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July 2012 Robert (Dobbin) T. Chow, MD, MBA, FACP, ACP Governor


Governor's Message

Dr. Chow

Throughout the year, we are pleased to send you updates regarding the various activities of our very productive Chapter. Over the past academic year, there were many accomplishments that we could proudly celebrate. In the interest of brevity, and because we Marylanders are humble people, I will resist the temptation to reiterate them in this newsletter. Instead, I will focus on one important issue/opportunity.

It has been a tough year for small practices. Physicians in small private practices have been challenged to convert to electronic medical records and participate in continuous performance improvement. The management of practices has become increasingly complex, with increasing costs, and yet flat or decreasing levels of reimbursement. It is not surprising, then, that many physician owners have given up the ship. Until 2005, approximately 2/3 of practices were physician-owned, a figure that had remained consistent for several decades. However, over the past 3 years, the percentage of physician-owned practices has decreased to less than 50%. Physicians, both specialists and primary care, have chosen to sell their practices to larger corporations or institutions and assumed salaried positions.

In speaking with currently practicing self-employed physicians, they speak of many challenges:

  • Recruiting new young graduates to join the practice. Those fresh-eyed graduates who are interested in the private practice of primary care as rare as a two-headed unicorn.
  • Decreasing reimbursement. According to the Center for Healthcare Change, primary care providers faced a 10% decrease in reimbursement over the past 15 years, when adjusted for inflation. Reimbursement for some specialists has decreased by 1/3, causing one subspecialist colleague to remark to me, “I’m getting paid like a primary care doc.”
  • Increasing overhead. According to MGMA data, primary care practices have the highest rates of overhead, generally at about 60% of revenues. With increasing administrative burdens being placed on practices, at some point in the not too distant future, overhead may approach total revenues.
  • Looming implementation of a new coding system, which is 10 times more complex than the current one. I am led to assume that the current system is not sufficiently complex.
  • Cost of EHR conversion. According to the California Healthcare Foundation, the total five year cost of the more sophisticated EHR systems increases by 70% per provider if the number of providers in the practice decreases from 50 to 5. The cost of EHR is estimated to be $30K to $50K per physician. Thus, larger practices stand to benefit from economies of scale while the smaller practices must pay more per physician for EHR implementation. Those in solo private practice must pay $50K to $70K for EHR implementation in their practices.

The rural areas are particularly vulnerable. Those practices are generally smaller than their urban counterparts, and those physicians have been documented to generally be older as well. They have more difficulty attracting new partners, as most young physicians prefer to reside in urban areas. The cost of EHR implementation will be higher in rural settings due to the smaller number of physicians per practice, and the relative distance between sites. Access to software support may not be as readily available.

We are in the midst of remarkable transitions for clinical medicine. For those who have been in practice for years and are now working as a salaried employee on behalf of an institution, what has that been like? For those who have decided to stay in private practice, how were they able to navigate the transition to EHR? According to the U.S. Department of Health and Human Services, as of 2011, 53% of Maryland physicians are using some form of an EHR and 39% plan to implement EHR in the near future. Between 2010 and 2011, the percentage of physicians who have a ‘basic’ system increased 36%. However, of those who do not have yet have EHR, 15% have no plans to apply for it. I wonder if these physicians feel particularly beleaguered or disenfranchised.

In making these game-changing decisions in their practices, or in choosing to not make these changes, physicians had to make choices that were in the best interests of their practices, their patients, and their practice styles. Yet, the main purpose for these changes, according to the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act, which authorized funding to help support the transition to EHR, is to improve the quality of care. I am not hearing about a transition to a higher level of quality care from the practicing physician in the trenches. I am concerned about this. I have the impression that practicing physicians feel that they already practice high quality care in spite of EHR, while health policy gurus feel that HITECH will improve patient care.

Though the more sophisticated EHRs offer the potential to measure quality metrics, the transition to higher level of quality care requires more than complex reporting and data gathering capabilities. Practices need to embrace a culture of safety, adopt a philosophy in which errors are scrutinized as opportunities to improve, and evaluate their processes of care in a systematic fashion. It should be less about meaningful use and more about a meaningful approach to patient safety. All physicians aspire to provide high quality care; how they respond to errors and their passion for preventing future similar errors will be the most meaningful measure of quality.

I certainly do not have the solution, but I believe that we here in Maryland have the resources and expertise to contribute in substantive manner. We will create a Patient Safety Committee in our Chapter, and I hope that you will consider joining if you have an interest in this area. I cannot think of a more important initiative. In the meanwhile, if you are interested in developing a culture of safety in your practice, one way to begin the process is to administer a survey to all members of the office staff, including the provider staff. The survey was developed by the Agency for Healthcare Research and Quality. The responses may be insightful and can direct efforts to improve communication and processes of care in your practice.

I feel privileged to have had the opportunity to meet many practicing physicians in the Maryland internal medicine community. I am impressed with the gravity of practice-changing decisions that many have had to make, and the thoughtfulness and candor that is incorporated into their decision-making process. It is not just about the balance sheets, though that is certainly important, but about good patient care in a style that fits each physician. As each of us transitions through changes, be it with EHR, ICD 10, or the impending SGR cuts, our professional priorities and values are reflected in our collective and individual responses. As we step forward into an uncertain future, let us do so with wisdom and the best interests and safety of our patients in mind.

Finally, I would like to thank Mary Ellen Woodward, the Executive Director of our chapter. She is our backbone, lifeline, guidepost, lighthouse, and any other analogy that fits. She has great organizational skills and keeps all of our activities on track. In the picture below, taken at the Maryland reception of the 2012 national ACP conference, which was held in New Orleans, she is on the right. I am on the left (not in the middle!). The reception featured live music and Cajun food and was well-attended by those Marylanders who went to the national conference. The person in the middle is a crayfish, and is not yet, to my knowledge, a member of our chapter.

big lobster

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Chapter Meeting – Congrats & Updates

We want to take one last opportunity to acknowledge the success of our annual scientific Chapter meeting held at the Turf Valley Conference Center in February. There were almost 300 attendees, including members, students and residents who attended this two day event. We are indebted to Drs. Ali Afrookteh & Steve Sisson for their continued success in arranging for top-notch speakers on a variety of topics. The feedback on the speakers and the program was extremely positive, certainly consistent with national CME programs. We are fortunate that in Maryland, we have access to nationally-recognized faculty from several local institutions who have generously contributed their expertise and knowledge to helping our attendees reach the learning objectives of the conference.

This past session, we successfully attracted members from other areas including DC, Virginia and Pennsylvania as well as our very own Chapter’s members from western Maryland and the Eastern Shore. We thank all for your continued support and hope that you will not only plan on attending the 2013 meeting, but also encourage your colleagues to attend as well. We are currently in the process of developing an agenda for our upcoming meeting. Please plan on joining us!

2013 MD ACP Chapter Meeting
February 1-2, 2013, Starting at Noon on Friday
Turf Valley Resort & Conference Center

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The 30th Mulholland-Mohler Associates Meeting

A Great Success!!

We are very pleased to report that the May 10, 2012 Mulholland Mohler Associates meeting held at St. Agnes Hospital was the largest meeting hosted by our Associates Committee. This year, we had over 240 abstract submissions in several different categories including research, clinical vignette and oral research and vignette. All eleven programs participated at our meeting and we had over 40 judges who gave of their time willingly to ensure that the meeting was such a success. Dr. Romulo Baltazar from the JHU/Sinai program was this year’s recipient of the C. Lockard Conley Award for his many years as a mentor for residents and students at Sinai Hospital. Dr. John Chessare, CEO of GBMC was our keynote speaker and presented a very informative session geared to our residents on “What is Your Future in our American Healthcare System?

We send our sincere appreciation and thanks to Drs. Paul Foster and Richard Williams, Chairs of our Associates Committee , for their support of this meeting, the planning of which begins with an organizational meeting in September. We also wish to thank Dr. Emile Mohler, who was able to present the meeting’s history, as well as a tribute to Dr. John Mulholland, one of its founders 30 years ago. Unfortunately, Dr. Mulholland passed away during the winter of 2011, but we were all sure he was smiling down at us throughout this great event. We also wish to thank our CRAB co-chairs, Drs. Mohit Girotra (JHU/Sinai), Raman Palabindala (GBMC) and Alireza Zarrabi (HHC) who were such able contributors not only to the Associates meeting but so many of the activities supported by the Chief Residents Association of Baltimore (CRAB) this year. Special awards were also provided by CRAB for 3 clinical vignette presenters. Lastly, our special thanks to our gracious hosts, Drs. Sapna Kuehl, Program Director, and Richard Pomerantz, Chair of Medicine, of St. Agnes Hospital who ensured that all ran smoothly throughout the day.

Award Winners

Chief Residents Award

1st Place
Dr. Sangye Shrestha
Maryland General Hospital
Treatment of Corticosteroid Dependent Acute Interstitial Nephritis

2nd Place
Dr. Shan Shan Chen
St. Agnes Hospital
Successful Treatment of Myeloma Cast Nephropathy with Plasma Exchange and Chemotherapy

3rd Place
Dr. Sumanto Som
Med Star Franklin Square Med. Center
Sequential Relationship Between Acid Reflux and Cough

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Oral Clinical Vignette

1st Place
Dr. Michael Allison
UMMS/VA Medical Center
A Case of Gadolinium Induced Kounis Syndrome

2nd Place
Dr. Sritika Thapa
Med Star Good Samaritan
On the Cutting Edge: A Case of Adrenal Insufficiency

3rd Place
Dr. Matthew Finn
Johns Hopkins/Broadway
A Rapidly Disseminating Rash in an HIV Positive Woman: Is It Really Just Another Case of VZV?

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Oral Research

1st Place
Dr. Charmian Dharini
Med Star Union Memorial Hospital
Outcomes of Inpatient-to-Outpatient Sittambalam Suboxone Therapy for Heroin Addiction

2nd Place
Dr. Jonathan Ronquillo
St. Agnes Hospital
MEWS Flash! The Predictive Value of the Modified Early Warning Score

3rd Place
Dr. Aditya Saini
Med Star Harbor Hospital Center
Improving the Transition of Care from Hospitalists to Primary Care Physicians

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Poster Research

1st Place
Dr. Panagis Galiatsatos
Johns Hopkins/Bayview
Left Ventricular Filling Pressure by Photoplethysmography

2nd Place
Dr. Preeti Mehrotra
UMMS/Baltimore VA Medical Center
Contact Precautions and Patient Satisfaction

3rd Place
Dr. Naveen Voore
Med Star Franklin Square Medical Center
Hospital Course of Chest Pain Patients with Low Cardiac Risk

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Poster Clinical Vignettes

1st Place
Dr. Agegnehu Gebreyes
St. Agnes Hospital
Be Aware of Wires in the Veins

2nd Place
Dr. Nidhi Goel
UMMS/VA Medical Center
Anti-NMDA Receptor Encephalitis

3rd Place
Dr. Angela DeRidder
UMMS/VA Medical Center
Iatrogenic Adrenal Insufficiency in the Setting of Concurrent Intra-Articular Steroid and Ritonavir Therapy

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Honorable Mention

Dr. Adnan Choudhury
Med Star Franklin Square Medical Center
A Case of Ehrlichliosis Causing High Ferritin Levels

Dr. Jiayan Chen
Greater Baltimore Medical Center
Dr. Oxana Makarova-Rusher
Med Star Harbor Hospital Center
UC is not Always UC – MRSA Colitis Radiofrequency Ablation as a Therapeutic Alternative for Chemoradiation Resistant Stage I NSCLC

Dr. Christopher Bach
Johns Hopkins/Bayview
Acute Interstitial Nephritis Associated with Dexlansoprazole Administration for Gastro-Esophageal Reflux Disease

Dr. Manjari Pandey
JHU/Sinai Hospital of Baltimore
Lactic Acidosis in Solid Tumors

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Please Mark Your Calendar!

Women in Medicine Workshop

Saturday, November 3, 2012, 8:00 AM – Noon
Kotzen Auditorium – MedStar Franklin Square Medical Center

Our Women in Medicine group, chaired by Dr. Claudia Kroker, continues to present workshops that are of interest to all of our members from students to residents to members (Both men and women). This year’s theme will be : Physicians' Health Thyself: Managing Aspects of Your Mental Health

Information will be provided on the Impaired Physician touching on topics of drug, alcohol, mental health problems and legal aspects , and the 2nd portion will be on Physician Self Care including prevention of burnout and how to effectively manage your own time and energy. Look for additional information and a flyer as the meeting gets closer.

For additional information about WIM, please go to their website at www.acp-md-wim.org

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IM 2012 Update

Maryland Evergreen Award Winner

This year we were very well represented at the IM 2012 held in New Orleans. Some of the pictures from the meeting are seen in this Newsletter. Our Maryland Chapter sent several representatives from Maryland including the resident winners of our Doctors Dilemma contest from MedStar Franklin Square Medical Center as well as our 2011 Associate meeting winners to compete in the clinical vignette and research abstract competitions. Maryland and D.C. also hosted a very well attended reception that was held on the waterfront in New Orleans and really gave everyone an opportunity to enjoy a festive evening and to meet both old and new friends.

We send “congratulations” to Dr. Roy Ziegelstein, who received the designation of mastership at this meeting. Dr. Ziegelstein has been a very active and important part of our Maryland ACP chapter for a number of years, and we were so pleased to see him receive this award. Congratulations to our new Fellows who were part of this year’s convocation. A listing of the newly elected Fellows for the last year is also contained in this Newsletter. We hope that you will take the opportunity to congratulate them on this wonderful achievement.

Last but certainly not least, we send a special congratulations to Dr. Janaki Deepak, Chair of the IMG Committee. Her committee’s innovative work was selected as one of only six recipients of the 2012 ACP Evergreen Award. Dr. Deepak’s group has been very active in our Maryland community and has organized several important programs for our IMGs. These include sponsorship of an international pot luck dinner with our CRAB group, several workshops with our Young Physicians Council on contracts, visas and negotiations, as well as providing information that is especially helpful to new IMGs to our area. Our Maryland IMG Committee is really unique, as there are not other similar committees in other chapters. We are very fortunate that Dr. Deepak and her committee are part of our chapter.

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Students "at work" in Maryland

The MD ACP has several committees that are extremely active in our community. One that we are very proud of is our Student group. This committee has developed several initiatives over the past several years that warrant merit and have become part of our activities. These include:

Mentorship program for students

Student Dilemma contest that included 10 teams from across the metro area

Participation in a regional “ Steps to Success” program that includes an abstract competition and practical workshops

Community Health Fair totally sponsored by students at a local church in the East Baltimore area

Participation in ACP Leadership Day, giving students an opportunity to meet with members of Congress to discuss issues that are of concern to them

Students are our future, and the Maryland ACP feels that an active student group ensures that the “next generation” engages in the ACP in the future.

We congratulate the student co-Chairs – Melissa Schmidt, UMMS, Krishna Juluri & Eugene Shenderov (Johns Hopkins).

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Updates re: Chief Residents Association of Baltimore (CRAB)

This year, our Chief Residents Association of Baltimore (CRAB) developed and implemented several unique programs under the co-chairmanship of Drs. Mohit Girotra (JHU/Sinai), Raman Palabindala (GBMC) and Alireza Zarrabi (HHC). The three co-chairs began work last year in August to ensure that their goals were achieved for this year. They included:

  • Joining with the IMG Committee to host an International Pot Luck dinner for residents across the city and to provide some needed books, etc to a local Baltimore City elementary school;
  • Development of a CRAB website on the Maryland Chapter webpage that provides information on the history of CRAB as well as current programs and activities;
  • Sharing information regarding morning reports with programs throughout the area;
  • Hosting a very well attended CRAB Grand Rounds on Contract Negotiations in the Spring
  • Planning and providing support for the Doctors and Student Dilemma, Associates Meeting and Leadership Day attendance

We thank our outgoing co-chairs and look for another wonderful year with our new CRAB members.

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Consortorium for Research in Internal Medical Education

In Maryland, we have a unique situation in that we have 10 internal medicine programs, including several community and university hospitals in a small geographic area. The year, the Maryland chapter took advantage of this opportunity by promoting a joint effort in internal medicine educational research. All of the programs were contacted and agreed to designate a faculty member as a member of this new committee, which aspires to promote and support joint ventures in educational research. The group agreed that there should be both long and short term research projects. To this end, a survey was developed that investigated how residents seek medical care for themselves. To date, we have received over 140 responses to this survey, and the data is currently being processed and reviewed. The second survey being planned will be on Career Choices of Residents, with particular focus on the factors that alter career choices made from the 1st to their 3rd year of residency. We are pleased with the outcomes of this new group, and will keep you updated on future surveys and projects.

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Health & Public Policy Committee

The Health & Public Policy Committee, chaired by Dr. Steve Kravet, continues to play an active role in the health policy activities, both locally and nationally. Under the auspices of the HPC Committee, we also network with MedChi as part of its Legislative Committee. Drs. Mary Newman and Saba Sheikh are the representatives of this group and keep our committee updated on proposed legislations during the Maryland session. Our HPC Committee is also part of a Primary Care Coalition that includes MedChi, family physicians and pediatricians who have reviewed and provided written input on number of different proposals and initiatives within the Maryland health care system. This year, our HPC sponsored a resolution to the ACP asking that patient information brochures be developed and distributed in members’ offices that would address several nondisease-related but crucial areas to our patients. This resolution was viewed as reaffirming the ACP’s position toward patient education. Unfortunately, funding is not currently available to develop brochures on topics such how to search for medical information on the internet, avoiding unnecessary testing, etc.

One of the most important areas that this group spearheads is ACP Leadership Day. During the 1st week of June, over 15 practicing Maryland physicians, residents and students took time out of their very busy schedules to go to Capitol Hill and voice their concerns about a number of legislative areas, ranging from the SGR to student loans. See below for two different perspectives that we are pleased to share with you:

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Chair of HPC’s “Viewpoint”

The Maryland Chapter participated in Leadership Day June 6-7. This was a very interesting year given the politics. I can say that ACP has made a significant impact. 4 years ago we began to make the case that primary care was critical to the redesign and d=salvation of our healthcare system. This year, more than ever, that message was internalized and repeated back to us by legislators on both sides of the aisle.

The issues have shifted in this election year to attempting to revise the flawed SGR, to assuring that critical programs don’t lose funding due to sequestration and cuts, that primary care training and funding needs to be preserved, and that the new liability reform option (first time I’d heard that euphemism for tort reform) is proposed use of health courts.

We had a large delegation this year and split into 4 groups. We had very engaged and bright students and residents. We had attending physicians, some with many years experience with Leadership Day and some with none. The teams came together nicely with the DC delegation. We visited legislators Edwards, Mikulski, Cardin, Van Holien, Bartlett, Harris, Ruppersberger, Hoyer, Holmes, Sarbanes, and Cummings. Each office was engaged and several offered to work directly and collaboratively with ACP.

Thanks to all who attended. It was a glorious day in our nation’s capital.

Steve Kravet, MD, FACP, Chair, Health & Public Policy Committee
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Students "Viewpoint"

First, this was an amazing opportunity and I am grateful that I was afforded the opportunity to attend. Going into this event I had very little understanding on the different issues physicians are faced with in terms of Medicare reimbursements, GME funding, and medical liability reforms. Needless to say, I was overwhelmed with the announcement that I would be taking an active part in speaking on behalf of the ACP and lobbying to obtain Senate and House support on these issues. However, the ACP did an outstanding job of preparing an inexperienced “lobbyist” such as myself, to be able to learn the issues, present them to senators or congressmen and engage in conversation about ways to compromise and resolve them. This was accomplished on the first day by having the student and associate members meet to discuss expectations of how medical students and associate members could maximize their efficacy when presenting the “key priorities” for this year’s meeting. After that, the general ACP meeting started where ACP board members spoke about each issue in detail giving key focal points to base your discussion around on the hill the following day. This was followed by workshops on how to be effective and adaptive in the short time you have to discuss your issues. Day two began with words from a couple of the house representatives, followed by an address from the U. S Surgeon General.

On the Hill, I was able to meet with delegates or their policy directors from the state of Maryland. My role on the team was to discuss the importance of GME funding and the importance of increasing primary care training positions to meet the current and future deficit. Also, I was able to give a student’s perspective on what influences the decision as to what field of medicine a student chooses. I was able to elaborate on the financial burden and debt a medical student graduates with, which often persuades one to a more lucrative medical specialty that will allow earlier repayment and financial freedom. With this I was able to allude to the continued effects of the SGR and the scheduled payment cut for Jan. 2013.

Overall, it was quite an experience getting to see the hustle and bustle of everyday life around the Capitol. It was a very intense environment to be around, heightened by the political division of parties and the upcoming election. This was a very educating and enjoyable two days. In the future, more students should try and take of advantage of this opportunity to meet with their states delegates and ACP chapter members.

Thomas Stoops, Student in Clerkship at Harbor Hospital Center

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Dinner with MED Mutual

Dr. Richard Williams, a member of our MD ACP Council, represented our Chapter at the “President’s Circle” meeting of the Med Mutual Insurance Group. We would like to share his report with you:

The leadership of MedMutual were all present, including the CEO, the Chairman of the Board, several VP’s, and the General Counsel. Five specialty societies were represented. Claims are down in recent in years in Maryland, as they are in many other states. The Cap was challenged recently in appellate court, but was upheld. Maryland is one of five states that uses contributory negligence rather than comparative negligence in determining liability, which is good for the defendant but is being challenged in a court case. MedMutual is developing a product that will assist and cover physicians for claims brought because electronic patient-specific information becomes unsecured. Wesley Foster, the Senior VP for Claims since 1989, is retiring.

Richard B. Williams, MD, FACP

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Members in the News

We are pleased to showcase just a few of our members “in the news” and hope that you will take the time to congratulate them on their recent achievements.

Dr. Mary Newman was featured on the front page of “Internal Medicine news” with an article about Medicare’s preventive medicine exam. Go to the link.

Dr. Sanjay Desai was selected to serve on the ACP Council of Young Physicians for the Eastern Region.

Dr. Robert Ferguson has published his fifth edition of the “Journal of Community Hospital Internal Medicine Perspectives” (JCHIMP). This online journal features articles on a variety of subjects from perspectives, research articles, case reports, and ECG images. It has been read in over 112 countries…the link is www.jchimp.org.

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New Fellows

Ayoola O. Akinbamowo, MBBS, FACP
Muhammad Amer, MD, FACP
John N. Aucott, MD, FACP
Sanjay Desai, MD, FACP
Anand Dutta, MD FACP
April S. Fitzgerald, MD, FACP
Neda Frayha, MD, FACP
Jin Gu, MD, FACP
Sukhpal S. Jassi, MD, FACP
Kenneth Patrick L Ligaray, MD, FACP
Maura J. McGuire, MD, FACP
Hmu Minn, MBBS FACP
Rameen J. Molavi, MD, FACP
Michael P. Moran, MD, FACP
Anand K Parekh, MD, FACP
Vaibhav A. Parekh MD, MBA, FACP
Barbara L. Sanico, MD, FACP
Cynthia Sears, MD, FACP
Muhammad Kamran Siddique, MD, FACP

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Photo Gallery

Associates Meeting

Dr. Baltazar
Dr. Romulo Baltazar, recipient of 2012 C. Lockard Conley Award

Dr. Chessare
Keynote Presenter, Dr. John B. Chessare, CEO, GBMC

Drs. Mohler and Mackowiak
Drs. Emile Mohler and Philip Mackowiak, Past Governors

mcleod
Dr. Dobbin Chow and CRAB co-chairs Drs. Alireza Zarrabi, Mohit Girotra & Raman Palabindala

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IM 2012

Convocation
Dr. Dobbin Chow and our new Maryland Fellows

Dr. Newman
Drs. Mary Newman, new Master Dr. Roy Ziegelstein & Dr. Dobbin Chow

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Contact Information

Stephen D. Sisson, MD, FACP,
Governor, Maryland Chapter

Maryellen Woodward
920 Trinity Street
Baltimore, MD 21202
Chapter Administrator
Office: 410-332-8444
E-mail: mew4work@aol.com