, FACP

There are many factors influencing the practice of medicine. Decreasing reimbursements, rising overhead, skyrocketing malpractice costs and increasing governmental regulations certainly top the list. We are on the cusp of a major health care crisis if we do not change the way we do and think about things. We need to let the past be just that, the past, and forge new ground rules blazing a trail for the physicians of the future. We are their forefathers. There is no way that Hippocrates could have predicted the tremendous changes in the technology or politics of medical life. We will use the basic foundation of information given to us by our past leaders and use that information as the backbone for the new world of medicine.

We all need to develop a new business plan for our practices that includes all of the current issues affecting our practices so that we can account for changes as they occur. A basic outline for my series is included below. If you wish you can use "Hurdle, the book on business planning" by Tim Berry or Business Plans by - as a guide during my columns. If you have questions you can email me at choward@xptt.com and I will answer them in a timely fashion.

Company Description - Let's start with the description of your company. Summarize who you are and what you, as a business, have to offer. Do you have a special area of interest? Can you perform specialized procedures? Does your practice style lend itself to improved patient care? These are just some of the questions you should ask yourself. Write the answers down, review them and define who you are. What else may give your practice a competitive edge? Is it your caring persona or your technical savvy? Are there awards and specialized training that can set you apart from your peers? Listen to what others, including your patients, say about you (if you have been in practice) and utilize those remarks when creating this section.

Mission Statement - Before we talk about the all-important financials we need to further define who we are and what we do. Of course, we are all physicians with certain skills specific to our specialties but if there were not differences then no one would be advertising. The Mission Statement should define your business concept. The focus should be on the care you deliver to your target market. Target market? Oh yes, target market. You need to define who you want to treat. Are you an OB/GYN who wants to drop OB for whatever reason or a surgeon who concentrates on a specific area? Your target market will be quite different and your mission statement might reflect that.

The easiest way to start the mission statement is to make an outline of the related topics and cut it down to its most essential and poignant points. These are some outline topics to use: 1) Define your product and service {in relation to your special talents}, 2) What makes you stand out from the rest of the pack. I suggest you write everything down here, no matter how silly it may sound, and clean it up later. 3) Define your ability to communicate with your patients. Be specific. Make sure listening is high up on your list. This sends the message to all who read the statement, including your staff, how you intend on interacting with your patients. 4) Define your management style and your relationship with your staff. Happy employees can make your office. Set the tone of the environment so that your patients can "hear" your employees smile when they answer the phones. 5) Define how you intend on incorporating technology into your office and how it will benefit your patients and staff. Technology can benefit you in many ways including improving efficiency. Unfortunately, technology can be costly. It is a tradeoff you have to decide. 6) Community involvement. Patients want to know if your practice is self centered (i.e.: looking only for profit) or well rounded. 7) Finally, you should note what your goals for the practice are. Both short and long term goals are important.

Here is an example how this information can help you define a mission statement.

"The goal of our practice is to provide quality specialty care to our patients in a safe and compassionate environment that will foster a long-term relationship. We will treat our patients as individuals and not as a number. Our dedication to our patients will be amplified by the caring workplace we provide for each individual employee. We will reach out to the community and donate our personal time and energy to help those who are less fortunate…"

You get the idea. This is just a template. Make the statement your own. If you take the time to fill in the topics noted above you will be on your way to an outstanding mission statement. Next time we will talk about market analysis. Good luck and see you then.!