Governor's Newsletter, December 1998
Mark Your Calendar for the 1999 Oregon ACP-ASIM Meeting - November 4-6 in Eugene
Bob Gluckman, MD, FACP, will again Chair the Program Planning Committee. Please let the Committee know your thoughts about program content and format. Bob can be reached at 503-216-7451 or via e-mail at email@example.com.
The following are members of the Chapter's Councils for 1998-99. Thanks to all for their work on behalf of the Chapter and College.
Council of Associates Update
The ACP-ASIM Council of Associates has had a busy and productive autumn. We launched a Career Planning Series for Senior residents, which drew about 50 residents from all four training programs in the Portland area. Academic faculty, private practitioners, and the medical director of a large managed care organization discussed different career options for internists and gave some help in writing a CV. The Series will continue in December with a discussion of interviewing techniques and how to determine which job is right for You. The long-standing ACP-ASIM Associates' Competition at the Oregon ACP-ASIM meeting in Eugene was hosted by the Council of Associates. Residents from each program presented clinical vignette posters, research posters, and oral clinical vignette presentations. It was a fun and energetic evening, and all presentations were very impressive! In fact, one of the judges visiting from Boston declared the posters to be "better than 95% of the posters he has ever seen". Good work, residents!!
Winners in each category are as follows:
- Jane Dunham, MD, of Providence Portland Medical Center, recipient of the first-place award in the Associates' Oral Competition.
- Stacy Tribble, MD, of Legacy Portland Hospitals, recipient of the second-place award in the Associates' Oral Competition.
- Lisa Els, MD, Mark Harrington, MD, and Rhonda Tetz, MD, of Legacy Portland Hospitals, recipients of the first-place award in the Research Poster Competition.
- Chad Pfefer, MD, of Legacy Portland Hospitals, recipient of the first-place award in the Clinical Vignette Poster Competition.
Women's Issues Committee
Thirty women attended the Women's Issues Committee breakfast at the Chapter meeting, November 7, to learn about public speaking skills from Dr. Andrea Kielich. ACP-ASIM Regent, Dr. Risa J. Lavizzo-Mourey, joined the group and spoke from her experience as well. Skills for working with the media and for testifying were also covered. The Committee reviewed the fact that there are only 16 female Fellows of the dozens of Fellows from Oregon. Applications for Fellowship were encouraged. Those interested in applying for Fellowship in any of the tracks should contact Jocelyn White at firstname.lastname@example.org.
This edition's Community Service column is authored by John W. Forsyth, MD, an internist/cardiologist at the Medford Clinic for the past 27 years. The architect and continuing director of VOLPACT (Voluntary Patient Access to Care and Treatment) a joint venture between physicians in Jackson County and the three area hospitals and two outpatient clinics which serve low-income patients, Dr. Forsyth received the OMA's 1998 Doctor-Citizen of the Year Award and the Mother Joseph Medal of the Sisters of Providence system for "compassionate care in helping meet the unmet health care needs of his community".
1994 was a tough and seminal year for both caregivers and low income patients in Southern Oregon. First, the Clinton Health Plan for near-universal coverage died in the U.S. Congress. Then, the Oregon Health Plan's employer mandate (also designed to increase access for the working poor) was laid to rest in the back halls of the Oregon legislature.
In Jackson County, where physicians have had a long tradition of trying to provide care for all its citizens, we were confronted daily with both the economic mandates of managed care and the awareness that 20-25% of our neighbors and had no access to health care other than through emergency rooms in crisis situations. Fortunately, our community had three resources with which to respond to this enormous challenge.
First, there were already two long-established low income clinics (La Clinica de Valle and the Community Health Center), each providing remarkably good outpatient primary care to this population on a shoestring budget. However, they had little or no access to specialty consultation, procedures or hospitalization.
Second, Jackson County was served by three very community oriented hospitals (Rogue Valley Medical Center, Providence-Medford Hospital and Ashland Community Hospital), each of which was willing to subjugate some of the mandates of managed care competition to the higher priority of health in larger community. They each agreed to donate all hospital and diagnostic services for patients referred through the VOLPACT program.
Finally, the physicians of Jackson County, who had a long history of providing care to the needy during times of economic hardship, again responded magnificently. 85% of them volunteered for VOLPACT and have each subsequently donated a yearly average of three consults or procedures or hospitalizations for uninsured patients ("the working poor") referred either form the low income clinics or their own offices. With over 300 physicians participating, that equaled a lot of care!
In 1995, then, these three entities cautiously joined hands to form VOLPACT. Most remarkably, this all took place at the height of a managed care war which still threatens this community. Referrals were (and are) screened and equitably dispersed by a nurse at Jackson County Medical Society. Spreading the work so widely over so many physicians and facilities has successfully limited the burden on any one of them. The results have been gratifying, at times heart warming, for all of us. Although we have certainly not eliminated "the gap" between welfare and affordable private insurance, we have, indeed, narrowed that gap considerably. Far more important is the sense of each other as respected partners in a community of caregivers. (We are decidedly not just economic competitors).
Perhaps most important has been the personal reaffirmation of ourselves as being, first and foremost, compassionate physicians.
Have we solved all the problems for ourselves or this group of our impecunious neighbors? Obviously, not. However, we have gained an awareness of the magnitude of the problem of access to medical care in our own community. We have begun to appreciate the personal anguish which occurs when a friend or neighbor is poor and sick and has nowhere to turn for care. Answering that need has been a moral priority for our profession for a long, long time. We are thankful (and just a little proud) that our community has recognized the opportunity and reconnected with our professional roots. Currently, we seem committed to continuing VOLPACT for as long as the need exists.
As an increasing number of Chapter members will be facing recertification in the coming years, the following information is provided as an overview of the process and is contained on the ABIM's web page (www.abim.org).
In 1986, after two decades of discussion and debate, the American Board of Internal Medicine (ABIM) decided to limit the duration of validity for all Board certificates to ten years. This policy became effective in 1987 for critical care medicine, 1988 for geriatric medicine, and 1990 for certificates in internal medicine, each of the subspecialties of internal medicine, and all other added qualifications.
The rapidly changing scope of medical information, evidence that the knowledge and skills of practicing specialists decline with time, and growing public concern over the need to periodically recredential physicians were the major determinants in the Board's decision.
Certificates in internal medicine or a subspecialty issued prior to 1990 are not time-limited and, therefore, are valid for life. Individuals holding these certificates are encouraged to recertify and may do so without placing their time-unlimited certificate at risk. When Diplomates are successful on the Recertification Examination, the Board will issue an additional certificate, valid for ten years.
The recertification process recognizes the Board's commitment to professionalism and our belief that lifelong scholarship is required for clinical practice and the care of patients. Recertification provides a peer-recognition of excellence that the Board has aspired to since its inception in 1936.
ABIM's goals for recertification are to: 1) improve the quality for patient care; 2) set high standards of clinical competence within internal medicine, its subspecialties, and areas of added qualifications; and 3) foster the continuing scholarship required for professional excellence over a lifetime of practice.
Entry into the Process
The Board intends entry to be simple and straightforward. Diplomates may apply for entry into the process of recertification at any time after initial certification or recertification. The only requirement is that Diplomates must have been previously certified by the ABIM in the areas(s) in which they seek recertification. Diplomates may be recertified in several disciplines simultaneously.
Recertification in a subspecialty does not require recertification in internal medicine. However, candidates seeking recertification in added qualifications (e.g., critical care medicine, geriatric medicine, interventional cardiology, clinical cardiac electrophysiology, adolescent medicine, and sports medicine) must possess valid certificates in the underlying discipline to which the certificate is added either internal medicine or a subspecialty. (For example, we require Diplomates recertifying in clinical cardiac electrophysiology to have a valid certificate in cardiovascular disease).
For subspecialists, this policy means that Diplomates can allow a time-limited certificate in internal medicine to expire without jeopardizing recertification in their subspecialty. But, if a Diplomate permits expiration of his or her time-limited certificate in internal medicine, he or she will no longer be regarded by the Board as a certified internist or listed in the ABIMs Directory for Board Certified Internists as certified in internal medicine. For those subspecialists whose practices include general internal medicine, this option may not be desirable.
There are three steps for recertification: a self-evaluation process, assessment of clinical competence, and a final examination. Diplomates may do steps 1 and 2 concurrently, but all three steps must be completed within established time limits.
Step 1. The Self-Evaluation Process
The Self-Evaluation Process (SEP) is an at-home, open-book, self-evaluation examination that provides the Diplomate an opportunity to assess broadly his or her strengths and weaknesses before taking the recertification Final Examination.
Step 2. Assessment of Clinical Competence
The Board requires peer assessment of clinical performance at the local level for recertification. Diplomates need a valid and unrestricted license, a current Basic Life Saving (BLS) or Advanced Cardiac Life Support (ACLS) certificate, and validation by a chief of staff or credentials committee at a hospital, clinic, institution or other similar organization that the Diplomate is in good standing and possesses satisfactory clinical competence.
Step 3. The Final Examination/Simultaneous Recertification
The last step in the recertification program is a one-day, proctored, multiple-choice Final Examination. Like the Self-Evaluation Process, the Final Examination contains 60-question modules. It will be administered annually at multiple centers and three attempts are permitted before we require Diplomates to repeat the SEP step.
Registration and Examination Schedule
There is an open registration for application to the Recertification Program, and the Final Examination is administered annually in November.
Registration for a November Final Examination requires completion of Steps 1 and 2 and application by September 1 of the year of examination.
Applications may be requested 24 hours a day during the registration periods by e-mail or by FAX (215-446-3590 or 215-446-3470).
This edition's column related to career paths taken by internists is authored by Gene George Hong, MD. After completing medical school at Stanford and residency training at Legacy Emanuel Hospital, Dr. Hong received an Acupuncture Practice Certificate from the China International Acupuncture Training Centre in Beijing and did an acupuncture apprenticeship in Taichung, Taiwan. Certified by the ABIM and the American Academy of Medical Acupuncture, Dr. Hong practices medical acupuncture in Portland.
My interest in acupuncture and alternative medicines began early in my training as a physician. During my last year at Stanford Medical School, I helped organize a seminar series in acupuncture. My colleagues and I at Stanford had found many of our patients to be users of both alternative and Western medicines. Our patients were also reluctant to tell us about this, which only made us more interested. As Stanford students, we were able to invite local practitioners of acupuncture to come and speak to the faculty and students regarding the use of these alternative techniques. The numbers of patients who used these techniques and what conditions were treated was quite surprising to us. Among the practitioners who were invited to speak there were a number of visiting Chinese professors at Stanford who also gave presentations about the use of acupuncture in China. One of these visiting scholars described a program that was sponsored by the World Health Organization and the Chinese government to train foreign physicians in acupuncture. I was invited to apply and to study acupuncture in China.
After graduating from Stanford in 1989, I completed my residency in Internal Medicine at Emanuel hospital in Portland, Oregon. I went to Beijing to study acupuncture at the China International Acupuncture Training Centre of the China Academy of Chinese Medicine. I returned to the U.S. and passed my Boards in the Fall of 1992. Instead of directly going into practice, I went to Taiwan to further my training and practice of acupuncture. I returned to the U.S. in April 1993 and began my practice in medical acupuncture. It was a difficult first year. However, by my second year of practice, I had built up a base of patients so that I was no longer worried about paying the monthly rent. Currently, my practice consists entirely of acupuncture, and I am very busy.
I enjoy my practice very much. Acupuncture gives me an opportunity to help patients when the standard medical interventions are not effective or when the interventions are potentially harmful. In such situations, acupuncture is an effective adjunct that can reduce the patient's pain and suffering. Often, I am the physician that they see as a last resort. Because other physicians have been unable to help, just being able to help a little is a huge success in the eyes of the patient. Given that acupuncture is very effective in many conditions, I am successful in the majority of cases that I treat. My patients appreciate the care that they receive from me, and will then refer family members or friends to me. As a result, my practice has grown primarily through patient referrals.
Because of this clinical success, the acceptance of acupuncture has been increasing in the U.S. over the past several years. Until recently, most physicians remained skeptical about the effectiveness of what they perceived as an unproven and potentially dangerous folk remedy. Even if they did not actively discourage their patients from using these alternative techniques, they could truly say that there were simply no Western scientific studies published that supported the effectiveness of acupuncture. Without these studies, most physicians could not recommend alternative medicines even if they wanted to. However, over the past decade, this is no longer the case. There are now several hundred scientific articles and studies published in accepted Western medical journals about the relative effectiveness of acupuncture in clinical trials and physiological studies on the biologic mechanisms of acupuncture. The NIH, in November, 1997, issued a consensus statement regarding the effectiveness of acupuncture in the treatment of disease. In this statement, acupuncture was found to have enough clinical effectiveness as evidenced by studies to warrant usage and further investigation. Given these developments, the support that I have from my physician colleagues has grown substantially. Other internists, especially those who I trained with, have referred patients to me. They have also consulted me regarding acupuncture therapy for both their clinic and hospitalized patients.
Often I am asked if I feel that my training in Internal Medicine has been wasted. In truth, I am comfortable offering acupuncture therapy to my patients precisely because I am confident of my knowledge of Internal Medicine. When I see a patient and take the standard history and physical, I know the benefits and risks of the Western medical therapies that they have been prescribed. I am also aware of other medical tests and specialist evaluations that may help the patient if they have not already had these interventions especially if the patient has unusual responses to acupuncture. In my practice, I emphasize to the patient that acupuncture and Western medicine are not mutually exclusive. Many techniques can be used so that optimal health can be achieved. And, above all, do no harm.
This phenomenon of alternative medicine is growing rapidly in the U.S. It is fast becoming a component of standard health care. Those of us who have training in both Chinese and Western Medicine are in a unique position. We are asked to be leaders to guide and foster understanding and acceptance of this newest part of medicine. In Oregon, a group of us, MD/DO practitioners of acupuncture, have recently created the Oregon Academy of Medical Acupuncture to promote the practice of acupuncture by physicians. We are a local chapter of a larger organization, the American Academy of Medical Acupuncture. This national organization, of which I am also a member, has been working to create standards of acupuncture training and practice for physicians. In the future, acupuncture may become a medical specialty. I have also been helping to establish standards of acupuncture practice so that insurance companies can begin covering acupuncture as a medical service. The company where I am a board member and also serve as medical director of acupuncture, AcuMedNet, has recently signed contracts with Providence and Kaiser to provide "managed" acupuncture services. It is a brave new world.
Like the National ACP-ASIM, 21% of the Chapter's membership (241/1169) is comprised of Associates (and growing). The following is some information about Associate membership:
- If you are enrolled in an approved internal medicine training program, you are eligible to be an Associate at the lowest member rate for up to 6 years beyond medical school graduation, or for as long as you are in a residency or fellowship training program in internal medicine or one of its subspecialties.
- As your Associate term draws to a close, you will be notified and invited to apply for full membership (this is not automatic).
- There are National (14 member) and Chapter Councils of Associates.
- At the Oregon Chapter level, we have included the right to vote for Associate members in our new bylaws.
- Dues are $96 annually and include Annals, Journal Club and Observer.
- Tell your colleagues about ACP-ASIM. For more information, call 1800-523-1546, ext. 2700.
This edition's Media Column is authored by Don Venes, MD, MSJ, ACP-ASIM Member from Brookings. A graduate of the New York University School of Medicine, Don did his housestaff training at the University of Virginia and OHSU and has been a staff internist at Siskiyou Community Health Center in Cave Junction. Don also has a Master of Science in Journalism degree from Medill School of Journalism, Northwestern University, and is Medical Editor of Taber's Cyclopedic Medical Dictionary (19 th edition in 2001).
I'd like to tell you something about physicians and the press, not as a professionally trained journalist, nor as a board certified internist (I am both), but as an amateur observer of modern culture.
Very few physicians approve of the coverage that medicine gets in the press.
In our view, journalists usually get the story wrong, place emphases where they shouldn't, foul up some of the details, have an axe to grind, or worse, just don't understand what contemporary medicine is about.
Why do we feel this way? What can we do to improve matters?
I will submit, with not data and a silo-full of speculation, that cultural distinctions between our two disciplines play a large role in our lack of comfort with journalism.
To understand our differences from the press, we must make an effort to see ourselves in our intellectual culture, to study how we think as professionals, and then try to gain some insight into the work done by our counterparts in the press.
Let's begin by defining our tacit epistemologies. Quite generally, we tend to think about things analytically, probably as a result of our scientific and technical training. We learn about the brain, for example, by putting neurons into solution. This seems so natural to us, we may forget that it is wholly alien to almost everyone else.
We like scrupulous randomization; we like to be blinded to outcomes. We require exclusion criteria in order to understand how drugs work, whom to treat, when to act. We have nearly religious interest in the acquisition - and the advancement - of Knowledge. We eschew anecdotes. We take our lead from the techniques of physics even though our clinical work is a most human endeavor.
We are uncomfortable when what we know accrues in uncontrolled settings. We learn from our experiences, but we really trust only that information that has been edited by a blue chip journal.
Our speech is cautious, prescribed, and often dictated to us by experts, specialists, or managers. It is not in our character to wing it.
Journalists think and act quite differently. Their role is to communicate what is new, what is different, what is beautiful, tragic, outrageous - what is at the leading edge - and yes, what is worthy of funding. To identify the heroic. To highlight the ripoff. To point out what the emperor is actually wearing. To speak freely. To communicate complex material efficiently.
In short, journalists aim to describe the human comedy, not to cure it.
The news is a cavalcade of good and bad deeds, of personality and character, of metaphors, of blockbusters, of flops. It defines on a daily basis not what is provable or profound, but what is meaningful to you and me today.
So as the millennium nears, the economic or social consequences of medical research are more important to the journalist than the details of the research itself. The way resources are allocated in medicine will likely get more play, and certainly more commentary, than the fact that the resource was developed from a DNA-dependent RNA gyration. The journalist is uncomfortable with what we do in medicine when facts collide and the story isn't clear - when medical science looks more like modern art - all paint and feathers - and less like the cold truth of the universe revealed. This is especially so in trying to understand our recommendations about lifestyles and common ailments. To the reporter, scientific reports on diet or exercise (or cancer) look like a moving target, full of qualifications, revisions and footnotes. To the press (and in the press) our epidemiology seems to be the product of an overeducated, arrogant group of nerds who have come unglued.
How can we improve our communication with reporters? Where do our two disciplines meet? At the crossroads of what is credible. At the juncture of what can be substantiated. At the nexus of meaning. At the gateway to the future. And these are just the intersections where physicians and journalists daily greet each other or collide as we fulfill our own unique roles in a democratic, complex, and eccentrically progressive society.
- Andrea M. Kielich, MD, FACP - Recipient of the 1998 Howard P. Lewis Distinguished Service Award of the Chapter
- D. Lynn Loriaux, MD, Ph.D., FACP - Recipient of the 1998 Howard P. Lewis Distinguished Teacher Award of the Chapter
- Andrea Chun, Ian deBoer, Lisa Johnson, and Adam Williams, ACP-ASIM Student Members and members of the Class of 1999, School of Medicine, OHSU, for election into AOA Honor Medical Society
- Peter Kohler, MD, FACP, for being named Chair of the Board of Directors of the Association of Academic Health Centers and Chair of the Committee on Quality in Long-Term Care of the Institute of Medicine
- John A. Benson, Jr., MD, MACP, for being named Chair of the Institute of Medicines' Review Committee "Medical Use of Marijuana: Assessment of the Science Base"
- Thomas G. Cooney, MD, FACP, Chair, Federated Council for Internal Medicine, 1998-99
|April 22-25, 1999||ACP-ASIM Annual Session - New Orleans, LA|
|June 1, 1999||Fellowship Applications due at ACP-ASIM|
|August 24-25, 1999||ABIM Certification Examination in Internal Medicine|
|November 4, 1999||Infectious Diseases Society of Oregon Meeting
|November 4-6, 1999||OR-ACP-ASIM Chapter Annual Meeting, Eugene, OR|
|December 1, 1999||Fellowship Applications due at ACP-ASIM|
|April 13-16, 2000||ACP-ASIM Annual Session, Philadelphia, PA|
How to Reach Us
|James B. Reuler, MD, FACP
Section of General Medicine
Veterans Affairs Medical Center (P-3-MED)
PO Box 1034
Portland, OR 97207
503-220-8262, ext. 55582
|Mary A. Olhausen
Department of Medicine
Oregon Health Sciences University
3181 SW Sam Jackson Park Road, OP-30
Portland, OR 97201-3098