Governor's Newsletter, Summer 2002
Joseph W. Stubbs, MD, FACP
Governor, Georgia Chapter
From the Governor's Corner
One of the most frightening situations we can encounter is that of being lost. Reflect for a moment on the confusion, fear, and sense of aloneness a young child experiences when he loses the familiar hand of the parent and becomes lost in a large crowd, losing all sense of location and direction. With the rapidly changing environment of medicine, I think we, as physicians, have experienced a collective angst that grows out of a sense of being lost. Economic, political, and social forces have pummeled us so fiercely that we have lost our anchor and feel adrift in a large and stormy ocean. This identity crisis led to the idea of a charter, which defines us as a profession and defines what our relationship or contract is with society.
The writing of the Charter on Medical Professionalism was sponsored by an international group of medical organizations including the ACP-ASIM Foundation, the European Federation of Internal Medicine, and the American Board of Internal Medicine Foundation. It appeared simultaneously in the February 2002 issue of the Annals of Internal Medicine and the February 9, 2002 issue of The Lancet to symbolize its universal applicability and relevance. The charter is a distillation of the essence of the principles and responsibilities that defines professionalism for all physicians. It outlines three fundamental principles and a set of ten professional responsibilities that should be applicable to all physicians of all ages and nationalities. The fundamental principles include the principle of primacy of patient welfare, the principle of patient autonomy, and the principle of social justice. The responsibilities include a commitment to professional competence, commitment to honesty with patients, commitment to patient's confidentiality, commitment to maintaining appropriate relations with patients, commitment to improving quality of care, commitment to improving access to care, commitment to a just distribution of finite resources, commitment to scientific knowledge, commitment to maintaining trust of managing conflicts of interest, and commitment to professional responsibilities. While the charter explicitly discusses the principles and responsibilities of the physician, it also inherently addresses the role of society in which the professional's practice. For professionalism to exist, not only is it important for physicians to actively demonstrate the explicitly stated principles and responsibilities, but it is also important for society to provide respect and adequate economic resources to fulfill those roles. As individuals, our cry for societal reciprocity often goes unheard.
Realistically, for our voice to be heard, we need to continue providing strong participation and support in our professional societies, which can provide a louder and more effective collective voice. At the moment, the Medical Professionalism Charter is little more than a series of letters and characters printed on a page. Like other great charters such as the Magna Carta and the Declaration of Independence, the value and importance of this charter is derived solely from the faith and actions of those of us affected. If we relegate this document as just another one of those irrelevant guidelines that we store in a pile in the corner to collect dust, then it will become little more than flotsam floating aimless in this huge and complex storm created by the medical climate of today. On the other hand, if we seek to make this charter an essential core component of our medical curriculum, if we as mentors of medical students and house staff become active beacons of this charter "both on and off the field," and if we try to incorporate this charter into our medical practice, every day and with every patient, then this charter can truly be a strong and powerful foundation upon which lasting improvements can occur in the delivery of health care.
The path has been cleared. Is it time for the journey to begin?
Halting Cuts In Medicare Fee Schedules
By now, most of you are keenly aware of the 5.4% cut in the Medicare fee schedule for all services of physicians and other health providers that went into effect January 1, 2002. This cut has resulted in many physicians across the country closing their practices to any new Medicare patients. With our rising overhead costs, many internists and other primary care providers are finding that they are actually losing money in seeing Medicare patients. The Center for Medicare and Medicaid Services (CMS) has argued that we will counter this reduction in fee schedule by increasing our volume. With the increasing complexity of diseases that Medicare patients face, they are, if anything, requiring more of the internists' time than ever before making it impossible for physicians to increase the volume.
The 5.4% cut in the Medicare fee schedule was a result of a flawed statutory formula currently in effect which links fee schedule updates to the performance of the overall economy (the gross domestic product). CMS is projecting further cuts of even greater magnitude. Unless Congress intervenes, Medicare payments will decline by 5.4% in 2003, and by as much as 20% cumulatively from 2002 to 2005. In constant dollars, the cut will amount to close to 30% over the period using a conservative inflation assumption of 3% per year. Coupled with the rising cost of practice, the cumulative affect of these reductions make it extremely probable that physicians will further limit the number of Medicare patients seen in their practices, lay off staff that help Medicare patients with appointments and medications, relocate to areas with younger, non-Medicare eligible patients, discontinue participation in the Medicare program, limit or discontinue indefinitely newer technology, and limit or discontinue charitable care, or retire.
There is strong bipartisan support for passing legislation that corrects this flawed reimbursement formula and restoring the cuts in the Medicare fee schedule. However, significant budgetary constraints have occurred due to the downturn in the economy as well as the increased costs due to the war on terrorism. Furthermore, members of Congress are feeling extraordinary pressure from organizations such as AARP to correct gaps in the Medicare benefit package, in particular, providing for a prescription drug benefit. Both the AMA and ACP-ASIM believe that our best hope lies in support of the "House Leadership Bill on Medicare." The House leaders that are proposing this bill include Representatives Bill Thomas (R-CA), W. J. Tauzin (R-LA), Nancy L. Johnson (R-CT), and Michael Bilirakis (R-SL), who are the leaders of committees that have jurisdiction over Medicare in the House. Their plan would provide updates of 2% next year, 1.8% in 2004, and 1.9% in 2005. These leaders also believe that it is likely that CMS will make an administrative change in the productivity adjustment of the Medicare Economic Index that would increase the updates by another .5%, resulting in increases of 2.5%, 2.3%, and 2.4% in 2003, 2004, and 2005, respectively. Although the plan would not provide any relief for years after 2005, congressional leaders have committed to making permanent changes in the law to prevent further cuts in 2006 and beyond. The increases that would result from the House leadership proposal contrast favorably with the estimated (current law) cuts, 5.4% in 2003, 5.7% in 2004, and 2.8% in 2005.
Clearly, this proposal is a temporary stop gap measure to soften the impact of the cuts in the Medicare fee schedule. Only when the current flawed reimbursement formula is replaced with one that is based on projected increase in actual physician costs will assure that the fee schedule is updated in a rational, stable, and predictable manner in future years. Nevertheless, the House leadership proposal appears to be our best hope at the present time. Please contact your representatives and urge their support of the House Leadership Plan.
ACP-ASIM Announces Plan For Health Coverage For All Americans
The ACP-ASIM used Leadership Day, May 21-22, 2002, as an opportunity to publicly announce their plan to achieve affordable health care coverage for all Americans within seven years. The ACP-ASIM has been at the forefront of educating Congress and the public on the financial and health consequences of the uninsured. Each year, almost 40 million Americans delay seeking care for preventable and treatable services. Of the uninsured, eight out of ten are part of a working family. Being uninsured, they often fail to receive life saving preventive services such as cancer screening, cardiovascular screening, and mammography and breast exams. Such individuals are nearly 50% more likely to die of breast cancer, 50% more likely to be diagnosed with late stage prostate cancer, and nearly 33% more likely to die in a hospital. The seven year plan calls for Congress to immediately adopt a resolution establishing a goal of making health insurance coverage available to all citizens in seven years. It also calls for Congress to immediately create an advisory commission to report annually on the effectiveness of measures to expand health insurance coverage. The commission will also develop a basic benefits package that will be required with all health plans. Over the ensuing seven years, the plan calls for Congress to expand and modify existing private and government health insurance programs to enable all Americans to achieve affordable coverage.
For more information on this seven year plan
, you can contact the ACP-ASIM Washington DC office at 800-338-2746, or visit ACP-ASIM Online.
Leadership Day 2002
A record 131 College members attending Leadership Day visited their Senators and Representatives asking them to address a variety of issues affecting internal medicine, and our Chapter was well represented by Glenn Carter from Hinesville; Jacqueline Fincher from Thomson; Ric Fullerton from Atlanta; and Joe Stubbs from Albany. Ric Fullerton was instrumental in arranging for the delegation to meet with a number of representative officers including Senator Zell Miller, Senator Max Cleland, Rep. Johnny Isakson, Rep. Nathan Deal, Rep. Charlie Norwood, Rep. Bob Barr, and Rep. Jack Kingston. The event also gave our delegation an opportunity to hear from Rep. Michael Bilirakis, who is Chair of the Health Subcommittee of Energy and Commerce, to discuss prospects of passing the House Leadership Bill on Restoring Medicare Reimbursements. We also heard from William D. Novelli, who is the newly appointed Executive Director and CEO of AARP, who discussed many of AARP's positions on healthcare and the importance of Congress passing a prescription drug benefit plan this year. The priority issues that our delegation discussed with each of the legislative offices included halting the cuts in the Medicare fee schedule, Medicare modernization and prescription drug benefit proposals, Medicare regulatory relief proposals, and the College's seven year plan for expanding access to affordable healthcare. Other issues that were also discussed included funding for bioterrorism preparedness, the critical need for significant medical tort reform, anti-trust relief, and the patient's bill of rights.
Events such as Leadership Day must be viewed not as an isolated annual event, but as part of an ongoing dialogue in relationship that we as a professional society must maintain with our political representatives. Our chapter needs more interested physicians to join the ACP-ASIM Key Contact Program, which offers you the opportunity of receiving a periodic newsletter, The Capitol Key, which updates members on legislation affecting internists and their patients. Furthermore, through the Key Contact Program, you learn how to contact your representatives in Congress and become a more effective advocate for legislation affecting our practice and our patients. All members of our Chapter should really become key contacts. The process for enrolling involves a simple application process, which you can access on our Chapter website.
Georgia Chapter Annual Scientific Meeting Roundup
The 2002 Georgia Chapter Scientific Meeting held at Peachtree City, May 3-5, was a resounding success. Hats off to Dr. David Haburchak as Program Chairman for organizing an outstanding scientific program. One of the things that continues to impress me most is the extraordinary number of talented, educated researchers that we have in our state that are willing to give so much of themselves in order to make our scientific program a success. Notable highlights of the program included our guest speaker at the awards ceremony, John H. Stone, MD, FACP, on Humor in Medicine. We also heard from Mary T. Herald as our College Representative, updating us on the important role the College continues to play in terms of getting the recertification process right, expanding healthcare coverage for more American citizens, and reducing the bureaucratic red tape and hassles in our practice.
Next year, Harold Szerlip, Associate Professor of Medicine at the Medical College of Georgia, will take over as Program Director for our Annual Scientific Program 2003, which will be held at the Westin Hotel in Savannah, March 7-9, 2003. I am sure that the program will be every bit as good as prior programs have been, and everyone will enjoy the scenery, dining, and shopping available in Savannah. Please mark your calendars now for this important meeting so that we can have the best crowd yet. We have over 3,000 members in our Chapter, and I think it a reasonable goal that at least 50% attend this important meeting. Please help me to meet this goal.
Georgia Chapter Presents Laureate Award to Vincent Nicolais
This year's Georgia Chapter ACP-ASIM Laureate Award winner is Dr. Vincent M. Nicolais, MD, FACP, FCCM. Dr. Nicolais received his medical degree from the University of Bologna in Bologna, Italy, and subsequently did his postgraduate training initially in Bologna and then at Westchester County Medical Center in Vanhalla, New York. He went into private practice in White Plains, New York, at St. Agnes Hospital where he served as President of the Medical Staff from 1990-1991. In 1991, he decided to relocate to the South and accepted the Director of Emergency Services position at St. Francis Hospital in Columbus, Georgia. Since that time, he has continued to practice internal medicine and critical care medicine in Columbus.
He is currently a member of the faculty at the family practice residency program at the Medical Center in Columbus, where he instructs the family practice residents in critical care medicine and directs the critical care unit He is also Adjunct Clinical Faculty member at Auburn University, Associate Faculty member of the family practice residency program at Fort Benning, and Clinical Associate Professor of the Department of Medicine at Mercer University School of Medicine. Throughout his teaching career, Dr. Nicolais has been an extremely effective teacher, being awarded Attending of the Year at the Medical Center in 1993, 1998, 2000, and 2001.
In addition to his demanding teaching and clinical duties, Dr. Nicolais has been extremely active in both ACP-ASIM and the Society of Critical Care Medicine, becoming a Fellow of ACP-ASIM in July 1998, and a Fellow of the American College of Critical Care Medicine in April 1998. He has been on the Georgia Chapter ACP-ASIM Governor's Council from 1996 to the present. He served as Chairman of the Scientific Program Committee for the Georgia Chapter in 1997, 1998, and 1999. As Chair, he organized and oversaw the integration of the Associates Research Program with the regular Chapter Annual meeting.
During his career, Dr. Nicolais has received numerous awards, including a Certificate of Appreciation for Outstanding Contributions to the American College of Physicians, Georgia Chapter, in 1999, and the President's Citation for Outstanding Contributions to the Society of Critical Care Medicine in 1998, 1999, 2000 and 2001.
Dr. Nicolais has also been a very active member of the community in Columbus. He has been a popular radio talk show host, as well as a very active participant in the Children's Miracle Network. He is married to Angela Nicolais and has four children.
For his passionate and enthusiastic pursuit of excellence in teaching and practicing internal medicine and critical care medicine, and for his dedicated service to our professional organization and that of the Society for Critical Care Medicine, we recognize Dr. Vincent M. Nicolais as the 2002 Georgia Chapter ACP-ASIM Laureate Award winner.
Chapter Honors Walter J. Moore With The J. Willis Hurst Teaching Award
Dr. Moore is a graduate of Georgetown University School of Medicine. Over a 20 year career in the Army, he was recognized as an outstanding bedside and didactic teacher twice receiving Best Teacher Awards from the Department of Family Practice at the Dwight David Eisenhower Army Medical Center. His military career reached an outstanding and sustained pinnacle of leadership and teaching success as Deputy Commander for Clinical Affairs at Eisenhower from 1997 through 2000. He arrived at the Medical College of Georgia as an Associate Professor of Medicine in 2000. In his short tenure at the Medical College of Georgia, Dr. Moore has already taken on the responsibility of Section Chief -Rheumatology Service, Program Director of Rheumatology Training Program, Director of Student Education for the Department of Medicine, and Faculty Advisor to the MCG student Internal Medicine Club.
Associate's Competition
The annual Chapter Associates' competition was again held during our Annual Chapter Meeting in May. The quality of the presentations and the overall program was outstanding. Our thanks go to Mohammed Wehbi, Chief Resident at Atlanta Medical Center, and Miriam Parker, Program Director at Atlanta Medical Center, for heading up the organization of the competition. The following Associates were the winners:
Research Competition
1st Place: Ritu Kumar, "The Central Georgia HIV Pregnancy Cohort"
2nd Place: Bobby A. Wrights, "Anticoagulants and Stroke: Are We Using Evidence-Based Guidelines?"
3rd Place: Francisco Rhein, "Persistent Occurrence of P. Carinii Pneumonia (PCP) Despite Availability and Access to HAART"
Clinical Vignette Competition
1st Place: Mahi Aswathnarayanappa, "Recurrent Aseptic Meningitis-Induced by Different Non-Steroidal Anti-inflammatory Drugs (NSAIDS) Including Rofecoxib"
2nd Place: Mark Roschewski, "Splenic Capsular Rupture Presenting as Pancytopenia"
3rd Place: Elizabeth Tong, "A Case of Right Atrial Thrombus in Dilated Cardiomyopathy"
Poster Competition
1st Place: James White, "Recurrent Intractable Abdominal Pain: A Case of Eosinophilic Gastroenteritis"
2nd Place: Colette Morgan, "Chylothorax as a Rare Complication in Systemic Lupus Erythematosus"
3rd Place (Tie): Steve Keilin, "A Case of Whipple's Disease" and Ritu Kumar, "Septic Arthritis Caused by Chryseobacterium Meningosepticum in a Prosthetic Elbow Joint"
Medical Jeopardy Returns
No matter how tired or weary a resident in an internal medicine program may appear, just mention the words "medical jeopardy" and fire and lightning jump into his/her eyes. Residency programs across the state have been clamoring for a return of the medical jeopardy competition, so the Georgia Chapter ACP-ASIM brought back the competition at its Annual Chapter Meeting in May. Our grateful thanks to Mohammed Wehbi, Chief Resident at Atlanta Medical Center, and Harold Szerlip, Associate Professor of Medicine at the Medical College of Georgia, for their effort in making the medical jeopardy competition a reality. All of the residency programs participated, and it was indeed a grand affair. At the end of the day when the dust settled, the team from Eisenhower Army Medical Center was declared the 2002 champions. The members of the team are pictured from left to right: Matthew Pantsari, Mark Roschewski, and John Wilson.
Georgia Chapter ACP-ASIM Establishes "twinning" Relationship With Kenya Association of Physicians
Recognizing that we live in a smaller world with shared problems, concerns, and hopes, the Georgia Chapter of ACP-ASIM has begun a sister or "twinning" relationship with internist colleagues in Kenya. Expected to be a growing, long-term relationship that will benefit the health of citizens of both Georgia and Kenya, this groundbreaking activity is a first among chapters in the ACP-ASIM.
As the behest of Joseph Stubbs, Chapter Governor, David Haburchak, MD, FACP, was invited to represent the Georgia ACP-ASIM at the February 2002 Annual Scientific Meeting of the Kenya Association of Physicians (KAP). The ACP-ASIM International Office and Speaker's Program also provided support. Dr. Haburchak spoke on Developments in Antibiotic Resistance and Pitfalls of HIV Chemotherapy at the symposium, the theme of which was infectious disease problems in Kenya. He presented grand rounds lectures at three city teaching hospitals.
Dr. Haburchak met with the Governing Council of KAP, an organization analogous to the ACP-ASIM, representing internists in Kenya for over 20 years. The current president of this organization, Professor William Lore, MD, FRCP, was instrumental in providing both a hospitable as well as fruitful week of discussing mutual goals of the two organizations. The council forwarded to Georgia the following goals that were in turn adopted by our chapter:
Purpose:
To establish a twinning relationship to foster collegial ties and improve the health of the citizens of Georgia and Kenya.
Goals:
- To jointly conduct healthy lifestyle education and health systems research, targeting diabetes, cardiovascular disease, cancer, and weight control.
- To train Kenyan physicians to use current HIV chemotherapy.
- To assist the KAP in setting curriculum standards for post graduate and continuing medical education.
- To facilitate member participation in multi-center biomedical research projects.
- To conduct short term physician exchange and email correspondence.
The Georgia ACP-ASIM membership is now being solicited to participate in one or more of five committees to bring to fruition the goals of this relationship. The chapter also has extended an invitation to a member of KAP to speak at next year's chapter meeting in Savannah. If you are interesting in one or more of the areas listed above, please e-mail Dr. Haburchak.
Immunization Update
Melinda Wharton, MD, FACP
Smallpox Vaccine Recommended by ACIP for Smallpox Responders—On June 20, 2002, CDC's Advisory Committee on Immunization Practices recommended that smallpox vaccine use be limited at present to those persons responsible for initial response to first cases of smallpox. Each state and territory should form at least one Smallpox Response Team that would investigate cases of smallpox, and selected healthcare workers at hospitals designated to receive smallpox patients would also be vaccinated. As soon as case occurred, vaccination would be extended to other public health and health care workers. This recommendation was based on the current absence of smallpox disease anywhere in the world; the assessment that the risk of a bioterrorist attack is low; limited supplies of smallpox vaccine and vaccinia immune globulin; and the safety profile of currently available smallpox vaccines, which can be transmitted to contacts of vaccinated persons, resulting in adverse events not only in vaccinated persons but also in their contacts. The ACIP will review this recommendation periodically and reconsider it if circumstances change.
Smallpox vaccine is not available as a licensed product. CDC has a stockpile of about 15 million doses of Wyeth vaccine, which was recently demonstrated to be effective when administered as a one to five dilution (New England Journal of Medicine 2002;346:1265-1274). It has also been reported in the press that about 80 million additional doses of vaccine from Aventis Pasteur has been identified and found to be potent. The Department of Health and Human Services has contracted to obtain more than 200 million doses of new smallpox vaccine, grown in tissue culture, that is now in production. At present, any of these vaccines could only be administered as an Investigational New Drug.
Td Shortage Ends—A national shortage of adult formulation tetanus and diphtheria toxoids (Td) began in late 2000, when one manufacturer unexpectedly left the U.S. market. In 2001 CDC recommended that available Td supplies be used for wound management and other high priority uses, and that routine boosters of adolescents and adults be deferred until the supply situation improved. Supplies are now sufficient to resume boosters and recall patients whose booster doses were deferred (MMWR 51:529-530). We recently published a paper demonstrating that fewer than half of Americans 20 years of age and older had protective levels of diphtheria and tetanus antibodies (Annals of Internal Medicine 2002;136:660-666).
Projected Influenza Vaccine Supply for 2002-2003 Season—We have no indications at present of any problems with influenza vaccine supply for the coming influenza season. Based on manufacturers' projections, production of more than 90 million doses is anticipated, more than ever produced before. Updates on influenza vaccine issues are available on the CDC website.
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Contact Information
Vincent Nicolais, MD, FACP,
Governor, Georgia Chapter
Karen Townsend
Executive Director
Ph: 770-693-9973
Georgia Chapter
Michelle Dietz
Administrative Assistant
Ph: 770-920-6995