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Governor's Newsletter, Winter 2001

Joseph W. Stubbs, MD, FACP
Governor, Georgia Chapter

From the Governor's Corner

In many respects, 2001 has been a good year for both the College and our Chapter with regard to health policy and legislative matters. On a national level, the merger of the American College of Physicians and the American Society of Internal Medicine has continued to be a very positive unification step. Over the past two years, the College has become increasingly more effective in shaping national health policy and in reaching out and being a strong voice with government health agencies and health policy makers and with other organizations of medicine, such as the AMA. On a state level, we have begun working more collaboratively on legislative issues with the Medical Association of Georgia, and we have made the first steps towards forming a Primary Care Coalition with the Georgia Academy of Family Practice and the Georgia Academy of Pediatrics. Still, certain issues are being swept aside which if not addressed soon could prove disastrous to our profession.

Our Chapter is currently working with MAG to block legislation expanding the scope of practice of various midlevel practitioner groups. While we see the essential role of these midlevel practitioners, we also recognize the unique and essential training of physicians in acquiring the skills, knowledge, and experience to prescribe medications and various ancillary services.

A major challenge we face this legislative session is seeking a long needed improvement in Medicaid reimbursement. Currently, the level has been set at 90% of RBRVS. Despite Governor Barnes' promise to increase that level and the Department of Community Health's recommendation that it be increased to 100% of RBRVS, the Governor's proposed budget still calls for reimbursement to be set at 90% of RBRVS. The implication of this action is that not only will Medicaid's reimbursement not be increased, but also the reimbursement levels for elderly patients who are dually eligible for both Medicare and Medicaid, will actually fall. The result will be that fewer physicians will be willing to see patients that are either Medicaid only or Medicare/Medicaid. With your support and the projected budget surplus, we hope to get the legislature to restore this budgetary promise.

While we are working together more effectively than ever and are achieving some significant successes, physician organizations continue to ignore one of our biggest threats and challenges, the hospitals. Despite the financial troubles facing academic medical centers and small rural hospitals, many hospitals, especially the large regional not-for-profit hospitals, are making enormous profits. My regional hospital, Phoebe Putney, which is a 500-bed hospital in Southwest Georgia, operates with a profit margin of around 10% and made thirty million dollars in revenues last year. With their huge reserves of capital, these hospitals have built a tremendous base of power and influence within all aspects of the government, business, and political communities. They are rapidly consolidating their organizations into a monopolistic force that will control the way in which health care is delivered.

The majority of PHOs in this state are largely funded and controlled by hospitals. Many have created their own health plans such as Emory, Promina, South Georgia Health Partners and my own Phoebe Health Partners. These regional hospital health plans are now in the process of merging into one large statewide health plan. The bottom line is that physicians who have traditionally been the principal health care provider for patients are being co-opted by a much larger and financially and politically more powerful provider, the hospitals. The real danger is that the professional ethic that governed the traditioal provider-patient relationship will be superseded by the corporate ethic of the hospital/health plan.

Under this scenario, will health care costs for consumers fall? In my own community, health care costs actually rose dramatically. Will patients have a greater choice of providers? No. Will physicians be able to act solely in the best interest of the patient? I fear not. Will regional hospitals continue to enjoy large profits? Will physician reimbursement improve? You decide.

I believe there are several remedies that may help to maintain our influence and control in dealing with health care matters. The first would be for physician groups to continue to support independent physician associations. Such associations solely serve the interests and concerns of the physician and his/her relationship to the patient. As such, they are a more effective voice in addressing the needs of physicians when negotiating with both hospitals and managed care organizations. Second, when forming a PHO, physicians should first collectively form a strong physician organization to negotiate with the hospital rather than fall prey to the hospital as individual groups of practitioners. Third, physician organizations should unite to convince our Governor and the state legislature to abolish certificate of need. For too long, the certificate of need program has no longer served its original intent of trying to equally allocate and distribute scarce health care resources across the state. Rather, it has become a shield to further entrench the power and monopoly of regional health care centers in this state. The abolishment of CON would actually allow physicians the opportunity to effectively compete with the hospitals in the delivery of certain services such as ambulatory surgery and diagnostic procedures. The increase in competitive market forces between hospitals and physicians could provide patients with more choice at lower costs.

The merits of each of these and other remedies are certainly open to debate. The most pressing issue is that we start now to address this serious, threatening problem. To ignore it, we risk making all our other activities seem like rearranging the deck chairs on the Titanic.

The following article on mentoring is written by Dr. Hina Trivedi, FACP, who is a hospitalist in the North Atlanta/Kennesaw area. We highlight this issue because no one is more excited about becoming a practicing physician than the first year medical student. Unfortunately, for the past couple of years, we have had a shortage of internists willing to serve as summer mentors for these interested medical students. The influence and impact that you can have as a mentor in encouraging medical students to consider internal medicine as a career is enormous.

On Mentoring

Mentoring is an activity mankind has always performed. We are role models as children, parents, friends and colleagues. However, as physicians, we are most privileged to serve as mentors to our medical students and trainee physicians who seek both medical and psychosocial advise.

Our obligation to mentorship lies in the first vow of the 'Hippocratic Oath': "...to teach them this art, if they shall wish to learn it...by precept, lecture and every other mode of instruction..."(1). In my opinion, this is the foundation of our oath, to perpetuate the art and science of medicine.

Mentoring is actually THE most important tool in professional training, be it the corporate environment or the medical arena, although, surprisingly, there is a general paucity of studies on the effects of mentorship.

One such study at The John's Hopkins Medical School found mentorship did have a significant effect on the residency chosen by medical students. Personality, clinical skills, competence and teaching ability were the important characteristics of the most influential role models (2). Interestingly, race and gender played little to no role (3).

As expected, success of mentoring programs was directly proportional to the time spent with residents. Furthermore, these programs are more successful when the mentor was chosen by the protégé as opposed to being appointed (2). Excellent role models clearly enjoyed teaching (stressing the importance of the doctor-patient bond) and built relationships outside of teaching (4). In contrast bringing donuts to rounds was not identified with good mentoring ability!!

Nevertheless, however noble our intentions, the current healthcare climate does not always allow us to perform such a time consuming role.

I do urge you to reconsider.

Many of us remember how eager we were (as students) to be taught and how eternally grateful we were when we finally understood a difficult concept. How we held a deep regard for a special teacher and mentor who emanated brilliance, enthusiasm and compassion.

Sir William Osler revolutionized medical education over a century ago by including mentoring as a teaching method. In his essay 'The Qualities Required of a Physician', he states, "Knowledge comes but wisdom lingers..."(5). It certainly is most flattering, challenging and yet extremely humbling to be sought as a mentor. We draw on our experiences, successes and failures in educating our students (Osler's "knowledge"). Moreover we entwine this academia with the teaching of the more divine virtues: love, courage, patience and unprejudiced respect for humanity (Osler's "wisdom").

Let us all play a part in the passing of this Knowledge and Wisdom of medicine.

References:

(1) Hippocrates, Francis Adams (New York:Loeb) vol. I, 299-301

(2) Wright S, Wong A, Newill C : J.Gen.Intern.Med 1997 Jan; 12(1): 53-6

(3) Galicia AR, Klima RR, Date ES : Am.J.Phys Med Rehabil. 1997 Jul-Aug; 76(4): 268-75

(4) Scott M et al : N.Eng.J.Med. 1998 Dec 339(27): 1986-1993

(5) Osler William "Aequanimitas" (Mcgraw Hill). Hina Trivedi, MD

Catching Up With Ketchup

Many of you recently received a letter from MAG Mutual outlining the medical practice implications of a recent court decision in the Georgia Appellate Court entitled Ketchup vs Howard. Up until the time of the Ketchup Case, the process of informed consent was a formalized process required only in situations where physicians were planning to operate on a patient or give the patient anesthesia. In the Ketchup Case, the judges of the Georgia Appellate Court basically said that patients should receive the same informed consent for any process that a physician does that poses a risk or danger to the patient. In the letter, MAG Mutual encouraged physicians to have patients sign an informed consent, which was two pages in length, whenever they perform a venipuncture, prescribe medicines, change medicines, or do anything that could pose a material risk to the patient.

The implications of this decision are enormous and could have a severe negative impact on the process of caring for ones' patients. Internists across the state have sent me letters or e-mails indicating how ludicrous and impossible it would be to try to fulfill these new expectations. In short, this case single handedly raises the hassle factor bar into the stratosphere.

Our organization's strategy will be to try to work with the Medical Association of Georgia to better and more fully understand the implications of the case for your practices. In turn, we plan to communicate back with you our findings. We also hope to obtain legislative relief from some of the most onerous burdens that the Ketchup Case creates. Finally, we are seeking the help of the College in developing a strategy for dealing with and hopefully reversing this case.

Internists' Fine Arts Display

At our upcoming annual chapter scientific meeting June 8-10 in Augusta, we are hoping to have our first ever display highlighting the visual artwork of some of our many talented internists. We would like to encourage all internists who have had any inclination in photography, painting, or other visual arts to consider volunteering to have some of your works on display at our meeting. There will be no fees and no judging involved. This will simply be a source of great entertainment for those registered to come to the meeting and a great opportunity to show just how multi talented our state's internists really are.

If you are interested, please e-mail our Executive Administrator, Nancy Brady or me. Nancy's e-mail address is nbrady@mail3.newnanutilities.org and mine is jstubbs@surfsouth.com.

The Governor's Council Meets

On January 27, the Governor's Council met and discussed a wide range of issues. In particular, we addressed concerns about a declining medical student and resident membership in our state organization. Dr. Jacqueline Fincher announced that for the second year in a row, we would be offering a media-training workshop to train internists to more effectively address the media and improve your public speaking skills. The workshop will be held at the end of the Friday session, June 8, and there will be no additional charge. Members of the Council expressed interest in pursuing resolutions that address our opposition to the format of recertification that the American Board of Internal Medicine has developed. (Plan to hear more details about the recertification process at our upcoming meeting.) Members were also in favor of a resolution and urged the College to investigate the flu vaccine shortage and make recommendations that insure the proper distribution of the vaccination by manufacturer to those populations at greatest risk.

2001 Georgia Chapter Scientific Meeting
Augusta, Georgia
June 8 - 10, 2001

Technology in the Future of Internal Medicine

Areas of discussion:

Application of Informatics to Clinical Practice and Patient Education
Telemedicine
Genomics
Genetic Screening
Biotechnology - New Drug Development and Application
Ethical Issues of Application of Technology
Preventive Medicine in the Office and Community
Application of Technology to Geriatrics
Technology and Quality of Care

Course Outline