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Governor's Newsletter Winter 2002

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

Outstanding Annual Chapter Meeting

November 13, 2001, Eugene

The Program Planning Committee, chaired by Linda Humphrey, and ably and enthusiastically assisted by Mary Olhausen, Chapter Administrative Assistant, and Leslie Doering of the OHSU CME Department, once again organized and presented an outstanding Annual Meeting.

Here are some highlights:

Associates Competition
The high quality of the presentations continues. Congratulations to all the participants and to the winners of the competition.

Oral Clinical Vignettes
1st Prize: Ryan Petersen, MD---Providence Portland Hospital
2nd Prize: Katherine Schimidt, MD---Legacy Portland Hospitals

Clinical Vignettes Posters
1st Prize: Jennifer Marfori, MD---University Hospital
2nd Prize: Eric Bernstein, MD---Providence Portland Hospital
3rd Prize: Andrea Navarijo, MD---Providence Portland Hospital

Clinical Research Poster
1st Prize: Sharon Kenny---Legacy Portland Hospitals

Chapter Awards
Howard P. Lewis Teaching Award
Keith Harless, MD, FACP, Bend

Howard P. Lewis Community Service Award
Frank Baumeister, MD, Portland

ACP Excellence Award
College Representative, Eric Larson, MD, FACP, awarded the ACP-ASIM Excellence Award for Chapter management in the year 2000. Mary Olhausen and Jim Reuler are responsible for the work that lead to this recognition.

The Scientific Program was widely praised both for content and style. Yes, the computer generated A-V errors will be corrected for 2002, and time will be closely managed.

Four Oregon Internists Selected for Fellowship

Congratulations to four ACP-ASIM Members from Oregon who have been selected for advancement to Fellow by the College Membership Committee:

Ronald J. Dworkin, MD, FACP - Portland
Anne M. Hirsch, MD, FACP - Portland
Richard C. Gicking, MD, FACP - Portland
Sharon A. Meyers, DO, FACP - Eugene

Information about the requisite qualifications for Fellowship may be found on the web. I encourage ACP-ASIM Members to review the material at this site, and if you qualify, request an application from the conveniently listed Email address at this site.

Annual Session - Philadelphia - April

Join the College April 11-14, 2002 and be a part of Annual Session 2002 in Philadelphia. Experience over 275 sessions covering the spectrum of internal medicine and the subspecialties. Upholding tradition, ACP-ASIM promises to offer a rich educational experience with an emphasis placed on content that is clinically relevant and practice oriented.

Be Sure Not to Miss...

  • Clinical Pearls—
    Remember those words of wisdom from your most respected clinical teachers? Those Pearls were based on an experience of depth and knowledge of medical literature of remarkable scope. Pearls are noteworthy for their clarity, timelessness, and clinical applicability.

    Introduced at the 2001 Annual Session and an instant hit, Clinical Pearls rekindles the joy of bedside learning, using a highly engaging, case-based format. With the audience-response keypad-system, you'll have a chance to test the depth of your clinical acumen. You'll leave each session with a rich collection of Pearls, ready to be applied directly to your patients.

  • Multiple Small Feedings of the Mind—
    Rated by many as the best of Annual Session, Multiple Small Feedings of the Mind uses a creative format to address some of the most common, yet challenging or controversial, patient-management issues. In these highly focused, fast-paced sessions, faculty offers answers to some of the most frequently faced dilemmas in patient care.

  • The Learning Center—
    Experience the excitement of the Learning Center. Refine your techniques in a variety of office-based examination and procedural skills. Take advantage of small group or individual tutorials with experts in the field. The Learning Center is unique to Annual Session and offers a wide range of opportunities for closely supervised, hands-on practice. Become familiar with procedures and examinations you don't perform on a routine basis. Try out the latest software for clinical information management and patient care. The Learning Center is a dynamic collection of hands-on activities, which you can immediately apply to your clinical practice.

  • Update—
    Keep up to date on the year's most important published papers in the subspecialty areas. Learn significant findings and their impact on patient care. Nationally recognized faculty reviews the literature and presents the year's highlights.

Registration and other meeting information is available online. Visit the College website or contact Customer Service at 800-523-1546, extension 2600. Early sign-up is encouraged for the best selection of workshops and seating at breakfast/lunch sessions.

Oregonians Selected by Board of Regents for Major College Awards for 2002

John A. Kitzhaber, MD, will receive the Joseph F. Boyle Award for Distinguished Public Service given for outstanding public service to improve the delivery of health care.

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 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, Colorado.

James B. Reuler, MD, FACP will receive the Oscar E. Edwards Memorial Award for Volunteerism and Community Service. Dr. Reuler has been exceptionally active in the Society for General Internal Medicine and the ACP-ASIM. From the time he was a medical student to the present he has had an interest in the care of the medically underserved. In 1983, he helped found the Wallace Medical Concern, where he has served as volunteer physician and preceptor for medical students and residents. The Concern provides for those living on the streets or in shelters or without medical resources. It is funded almost entirely by voluntary contributions from corporations, agencies and citizens. Dr. Reuler has been a tireless advocate for the care of the poor, a potent fund raiser for the Concern, and served in every possible administrative role in the clinics including wielding a paint brush and moving furniture."

The Recertification Dialogue Between the American Board of Internal Medicine and the American College of Physicians---Review and Update

Herbert S. Waxman, MD, FACP, Senior Vice President, Education, ACP-ASIM

In the fall of 2000, ACP-ASIM began a dialogue about Continuous Professional Development (CPD), the ABIM's planned new recertification program, to be implemented in 2004. The ABIM sought College support of the program. The College sought fundamental changes in the proposed new self-evaluation modules.

Both organizations agreed to the establishment of a Joint Committee on Recertification, with ACP-ASIM represented by Drs. Bernard Rosof (Chair-elect of the Board of Regents), Barbara Schuster (Regent) and Barbara McGuire (Governor). Representing the ABIM were Drs. David Dansker (2000-2001 ABIM Chair), Douglas Zipes (2002-2003 ABIM Chair) and Ronald Loge (ABIM member). The staff members were Drs. Daniel Duffy (ABIM) and Herbert Waxman (ACP-ASIM).

The College has three concerns:

  • the burdensome, redundant nature of some of the self-evaluation modules,
  • the expansion in CPD of the ABIM's role from evaluation to education, which the College considers the purview of the professional societies, not the certifying boards, and
  • the absence of any requirement for ongoing education as an element of recertification. For its part, the ABIM seeks support by the College (and other professional societies) of CPD.

A survey of an ACP-ASIM membership sample showed that the concerns are highest about the proposed peer and patient evaluation module and the practice improvement modules. It was also ascertained that many members are already carrying out these activities in local or other programs and that the ABIM's specific requirements would therefore be redundant and of little value in enhancing the quality of practice.

However, the College is supportive of the concept of recertification. Importantly, the College also supports the four components of maintenance of certification, as agreed to by the American Board of Medical Specialties (evidence of professional standing, evidence of a commitment to lifelong learning and periodic self-assessment, evidence of cognitive expertise, and evidence of performance evaluation in practice.)

ACP-ASIM also accepts the appropriateness of a secure examination of medical knowledge and the additional self-evaluation of clinical skills. Further, there is support for the concept of self-evaluation of knowledge, but the College feels that high quality self-assessment programs (such as ACP-ASIM's MKSAP and self-assessment programs of specialty societies) should be acceptable alternatives to the ABIM's knowledge modules.

Over the course of the next six months, the discussions produced agreement in principle with the need to respond to the ACP-ASIM concerns but not agreement by the ABIM about the specific changes that would have to be made to satisfy the College's concerns.

At its March meeting, the Board of Regents (BOR) rejected a Joint Committee draft document, primarily because of the absence of sufficient detail to ensure that the ABIM's general accommodation would be translated into satisfactory specific modification of CPD. A further exchange of communications led to the articulation by the College, in a May letter to the ABIM, of what the College would consider a successful outcome of the negotiations. This letter was not responded to by the ABIM, which was also unwilling to see a resumption of negotiations at the level of the Joint Committee.

In July 2001, the BOR again articulated its support of a recertification process and a secure examination of medical knowledge. The BOR also sought to have the CPD peer and patient evaluation module made optional rather than mandatory and sought to allow other practice performance measures and quality improvement initiatives being carried out in the physician's practice to be substituted for the CPD practice improvement modules.

There was also that month a meeting of the leadership of the College, the subspecialty societies, and the member organizations of the Alliance for Academic Internal Medicine to discuss CPD and the various organizations' views and actions. A strong consensus emerged that was consistent with the major points the ACP-ASIM had raised with the ABIM. Indeed, several subspecialty societies had directly and independently communicated to the ABIM their proposals for changes in the CPD process, similar to those that were being asked for by the ACP-ASIM.

During the next two months, a dialogue continued, now involving Drs. Bernard Rosof and William Hall (ACP-ASIM President) from the College and Drs. Paul Ramsey (2001-02 ABIM Chair) and James Naughton (ABIM Secretary-Treasurer) from the ABIM. After several reiterations, a draft letter of agreement was signed by these four negotiators and sent to the ABIM and ACP-ASIM for action. We have heard that the ABIM has endorsed this letter. However, the BOR, at its October meeting, deferred action pending review of the letter by and receipt of input from the Board of Governors. This had been expected to take place in September, but the tragic events of September 11 caused cancellation of the September meeting of the Board of Governors, which will next convene in April 2002. The Board of Regents was encouraged by the changing tone of the ongoing discussions with the ABIM, although there remain issues to be resolved.

The ACP-ASIM is willing to continue negotiations with the ABIM but will take no action on any proposal from the negotiators until the Board of Governors has had an opportunity to provide input. Thus, until the spring of 2002, the College believes there exists a window of opportunity to move towards resolution responsive to the fundamental goals of both the ABIM and the ACP-ASIM.

Governor's Comments: As stated in the Summer Chapter Newsletter and at the "Meet the Professor", session at the Annual Chapter Scientific Meeting, November 2nd, I support the ABIM's Continuous Professional Development program. I am eager to hear your comments and encourage you to review the details of CPD at the ABIM website.

Regents Approve Resident Work Hours Position

The Board of Regents approved a position statement on resident work hours developed by the ACP-ASIM Council of Associates (COA). The six-point position holds that:

1. Safe working conditions for internal medicine residents and fellows is a top priority for the COA.

2. The COA encourages the ACGME to improve its systems of monitoring and enforcing their current regulations.

3. The COA believes the medical profession itself needs to be more responsible in monitoring and regulating the working conditions of internal medicine residents and fellows.

4. The COA fully supports the efforts of other national organizations in addressing and reforming resident work hours.

5. The COA feels that further systematic study of this issue is needed.

6. The COA feels strongly that any change in resident and fellow working conditions will require the resident's own involvement at an individual program level in order to overcome current traditions.

Governor's Comments: The majority of training programs in internal medicine comply with the Accreditation Council on Graduate Medical Education's Requirements that residents must work less than 80 hours per week on the average. This has been the standard in Oregon for the last decade, however, nationally, this remains the more frequent citation of training programs when reviewed by the ACGME Residency Review Committee for Medicine.

Volunteer Opportunities

Physicians and other clinicians are needed to staff free evening community health clinics. Patients include low-wage and recently unemployed workers, homeless adults and street youth. It's fun and rewarding and you can choose your own schedule!

Wallace Medical Concern
Clinics in downtown Portland and Gresham
503-274-1277 or walmed@telport.com

Neighborhood Health Clinics
Clinics in Northeast and Southeast Portland

ACP-ASIM End-of-Life Care Patient Education Project

  • A working group of physicians and patient advocates has developed a set of tools that can help patients live well with serious illness near the end of life. These educational materials can be used to facilitate conversations between physicians, patients, and their families. The materials are companion pieces to three end-of-life care papers prepared for physicians.

  • Patient Education and Caring: End-of-Life (PEACE) Series
    Brochures are available in print and through the Website http://www.acponline.org/ethics/patient_education.htm. A "tip sheet" is also available for physicians to help with common issues in end-of-life care practice.

    These three brochures will help patients and caregivers talk to their doctors about:
    • Living with a Serious Illness: Talking toYour Doctor
    • When You Have Pain at the End-of-Life
    • Making Medical Decisions for a Loved One at the End-of-Life

ACP-ASIM Survey Finds Nearly Half of U.S. Members Use Handheld Computers

  • America's internists are making room in their pockets for handheld computers, according to a survey from the American College of Physicians-American Society of Internal Medicine (ACP-ASIM) that shows 47 percent of respondents use them. Considering respondents who plan to use handheld computers in the future, the survey suggests 67 percent of ACP-ASIM members will be using them by the end of 2002.

  • Go to the ACP PDA website for valuable resources http://www.acponline.org/pda/index.html.

Observations on Obvious Changes

It is obvious that the practice of internal medicine is changing, but the extent of the changes that have taken place in the three decades since I finished residency occasionally surprises me. Such a surprise took place in November when a group of Oregon physicians was convened to discuss the core proficiencies in procedures that should be required of internists for certification by the American Board of Internal Medicine.

It was consensus of this group that it was more important to expect Board certified internists to show proficiency in soft tissue injection than to have the knowledge and skills necessary to personally review such evidence as purulent material that has been Gram-stained, peripheral blood smears, and urine sediment. It was clear that certain defining skills, themselves defined by sticking needles in body cavities and vessels, were no longer considered "core" and even the most anachronistic of us voted against requiring expertise in placement of the Swan-Ganz catheter. By the end of the day it had became clear to me that the procedures of internal medicine have dramatically changed in the 30 years since I finished my residency.

Procedures have never been the core of internal medicine: our core skills center in the relationship between the physician and the patient that has been symbolized by the history and the physical examination.

Procedures are important, and well-trained physicians must perform them. It is clear that for the most part two sets of procedures have emerged: those that are performed and practiced in the hospital and another set for the clinic. These sets in a way are symbolic of the emerging sets of internists.

The concept of the Oslerian generalist working at a steady pace between the hospital and the clinic is being abandoned. Full-time Hospitalists now work in most urban hospitals. The majority of internists are allocating their time exclusively to the clinic. There are many reasons for this shift, and it is hard to argue with the common theme: society's demand that we manage more complex illness with increased and uniform quality.

I believe that these practice changes become more generalized and that the agencies that set the standards that regulate training programs will likely demand that internal medicine training will be split up into tracks. These tracks will be more dramatically differentiated than the traditional categorical and primary care pathways that now exist.

I believe that it is likely that physicians will be explicitly trained for service in one of four general areas:

  • as Hospitalists;
  • as outpatient physicians with emphasis less on caring for well adults and more caring for adults with chronic illness;
  • as generalists physicians trained for service in small communities;
  • in preparation for medical specialty fellowship training.

To create the changes necessary for this shift, we will need to openly recognize that training for the last century has been shaped requirements of the inpatients. In urban teaching hospitals these service needs will continue and will be met in a variety of ways other than resident physicians. Part of the solution will be training more Hospitalists. Teaching clinics will be organized around the management of chronic illness. In the clinics, physicians will learn business management skills as well as patient management skills.

No matter what the setting, training will continue in the core of internal medicine: the history and the physical examination. In July 2000, The Accreditation Council for Graduate Medical Education initiated requirements for six core skills for training in all medical specialties:

  • Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care.

  • Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals.

  • Patient Care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.

  • Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.

  • Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care.

  • Systems-Based Practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value.

I interpret these core skills required by the ACGME as an extension of the history, physical examination and professionalism. These have been Oslerian principles and practices for the last century. Our procedures have changed, but the core training for internal medicine has not.

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

Chapter Council, 2002-2003

Martin Jones, MD, Eugene
Lynn M. Keenan, MD, Eugene
Charles E. Hofmann, MD, Baker City
James E. Leggett, MD, Portland
Robin H. Miller, MD, Medford
Karl D. Ordelheide, MD, Lincoln City
Mark D. Sternfeld, MD, LaGrande
Frances M. Yuhas, MD, The Dalles
Robert A. Gluckman, MD, Portland (Represents Chapter to the OMA)
Sima Desai, MD, Portland (Associates Council Coordinator)
Linda L. Humphrey, MD, Portland (Chair, Program Planning Committee)
Arthur D. Hayward, MD, Portland (Chapter Treasurer)
James B. Reuler, MD, Portland (Immediate Past Governor)
Stephen R. Jones, MD, Portland (Governor)

How to Reach Us

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

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

Chapter Web Site:

Contact Information

Thomas G Cooney, MD, MACP
Oregon Chapter Governor

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