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Governor's Newsletter Summer 2002

Stephen R. Jones, MD, FACP
Governor, Oregon Chapter

Greetings From the Governor

It has been a year since I took over the Chapter Governorship from Jim Reuler. At that time, I said that I would focus the Chapter's efforts in three broad themes: Education; Advocacy and Policy; and Financial Management of the Chapter. My assessment of the success of the Chapter in these areas is mixed.

Education. The fall meeting in Eugene was by most accounts successful. The program content was widely praised. The audiovisual support was widely criticized. The Program Committee, with the unanimous approval of the Chapter Council, has recommended that the Annual Chapter meeting, which has been held in Eugene since its inception in the mid-70's be alternatively held every other year in Eugene and in Portland. The 2003 meeting is scheduled for Eugene in the fall of 2003, and the 2004 meeting will be held in Portland. This is an important change, and the effect will be evaluated: remember a key acronym of current industry and medicine: "PDSA" which stands for Plan-Do-Study-Act. This is what the Chapter leadership pledges to do with the site selection for the annual meeting.

Advocacy and Policy. It was a major loss to the Chapter that Martin Jones of Eugene elected to turn his full attention to the leadership of the Lane County Medical Society. His advocacy in the name of the Chapter for gun control and smoking cessation was influential. Bob Gluckman has stepped forward to assume representation of the College to the Oregon Medical Association.The Chapter is working with Governor Kitzhaber's office to advocate for limiting budget cuts as a response to the State's budget crises.

Financial Management. The inertia of the Chapter leadership provided a wise strategy of non-investment: the Chapter reserves remain safely invested with low-yields but no losses. Our Chapter Treasurer, Arthur Hayward, will give the financial report at the business meeting of the Chapter in Eugene on November 15.

Annual Oregon Chapter Meeting, November 14-16, 2002

Please join your colleagues at the year's most important statewide meeting in our field: The 2002 Oregon Chapter Scientific Meeting, at the Eugene Hilton Hotel, Eugene, OR. Thursday evening starts off with the Associates Council Clinical Vignette & Research Poster display and Clinical Vignette Presentations following dinner. At the Scientific meeting, on Friday & Saturday, we will be hearing the latest on antibiotic use, new contraceptives, osteoporosis, diabetes mellitus, patient safety, integrative medicine, and preventive services task force. Keynote speakers include Joseph Silva, MD, FACP, Regent, College Representative; John A. Kitzhaber, MD, Governor, Oregon; and Christine K. Cassel, MD, MACP.

Infectious Diseases Society of Oregon

The Infectious Diseases Society of Oregon invites you to attend the 12th Annual Conference, which takes place November 14, 2002, at the Eugene Hilton Hotel, preceding the Oregon Chapter Scientific Meeting. The IDSO meeting will highlight Dr. Jack Bennett from NIH speaking on fungal infections, Dr. Joeseph Silva, MD, FACP, Regent from U.C. Davis speaking on management of Clostridium difficile infections, Sally Williams from SW Washington speaking on Hepatitis C, and Dr. James Leggett will make recommendations on judicious use of antibiotics for respiratory infections. Afternoon sessions will be on two tracks-one for primary care physicians and the other for infectious diseases specialists. For more information about the IDSO meeting, please contact Elizabeth Kerl at (503-215-6088), or email (ekerl@providence.org).

Profesionalism and Quality: How They Come Together

Christine k. Cassel, MD, MACP, Dean, School of Medicine, Oregon Health & Sciences University; President, American College of Physicians, 1996 - 1997

One of the major themes in medicine today is the increasingly vivid voice from consumers and purchasers for improvement in quality of care and accountability, linked by outcomes measurement. A second, happening in parallel to this quality crescendo, is a growing concern about professionalism within the practice of medicine. The challenges to professionalism are all around us, so it seems. Most immediately we perceive economic pressures to cut corners, reduce costs, see more patients, spend less time, become more efficient. To many physicians, these pressures are inimical or at least threatening to the fundamental basis of trust-that the physician is completely dedicated to the care of that individual patient and will spare no effort and no cost in the evaluation and treatment for the patient. Responsibilities to society, to health care organizations, to insurance companies and to government, as well as demands for population health to look beyond the individual to what really benefits whole populations, are potentially in conflict with that individual doctor-patient responsibility. These challenges and concerns have given rise to a lot of discussion about professionalism, raising the question of whether it can be strengthened, whether we are losing the core of values that support professionalism, or whether those values need to be redefined in the modern world.

Among the activities related to professionalism, one of the most notable has been the collaboration between the American Board of Internal Medicine Foundation, the ACP-ASIM Foundation, and the European Federation of Internal Medicine. This coming together of an international group of internal medicine colleagues demonstrated that many of these concerns are not just limited to the United States. Sharing concerns and ideas cross-nationally, created a consensus about both the core challenges and also the core values for a modern physician charter. This charter is meant to be a strong message to society and to patients of the values of professionalism, as well as a shared pledge for physicians. It was published in the February Issue of the Annals of Internal Medicine and simultaneously in Lancet (Annals of Internal Medicine: 2002, 136: 243-246). It received a very wide audience, was picked up by a number of public media, including USA Today, and has generated ongoing interest. Medical schools across the nation and in Europe are using this document to teach and to stimulate examination of the values of professionalism. Medical organizations are distributing it widely. Hopefully, civic groups, hospital boards and others are doing the same. I believe that this new examination of professionalism is a healthy one and that if we examine it we will recognize that the quality movement is in fact an opportunity for a clear response to the demand for professionalism in the modern world of medicine.

The reason why quality and professionalism go hand in hand is precisely because over the last century medicine has evolved from an isolated cottage industry without much of an effective science base to a highly complex, highly technical and extremely effective, scientifically driven enterprise. We can do much more good for patients now, but we also have the potential to do much more harm, as described in the IOM report on medical errors. Our powerful technologies do not in any way diminish the importance of the humanistic aspects of medicine; communication skills, empathy, care and attention to the relief and compassion about sources of suffering. But in order to take advantage of the effectiveness of modern medicine, great expenditures are needed. Modern medicine is expensive and patients and families cannot afford to pay entirely out of pocket for it, thus enter other sources of payment: insurance companies, the government through Medicare and Medicaid, the Veterans Administration and the Military Health System, employers through their contribution to insurance and others. Even though our health system is built on the third party payer, as costs have continued to escalate more and more of the payment is being loaded back onto families and patients. All of these stake-holders, the payers and the patients, have a right to demand some evidence that what they are paying for works and is of value to them.

The characteristics outlined by the Institute of Medicine's in Crossing the Quality Chasm, are what every patient and every payer has a right to expect, that care is safe, timely, effective, efficient, equitable, and patient-centered. The fact is that, as we look around at our complex and often fragmented health care system, these simple criteria very often are not achieved. And if they are, we have no way of knowing or demonstrating that except in anecdotal cases. But we now have the science of quality measurement, like medicine itself is a science that is advancing and improving in its effectiveness. As we are able to measure quality, we are more able to justify the costs that go along with health care and to reduce unnecessary costs wherever that is possible. When we, physicians, think of quality and outcomes measurements we tend to think of hospitals, of accrediting bodies such as the Joint Commission and NCQA, but we should also be thinking about our own profession. Our measurements of quality include: board certification and accreditation of our training programs through the ACGME. In both of these areas we are see more progress in a form of accountability to the public that means the demands of the modern quality movement and gives the profession an important leadership role in that. Outcomes measurement is not just a regulatory tool, but also more importantly a way to improve quality. Practical quality measures, reported back to physicians, create a way to improve performance in a continuous manner. The ACGME is, this year, initiating requirements for competencies in health care that reflect the challenges of the Institute of Medicine's report on quality. At the same time, the American Board of Internal Medicine has initiated an important step to take recertification, a simple paper and pencil test, into the modern world of a non-punitive quality improvement model that will allow physicians throughout their careers to evaluate their own performance, using the specialty base and patient population specific to their practice and to develop models of both demonstrating the quality of outcomes and using that data to continually improve that quality. This is an exciting new area, challenging because it is unfamiliar to many of us, but inherent in the values of professionalism.

Prescription For Safety

Physicians' handwriting is a source of endless jokes, but illegible orders are no laughing matter. Illegible handwriting on prescriptions takes extra time to interpret, and pharmacist callbacks result in lost time to the practitioner. Tragically, illegible handwriting is a common cause of medical error and has led to patient injury and death. According to a 1997 American Medical Association report, errors related to misread prescriptions were the second most common and expensive malpractice claim over a seven-year period. To prevent errors, prescriptions should:

  • Be legible
  • Use the metric system
  • Avoid abbreviations and decimals
  • Include the medicine's

ACP-ASIM promotes patient safety through its three-year initiative, Patient Safety: the Other Side of the Quality Equation, supported by a grant from the Agency for Healthcare Research and Quality. To find out more about the College's patient safety program, visit ACP-ASIM Online, or call Kyle Bartlett, PhD, at (215-351-2838).

PIER- Physician's Information and Education Resource

The Physicians' Information and Education Resource: Authoritative, evidence-based guidance to improve clinical care.

As of Annual Session 2002, the College opened the Physicians Information and Education Resource (PIER) Web site to all College members. Members can use it to access clinical information in the patient care setting and at other times as a practical medical knowledge resource. Sign on to PIER by going to (http://pier.acponline.org).

The College is counting on feedback to make PIER better. Please be aware in urging fellow members to use PIER and in doing so the "Contact Us" link can be found at the bottom of each web page in PIER. It can be used to suggest new topics, to send comments or to report technical problems. PIER will be constantly growing and changing, and there will be much to comment upon. In addition, the College plans to introduce a brief electronic questionnaire requesting additional feedback.

2002 Convocation Ceremony: Inducted Fellows

There were 613 Fellows inducted at the 2002 Convocation ceremony held at the Pennsylvania Convention Center on April 11, 2002. Among the inductees was Richard Gicking of Portland. It is anticipated that many of the Oregon Members who have been accepted for Fellowship, but who had not been inducted, will attend the next Annual Session, which will be held in San Diego April 3-5, 2003. These include, Charles R. Elder, Portland; Todd N. Guenzburger, Portland; James W. Hall III, Jackson; Robert C. Lusk, Portland.

Further Observations On Change

Stephen R. Jones, MD, FACP, Governor, Oregon Chapter

The Federated Council for Internal Medicine (FCIM), have recently published a detailed Resource Guide to Curriculum Development for Internal Medicine. Examination of this document confirms the dramatic changes that have and continue to shape the specialty of internal medicine. While this document is intended for directors and faculty of training programs, all internists will find interest in parts of the document. For example, Chapter 1 is titled The Forces Shaping Internal Medicine. It is pointed out that recent changes are only an acceleration of changes started in the 1960's: First the rapid growth of subspecialty medicine; and secondly, society's desire to control medical costs. In later decades, the corporatization of health care delivery systems with the industrialization of processes and necessarily people emerged. This document suggests seven external forces that will affect American medicine:

1. Medical care will continue to move out of the hospital and into other settings. Internists who previously had many inpatients now typically have only a few. Often, they have no one in the hospital. More and more, one's inpatient service consists of patients who are critically ill or dying and who represent a very small, though still very important, proportion of internal medicine practice.

2. The role of the primary care physician will expand. Physicians who embody traditional strength of internal medicine and have the new ambulatory skills (e.g. behavioral disorders, musculoskeletal injuries, women's health, and prevention) will always have a special role in the community.

3. The practice of medicine will become more highly organized. These trends mean that physicians must now be prepared to function in teams whose success will be measured by medical outcomes, cost, and patient satisfaction.

4. Medical knowledge will continue to expand rapidly. The rapid pace of care in the ambulatory setting poses a particularly sharp challenge to learning the scientific basis of clinical phenomena. Nonetheless, we must find a way.

5. The growth of the elderly population in the United States will strongly influence medical practice. a)All internists will need to have skills in geriatric care. b) Long-term care venues will be practice sites for internists.

6. Internists will continue to have a spectrum of career opportunities.

7. Economic forces will change the structure of graduate medical education. a) GME will move into the ambulatory setting and become more expensive. b) Trainees will cover fewer inpatients & relatively expensive substitutes will be found. c) Ambulatory reaching will be more formal and, therefore, more expensive.

This document takes a fresh look at internal medicine. The recommendations that it contains for graduate medicine in internal medicine were drawn from the opinions of hundreds of internists who represented many perspectives: both academia and community as well as practitioners of both primary care and specialty medicine. I believe that a brief review of the document will convince you that your practice is not alone in change, but you are in the company of many who share your discomfort. This document is not literature, but reading this document is similar to reading good literature: it gives us an opportunity for the recognition that we are not alone in our experiences and our dilemmas, and as such it provides both comfort and guidance.

Oregon Chapter Supports Physician Well-being Conference Sponsored by the Foundation for Medical Excellence

The Chapter has made a major financial contribution in support of The Foundation For Medical Excellence's Physician Well-Being Conference, to be held on Saturday, October 12, 2002, at Skamania Lodge in Stevenson, WA. This highly regarded conference brings area clinicians together with an outstanding group of regional and national educators to discuss issues of mutual concern that affect physician well-being. This year Rachel Naomi Remen, MD; Thomas Inui, MD; and David Grube, MD have been chosen as keynote speakers. For more information, contact: The Foundation For Medical Excellence, One SW Columbia Street, Suite 800, Portland, OR, 97258. Phone: (503-636-2234) Fax (503-769-0699) Email (info@TFME.org).

Awards

Joseph F. Boyle Award for Distinguished Public Service-John A. Kitzhaber. Dr. Kitzhaber is the highly regarded Governor of the State of Oregon. He is nationally recognized for authoring the groundbreaking Oregon Health Plan. He is credited both with the crafting of the plan itself and for bringing together diverse interest groups to pass the law. The plan, which went into effect in February 1994, has reduced the number of uninsured Oregonians by 200,000. It directs state monies to those areas of health care that provide the greatest value to the patient. Governor Kitzhaber has provided outstanding public service and improved the delivery of health care not only in Oregon, but, through his example, nationally as well. He continues to seek better health care for the underinsured in Oregon, devoting his energies in 2001 to improving access for needy children. In addition to his busy schedule as State Governor, he is Clinical Associate Professor of Health and Preventive Medicine at the Oregon Health & Science University in Portland. He is also a faculty member of the Estes Park Institute in Englewood, CO.

Oscar E. Edwards Memorial Award for Volunteerism and Community Service-James B. Reuler. Ever since volunteering in a free clinic in a public housing project as a medical student at the University of Chicago, Dr. Reuler has devoted his career to bringing health services to the underserved. In 1983, he founded the Wallace Medical Concern, a nonprofit agency delivering health care to homeless adults, street youth, and medically needy families in emergency shelters, drop-in centers, and single room occupancy hotels. The Concern, a founding member of the coalition of Community Health Clinics in Portland, operated clinics four evenings each week with over 225 volunteer physicians, nurses, medical students, and interpreters providing general medical, dermatology, podiatry, and chiropractic services free of charge. The Concern is funded almost entirely by contributions from individuals and local businesses and foundations. In addition to acting as a preceptor to students and residents in community service advocacy for the poor, Dr. Reuler has served in every possible administrative role in the clinics, including wielding a paintbrush and moving furniture.

Founders Award:Association of Program Directors in Internal Medicine (APDIM)-Thomas G. Cooney. The highest award bestowed by the APDIM, Dr. Cooney is a strong leader and advocate for education, and the protection of residents and patients. He received this award in recognition of his spectacular leadership and contributions to undergraduate and graduate medical education; his organization and development of training programs in internal medicine; and his contributions to several other organizations that have a leading role in the training of internists.

**If you have suggestions or nominations, please contact Bob Gluckman, MD, at (rgluckmanmd@providence.org).**

How to Reach Us

Stephen R. Jones, MD, FACP
Legacy Good Samaritan Hospital
1015 NW 22nd Avenue (R-200)
Portland, OR 97210
Phone: 503-413-8258
FAX: 503-413-7361
Email: sjones@lhs.org

Mary Olhausen
Department of Medicine (OP-30)
Oregon Health & Science University
3181 SW Sam Jackson Park Road
Portland, OR 97201-3098
Phone: 503-494-8676
FAX: 503-494-5636
Email: omary@teleport.com

Upcoming Dates

October 2002
Physician Well Being Conference, Skamania Lodge, WA

November 14-16, 2002
Oregon Chapter Scientific Meeting, Eugene, OR

April 3-6, 2003
ACP - ASIM Annual Session, San Diego, CA

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Page updated: 06-24-03

Contact Information

Thomas G Cooney, MD, MACP
Oregon Chapter Governor

Mary Olhausen
Phone: 360-892-1814
Fax: 360-326-1844