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December 2012 Julie A. Blehm, MD, FACP, ACP Governor


From the Governor

Dr. Blehm

Happy Holidays to all of you!

I know this time of the year is busy and challenging both personally and professionally – so much happening. I hope you all have time to enjoy the holidays and spend time with family and friends.

We had a very successful fall meeting. Our attendance was good and all of the speakers were excellent. The transitions in care topic resounded with everyone and there was very good discussion about the issues we are all facing with discharge of patients from the hospital to other settings. Sally Brock was an excellent speaker and had a great fund of knowledge about this topic. I believe most of us learned a great deal from her. We also had excellent presentations on palliative care, hepatitis C, and osteoporosis. The case presentation on abdominal compartment syndrome was fascinating. The evaluations of the meeting were very positive.

We are already looking ahead to the meeting next year. I would appreciate suggestions any of you have for the meeting. Please let me know if you are interested in assisting with the meeting. Next year it will be in either Fargo or Grand Forks.

Remember the next ACP internal medicine meeting is being held in San Francisco California April 11 through the 13th. Please consider attending as these meetings are excellent.

In October I attended a meeting on physician wellness in Montréal Canada. It was sponsored by the American medical Association and the Canadian medical Association. The meeting was outstanding. For me, it was a reminder that we need to be aware of the stresses in both our personal and professional life and be a support to one another. Physician burnout is occurring more frequently not only in our practicing physician but in our residents and medical student. It is important that in our organizations we advocate for physician wellness programs. This article by Dr. Richard Gunderman is worth reading. http://www.theatlantic.com/health/archive/2012/08/the-root-of-physician-burnout/261590/

Jennifer Raum attended the ACP leadership conference in Washington DC this year in June. Following is a report of her experience:

Last June I had the privilege of representing North Dakota’s ACP chapter at Leadership Day in Washington, D.C. It was a fascinating two days filled with background on the current state of affairs in the legislature regarding issues important to the ACP and its members. Perhaps one of the most memorable moments was when the Surgeon General, Dr. Regina Benjamin, spoke about her vision for the future of primary care and public health in our nation. Dr. Benjamin has an impressive career behind her, and as a family practitioner, understands the challenges facing the primary care physician today.

I met with the health care policy staff of Senators Hoeven and Conrad, and with Representative Berg. After a day and a half of training, I found myself ready to express the desires of the ACP regarding several pieces of legislation and how these “asks” specifically affect North Dakota’s patients and physicians. Specifically, I focused on the need for continued GME funding for our residency programs. We are able to retain a significant number of our residency graduates, and without continued funding for these programs North Dakota could face an even greater physician shortage in the years ahead.

I was proud to represent ACP and, after meeting dozens of internists from across the country whose passion for medicine was palpable, I left Capitol Hill reinvigorated and encouraged that the future of our fine profession, though ever changing and uncertain, is bright. I am also attaching an opinion written by several of our ACP leaders published in the NEJM that I felt you might find interesting.

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Sounding Board

Legislative Interference with the Patient–Physician Relationship

Steven E. Weinberger, M.D., Hal C. Lawrence, III, M.D., Douglas E. Henley, M.D., Errol R. Alden, M.D., and David B. Hoyt, M.D. N Engl J Med 2012; 367:1557-1559 October 18, 2012 DOI: 10.1056/NEJMsb1209858

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Article References: http://www.nejm.org/doi/full/10.1056/NEJMsb1209858#ref1 - Reference 1

Increasingly in recent years, legislators in the United States have been overstepping the proper limits of their role in the health care of Americans to dictate the nature and content of patients' interactions with their physicians. Some recent laws and proposed legislation inappropriately infringe on clinical practice and patient–physician relationships, crossing traditional boundaries and intruding into the realm of medical professionalism. We, the executive staff leadership of five professional societies that represent the majority of U.S. physicians providing clinical care — the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American College of Physicians, and the American College of Surgeons — find this trend alarming and believe that legislators should abide by principles that put patients' best interests first. Critical to achieving this goal is respect for the importance of scientific evidence, patient autonomy, and the patient–physician relationship.

Examples of inappropriate legislative interference with this relationship are proliferating, as lawmakers increasingly intrude into the realm of medical practice, often to satisfy political agendas without regard to established, evidence-based guidelines for care. Of particular concern are four specific types of laws or legislative proposals.

The first type of law prohibits physicians from discussing with or asking their patients about risk factors that may affect their health or the health of their families, as recommended by evidence-based guidelines of care. In 2011, for example, Florida enacted the Firearm Owners' Privacy Act, which substantially impaired physicians' ability to deliver gun-safety messages to patients. 1 The law also prohibited practitioners from routinely inquiring about whether patients own firearms and recording this information in a patient's medical record. Practitioners who violated the law were potentially subject to severe disciplinary action, including fines and loss of licensure. The concerns we have about this law were well explained by U.S. District Judge Marcia G. Cooke, who issued a permanent injunction on June 29, 2012, barring the law's enforcement. As Cooke noted in the opinion, “The State, through this law, inserts itself in the doctor–patient relationship, prohibiting and burdening speech necessary to the proper practice of preventive medicine, thereby preventing patients from receiving truthful, non-misleading information. This it cannot do. . . . This law chills practitioners' speech in a way that impairs the provision of medical care and may ultimately harm the patient.”2 Yet the state of Florida is continuing to push this issue: Governor Rick Scott recently announced the state's submission of an appeal of Judge Cooke's ruling.3

Second, some new laws require physicians to discuss specific practices that may not be necessary or appropriate at the time of a specific encounter with a patient, according to the physician's best clinical judgment. New York legislation that was enacted in 2010 and became effective in early 2011 requires physicians and other health care practitioners to offer terminally ill patients “information and counseling regarding palliative care and end-of-life options appropriate to the patient, including . . . prognosis, risks and benefits of the various options; and the patient's legal rights to comprehensive pain and symptom management.”4 Although the law requires only that the clinician offer to provide information, the Medical Society of the State of New York and others have criticized it for failing to recognize the complexity and uncertainty involved in end-of-life discussions among patients and their families and physicians.5,6 This is an area in which one size does not fit all and in which physicians are best able to determine what discussions with patients and families are necessary or appropriate at a given time. Yet failure to comply with the law can result in fines of up to $5,000 for repeat offenses and a jail term of up to 1 year for willful violations.

Third, still other laws would require physicians to provide — and patients to receive — diagnostic tests or medical interventions whose use is not supported by evidence, including tests or interventions that are invasive and required to be performed even without the patient's consent. In Virginia, a bill requiring women to undergo ultrasonography before having an abortion would have mandated the use of transvaginal ultrasonography for a woman in the very early stages of pregnancy.7 As the Virginia chapter of the American College of Physicians stressed in a letter urging Governor Bob McDonnell to veto the bill, “opposition to the legislation does not reflect our opinions individually or collectively on the practice of abortion itself,” but rather the conviction that “this legislation represents a dangerous and unprecedented intrusion by the Commonwealth of Virginia into patient privacy and that it encroaches on the doctor–patient relationship.”8 A modified bill requiring women to undergo transabdominal rather than transvaginal ultrasonography, which still represents inappropriate legislative intrusion into the patient–physician relationship, was signed by McDonnell in March 2012.9

Finally, there are laws limiting the information that physicians can disclose to patients, to consultants in patient care, or both. Four states (Pennsylvania, Ohio, Colorado, and Texas) have passed legislation relating to disclosure of information about exposure to chemicals used in the process of hydraulic fracturing (“fracking”).10 Fracking involves injecting into the ground toxic chemicals such as benzene, toluene, ethylbenzene, and xylene to extract oil and natural gas.11 Low levels of exposure to those chemicals can trigger headaches, dizziness, and drowsiness; higher levels of exposure can cause cancer. In Pennsylvania, physicians can obtain information about chemicals used in the fracking process that may be relevant to a patient's care, but only after requesting the information in writing and executing a nonstandardized confidentiality and nondisclosure agreement drafted by the drilling companies.12

Unfortunately, laws and regulations are blunt instruments. By reducing health care decisions to a series of mandates, lawmakers devalue the patient–physician relationship. Legislators, regrettably, often propose new laws or regulations for political or other reasons unrelated to the scientific evidence and counter to the health care needs of patients. Legislative mandates regarding the practice of medicine do not allow for the infinite array of exceptions — cases in which the mandate may be unnecessary, inappropriate, or even harmful to an individual patient. For example, a patient may already have undergone the test in question or may have specific contraindications to it. Lawmakers would also do well to remember that patient autonomy and individual needs, values, and preferences must be respected.

Laws that specifically dictate or limit what physicians discuss during health care encounters also undermine the patient–physician relationship. Physicians must have the ability and freedom to speak to their patients freely and confidentially, to provide patients with factual information relevant to their health, to fully answer their patients' questions, and to advise them on the course of best care without the fear of penalty.

Federal, state, and local governments have long played valued and important roles in our nation's health care. Various levels of government are appropriately involved in providing essential health care services, licensing health care professionals, protecting public health, determining the safety of drugs and medical devices, and investing in medical education and research. Government plays a particularly important role in ensuring health care access for vulnerable and special-needs populations, including the elderly and disabled (Medicare), the poor (Medicaid), children (the Children's Health Insurance Program), and veterans (the Veterans Health Administration). We are fortunate to have a broad-based and extensive health care system, whose improvement and future excellence depend on a continued partnership between health care professionals and government.

None of the concerns raised above imply that we object to these governmental roles. But we believe that health legislation should focus on public health measures that extend beyond the individual patient and are outside the capacity of individual physicians or patients to control. In contrast, government must avoid regulating the content of the individual clinical encounter without a compelling and evidence-based benefit to the patient, a substantial public health justification, or both.

Our objection to legislatively mandated health care decisions does not translate into an argument that physicians can do whatever they want. Physicians are still bound by broadly accepted ethical and professional values.13 The fundamental principles of respect for autonomy, beneficence, nonmaleficence, and justice dictate physicians' actions and behavior and shape the interactions between patients and their physicians. When physicians adhere to these principles, when patients are empowered to make informed decisions about their care, and when legislators avoid inappropriate interference with the patient–physician relationship, we can best balance and serve the health care needs of individual patients and the broader society.

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

Source Information

From the American College of Physicians, Philadelphia (S.E.W.); the American College of Obstetricians and Gynecologists, Washington, DC (H.C.L.); the American Academy of Family Physicians, Leawood, KS (D.E.H.); the American Academy of Pediatrics, Elk Grove Village, IL (E.R.A.); and the American College of Surgeons, Chicago (D.B.H.).

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Strengthen Our Chapter: Participate in ACP’s Recruit-a-Colleague Chapter Rewards Program!

The American College of Physicians and the North Dakota Chapter encourages all members to help strengthen the voice of internal medicine by recommending ACP Membership to colleagues. By joining the College, your colleagues will enrich their clinical knowledge and skills and have access to all of the ACP member benefits that you enjoy.

To thank you for your dedication to our organization, ACP offers incentives to members and their chapters that recruit new members through the Recruit-a-Colleague Chapter (RACC) Rewards Program.

As with the national Recruit-a-Colleague Program, the RACC Program rewards successful individual recruiters with dues credits for each new full Member recruited and a chance to win a trip to the annual Internal Medicine meeting. In addition, the RACC Program also provides rewards to the recruiters’ chapters. The Recruit-a-Colleague Chapter Rewards Program runs annually from April 1 through March 15.

To participate, simply forward to your colleagues the Membership application found at www.acponline.org/racc. To qualify for the program, your name must be listed on the recruiter line of this specially coded application.

Happy holidays to all of you. Please contact me if you have any suggestions for chapter activities or other ideas that would enhance our chapter.

Julie Blehm

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Contact Information

Julie A Blehm, MD FACP
ACP Governor
North Dakota Chapter

Pam Heisler
North Dakota Chapter Staff
Phone: 701-780-6129
Email: pheisler@altru.org