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Chapter Newsletter, Summer 2000

From the Governor's Desk

By any measure, our annual regional conference at the Radisson Airport Hotel in Warwick, Rhode Island was an unqualified success. On Thursday evening, April 27, medical residents of Rhode Island's teaching hospitals exhibited and discussed their research posters. There were 67 exhibits, with diverse topics ranging from "COX-2 Inhibitor Implicated in Toxic Epidermal Necrolysis," to "Limitations of Bone Scan vs. MRI for Bone Metastases."

At 8:20 Friday morning, I opened with brief remarks, then formally presented Dr. Munsey Wheby to the group. Dr. Wheby is immediate past chairman of the ACP-ASIM Board of Governors. He has extensive experience in both the art and science of medicine and the administrative aspects of health care. He is a dean at the University of Virginia Health Sciences Center. Dr. Wheby presented our chapter with the Evergreen Award and the Chapter Excellence Award. He commended our chapter for the national recognition it has received.

A brief business meeting then touched on the following: During 1999, chapter membership reached 640. Four of our colleagues advanced to Fellowship class - Raymond O. Powrie, MD, FACP; Mitchell A. Pressman, MD, FACP; Josiah D. Rich, MD, FACP; and Robert S. Emiguez, MD, FACP. In addition, 34 advanced to Full Member class and 32 Associate and 30 Medical Student members were added. Our financial position continues to be sound. No increase in chapter dues is planned for the year 2000. Our partnership with the Rhode Island Medical Society remains strong and productive.

A stimulating panel discussion - "Antimicrobial Resistance: A Real Threat in the New Millennium" - took place. Dr. Wheby and I moderated, while John Lonks, MD; Antone Medeiros, MD; Leonard Mermel, MD, FACP; and Charles Carpenter, MD, MACP comprised the panel.

Panelists addressed important facets of antimicrobial resistance within their areas of expertise. Audience participation was active.

Dr. Allan Erickson moderated the morning session of oral abstract presentations by medical residents Dimitrios Karmpaliotis, MD; Jeff P. Steinhoff, MD; and Alice Fan, MD.

Dr. Joseph R. Gaeta was introduced as Chapter Laureate and recipient of year 2000 Irving Addison Beck Memorial Award. I recounted highlights of Dr. Gaeta's distinguished career as a Rhode Island physician, and was pleased to introduce members of his family as well. His close friends, Dr. and Mrs. Michael DiMaio, were present. Dr. DiMaio is a past recipient of the Beck Award.

Meet-the-Professor luncheon sessions followed. Dr. Wheby's presentation was entitled "Too Much Iron-Too Little Iron." Dr. Milton Hamolsky spoke about thyroid disease, while Dr. Valerie Stone moderated a session on HIV for the practicing physician. Dr. Marilyn Weigner discussed cardiac conundrums and Dr. Bernard Zimmermann addressed rheumatologic abnormalities. The presentations featured an informal format, with actual cases forming the bases for discussions.

The afternoon session opened with four Associate oral abstract presentations, moderated by Alan Weitberg. Medical resident presenters were Hussam Hamdalla, MD; Jennifer Roh, MD; Thomas Vallone, DO; and Dmitriy Leongardt.

Next came a panel discussion moderated by Dr. Yul Ejnes, entitled "The Health Insurance Crisis: What Next Rhode Island?" Panelists included The Honorable Charles Fogarty, Lieutenant Governor of Rhode Island; Mr. Ronald Battista, President/CEO for Blue Cross and Blue Shield of RI; Dr. Michael Ingall of the Executive Council of the Ad Hoc Committee to Defend Health Care, Rhode Island; and Ms. Patricia Leddy, Administrator, Center for Child and Family Health, RI Department of Human Services. Following introductory remarks by each panelist, the audience engaged in lively discussion which illuminated many of the concerns surrounding health insurance in Rhode Island.

After closing remarks at 4:15 p.m., the meeting adjourned.

Subsequent to the regional conference, Dr. Wheby contacted me to relate how much he had enjoyed the meeting and working with Rhode Island Chapter members.

A reminder - our fall 2000 scientific meeting will be held on Wednesday, November 15 at the Park Hyatt Hotel on Goat Island in Newport (formerly the Doubletree Islander Hotel). The session will be extended to a full day to accommodate the many important medical issues which we believe demand updates.

In May, Drs. Yul Ejnes and Scott Hanson met with our state's elected representatives in Washington. At that time, they were presented with the ACP-ASIM Top Ten Key Contact Special Recognition Award for 1999-2000. The Awards Program was started by ASIM in 1995 as a way to recognize those individuals who have made exceptional efforts in response to legislative requests. Winners are determined by tallying the number and quality of responses to Legislative Alerts.

Our chapter has acquitted itself beautifully on so many fronts over the past year. While we are proud of our accomplishments, we would like to continue to improve. Your contributions are crucial to that improvement, so please contact us with your suggestions and criticisms.

Fred J. Schiffman, MD, FACP
Governor, RI Chapter ACP-ASIM

Observations on the Board of Governors Meeeting

Yul D. Ejnes, MD, FACP

Fred Schiffman and I attended the Spring 2000 Board of Governors (BOG) meeting in Philadelphia in April. This was my fourth BOG meeting and I came away from it even more energized and impressed than I did from the Fall meeting in Asheville, NC. I particularly enjoyed the opportunity to interact with internists who, as they say, write the chapters and landmark articles that we all read. Indeed, at a dinner of the "class" of Governors whose terms run through 2002, I had a great time with the colleagues at my table and their spouses. It was only afterwards that I realized that I had dined with an associate editor of the Annals of Internal Medicine and the editor of Scientific American Medicine. Which brings me to the point of this anecdote - this organization's strength is in its ability to bring together internists from all corners of the geographic and professional map. Chairs of Departments of Medicine, deans of medical schools, rural private general internists, urban subspecialists, researchers, medical students, and residents - all have a home at ACP-ASIM.

An emerging issue that will occupy much of the College's attention this year is patient safety. This was on the radar screen before the Institute of Medicine's report in December of 1999 that focused the public's attention on the topic, but with that report, momentum is building for something to be done to reduce the number of preventable errors that occur in the delivery of care. We heard from John Eisenberg, MD, MACP, Director of the Agency for Healthcare Research and Quality (AHRQ, formerly AHCPR), who described the federal government's plans for addressing this problem. I see this as another "motherhood and apple pie" issue. Whether the 98,000 deaths per year figure is overblown or not, I'm sure that most of us can recall preventable errors in our daily practices. My concern is the cost of implementing the systems that will reduce errors, especially in the private office setting. A computer system that allows electronic entry of prescriptions and provides reminders of overdue screening services may save the system money, not to mention save lives, but these systems are beyond the reach of most of us, especially during these times of cash flow difficulty due to events beyond our control. My second concern is that abandoning the "culture of blame" in which many of us live and which hinders the reporting of errors and system improvement is easier said than done. Many of us are too accustomed to asking the question "who screwed up?" to instead ask "why and how did we screw up?" which is what a systems approach requires. I see a role for the College in addressing both concerns, by serving as a focal point for partnerships among insurers, government, and other stakeholders to make the systems changes affordable for the average practicing internist, and by providing the training that many of us will need to incorporate a systems improvement approach to reducing medical errors.

Finally, ABIM recertification continues to generate much debate among members of the BoG. What evidence is there that recertification results in improved quality and justifies the time, effort, and cost that is required for the process? That is the question raised by many Governors. The College is in an unusual position on this issue, as it values ABIM Certification as a desired qualification for membership, sells a product that is widely used to prepare for the Board exam (MKSAP), yet has made the elimination of hassle a top priority and takes an evidence-based approach to matters. Many of you are preparing for recertification and can attest to the value or burden of the process. Please share your thoughts with Fred or me.

New Products for Young Physicians

The Young Physicians Subcommittee (YPS) of the ACP-ASIM was formed just over a year ago to meet the needs of young physicians under the age of 40 and to facilitate their passage from Associateship to Membership. The YPS has developed two new products for young physicians - the Young Physician Practice Management Survival Packet and the Evaluation and Management Coding Card.

Aimed at the young physician who is beginning his/her practice, the Young Physician Practice Management Survival Packet provides information about the resources that the College has to offer the young physician in the early stage of his/her career. In addition, the booklet contains information from a variety of sources that can help you successfully launch a career. The information provided contains references to Internet sites and telephone numbers. It also contains a checklist for getting started.

The Evaluation and Management Coding Card is a laminated, pocket sized sheet designed to help the young physician select appropriate levels of service for history, exam and medical decision making. It presents a great deal of information from a variety of sources in one easy to read card.

If you would like copies of the survival packet and/or coding card, please contact Jean Elliott, Staff Liaison, Young Physicians Subcommittee, at (800) 523-1546, ext. 2692.

RxAssist.org Helps Physicians Obtain Free Drugs for Uninsured Patients

Johanna Bell
Deputy Program Director
Volunteers in Health Care

A new searchable database available on the Internet simplifies the efforts of physicians to secure free and reduced price medications from patient assistance programs offered through pharmaceutical companies. Called RxAssist, the program is part of Volunteers in Health Care (VIH), a national resource center providing information, software tools, technical assistance and seed grants to physicians, free clinics, and other health care providers who care for uninsured and underserved patients either as individuals or as part of volunteer initiatives in the community. Funded by the Robert Wood Johnson Foundation, VIH is headquartered at Memorial Hospital in Pawtucket and directed by H. Denman Scott, MD, MPH, FACP, Associate Dean of Medicine at Brown University and former Rhode Island Health Commissioner and Governor of the ACP Chapter.

"The pharmaceutical companies' patient assistance programs are a rather well-hidden secret," notes Dr. Scott, "and for those physicians who know about them, it's a daunting task to find out which drugs are available, determine the eligibility requirements, and obtain and fill out the application forms. The hoops you have to go through effectively limit the utility of these programs."

RxAssist brings all of this information together in one place, and even makes the application forms available. Information is available on nearly 100 programs, covering about 700 medications. The RxAssist database allows the physician to search for covered drugs by company, brand name, generic name, or drug class. The website also enables physicians to download application forms for about 30 programs and provides information on how to obtain forms for the others. The VIH staff updates the material continually and includes on the website comments and helpful tips from past users to ease the way for first-timers.

The website is found at www.RxAssist.org and program staff are available for assistance at a toll-free number (1-877-844-8442). Physicians should also check the program's main website - www.volunteersinhealthcare.org - which features models, materials, and lessons learned from voluntary initiatives around the country to care for uninsured and underserved patients.

Beck Award Given to Joseph R. Gaeta, MD, FACP

Yul D. Ejnes, MD, FACP

The year 2000 Irving Addison Beck Memorial Laureate Award was presented at the RI Chapter Regional Conference in April to Joseph R. Gaeta, MD, FACC, FACP. Dr. Gaeta received his undergraduate degree at Brown and graduated cum laude/AOA from Boston University School of Medicine. He trained in internal medicine at University Hospital in Boston and at the Boston VA Medical Center and completed his cardiology fellowship at Rhode Island Hospital. Since 1964, Dr. Gaeta has practiced internal medicine and cardiology in Providence and has been on the staff of Rhode Island Hospital. In that time, Dr. Gaeta has also been an active member of the clinical faculty at Brown and organized medicine in Rhode Island. Among his many professional achievements is his being one of the first recipients of the Brown University School of Medicine's Distinguished Teacher Award, presented in May as part of the Medical School's 25th anniversary celebration. From 1987-1989 he was President of the Rhode Island Society of Internal Medicine (RISIM).

Dr. Gaeta joins a distinguished "Who's Who" of practicing internists who have been recognized for their outstanding work as recipients of the Beck Award. The Rhode Island Chapter salutes Dr. Joseph Gaeta.

Editor's Note: I would be remiss if I didn't note that during his tenure as RISIM President, Dr. Gaeta invited the then-Chief Medical Resident at Rhode Island Hospital to join RISIM's Executive Council, in order to encourage house officers to get more involved with the organization. That first "taste" of organized medicine changed my professional life in a major way, needless to say. After getting me into this mess, Joe continues to be a source of encouragement and positive reinforcement. I congratulate him on his achievement.

The IOM Report: To Err is Human

Edward Westrick, MD, MS
Principal Clinical Coordinator
Rhode Island Quality Partners

Last November the Institute of Medicine (IOM) released the "To Err Is Human" report highlighting the burden of deaths due to medical errors in hospitals. There are two general approaches to this problem, an area of confusion, and the issue of reporting that I want to address.

The two general approaches to medical errors I will label as quality assurance (QA) and quality improvement (QI). The QA approach will rely upon reporting of errors, potentially mandatory and for public scrutiny. This approach counts upon accountability to motivate improvement. The QI approach calls for confidential reporting of errors so that root causes can be identified and systematic improvements can be made. The QA approach fosters a "culture of blame" while the QI approach fosters a "culture of change." In a culture of blame, individuals who commit errors are blamed and often ridiculed in front of their peers (e.g. M&M). As a consequence, errors are hidden and the opportunity to learn from them is often lost. In a culture of change, it is recognized that to err is human and error prevention must involve solutions that address the root causes of errors.

There are two concepts that have been confused in recent discussions: adverse events and errors. We all want to avoid adverse events. Some are due to errors; many are not. Many errors do not lead to adverse events. We should look to engineer errors out of our systems to reduce the risk for adverse events. The culture of change will be helpful. The culture of blame will not. Watch the discussions on error reporting. As always, Rhode Island Quality Partners will continue to support the QI approach and the culture of change.

The author may be contacted at:

Rhode Island Quality Partners
9 Hayes Street
Providence, RI 02908
401-528-3250 voice / 401-528-3210 fax

Documentation and Billing When Teaching in the Office Setting

Patrick C. Alguire, MD, FACP
Director, Education and Career Development

Many internists teach students and residents in their office setting. Frequently, these preceptors have questions regarding proper documentation for Medicare billing when a learner is present. Here are some useful guidelines.

Documentation Requirements for a Resident: Current Medicare rules permit a teaching physician (preceptor) to substantiate a bill based on the combination of the resident's and the teaching physician's documentation of a specific service. The teaching physician must clearly convey that he/she saw the patient and participated personally in the patient's care up to the level of the EM services billed. The teaching physician can confirm that he or she verified the findings in the resident's note and agree with findings as documented by the resident. The teaching physician can also indicate that he or she agrees with the diagnosis and plan as written by the resident. These requirements, for the most part, permit a certain amount of time saving by using the resident's documentation as part of your own note. This will somewhat decrease the overall work associated with teaching by allowing you receive some "service" for your educational endeavors.

Documentation Requirements for a Student: The only documentation by medical students that may be used by the teaching physician is their review of systems (ROS) and past history, family history, and social history (PFSH). Currently, the teaching physician may not refer to a medical student's documentation of physical examination findings or medical decision making in his or her note. These restrictions will obviously have an impact on office efficiency. However, there are certain strategies that can be used to maximize efficiency in spite of these regulatory requirements. The use of the "wave scheduling" collaborative examinations, and presenting in the room are other methods to help manage documentation requirements when a student is present.

For more information regarding these techniques, contact the ACP-ASIM Community-Based Teaching Program at 800-523-1546, ext. 2845, or e-mail palguire@acponline.org.

RI Chapter Honored at Board of Governors Meeting

Yul D. Ejnes, MD, FACP

At the Spring 2000 ACP-ASIM Board of Governors meeting held in Philadelphia on April 11 and 12, the Rhode Island Chapter received two awards. A Chapter Excellence Award was presented for the quality and variety of services provided by the chapter. Nineteen chapters were so honored this year. This is the first time that the RI Chapter received this award. The other award was an Evergreen Award in the category of Advocacy. The chapter won for its successful effort to stop UnitedHealthcare's mandatory hospitalist program. This success story was also the subject of a panel discussion at the combined Board of Governors/Board of Regents meeting. Our Evergreen award was also a first for the chapter and was one of nine awarded to chapters nationwide.

Congratulations and thanks to our members for their contributions through participation on committees or the Council and their responses to our calls for action or feedback on issues of concern.

Resolution on Health Insurance Adopted by Board

Yul D. Ejnes, MD, FACP

At the 2000 Spring meeting of the ACP-ASIM Board of Governors, a resolution submitted by the RI Chapter on individual ownership of health insurance was adopted with amendment. The amended resolution calls on the Board of Regents to study alternatives to employer-based insurance, "including individual ownership of health insurance."

While there was general support from other Governors for our call for a step away from employer-based coverage to promotion of individual ownership of coverage, there was concern that our resolution called for too dramatic a change, especially during a year when the College is devoting much effort to raising the profile of the issue of the uninsured.

The next step is for the resolution to be discussed by the national Health and Public Policy Committee, which will then develop a report for the Board of Regents. We'll keep you informed of developments.

Locally, the Chapter continues to work with the Rhode Island Medical Society as it explores solutions to the problems of access and coverage in our state. Individual ownership of health care coverage is included in the draft requirements for a health care system that RIMS is developing.

Community-Based Teaching Participation Award Winners

We are pleased to announce that Munawar Azam, MD, is a recipient of the ACP-ASIM's Community-Based Teaching Participation award. This award acknowledges at least two years of office-based teaching of medical students, residents or fellows in internal medicine practices. Congratulations to Dr. Azam.

Contact Your Legislators Through the Legislative Action Center

To make participation in grassroots advocacy easier for its members, ACP-ASIM established a Legislative Action Center (LAC), which may be accessed from ACP-ASIM Online. The LAC allows you as an ACP-ASIM member to view the most current ACP-ASIM Legislative Alerts, find out who your federal legislators are, and send e-mails or faxes to your members of Congress. It also provides you with the status of key legislative issues of concern to ACP-ASIM, Congress' schedule, and tips on communicating with your legislators. ACP-ASIM encourages you to try the LAC by sending an e-mail to your members of Congress in response to the current Legislative Alert posted on the LAC.

You can access the Legislative Action Center through the "Where We Stand" section of ACP-ASIM Online, or by going straight to the LAC at http://congress.nw.dc.us/acp/. To send a message to Congress, you are prompted for your zip code and are zip-matched to your federal legislators. You will then be asked for your name and address (so that congressional offices can identify you as a constituent). ACP-ASIM encourages you to send a message based on the sample message posted for you, with your own personal anecdotes added. If you have any questions about the LAC or ACP-ASIM's Key Contact program, please contact Jenn Jenkins, Associate for Grassroots Advocacy, at jjenkins@acponline.org or at 1-800-338-2746, x4536.

Leadership Day 2000

Yul D. Ejnes, MD, FACP

On May 16 and 17, Scott Hanson, MD, and I represented the Rhode Island Chapter at the fifth annual Leadership Day in Washington DC. The first day consisted of briefings and lectures by experts in public policy and elected officials. We spent most of the 17th in the offices of our Congressional delegation. Scott and I met with Senators Jack Reed and Lincoln Chafee and with members of the staff of Representatives Robert Weygand and Patrick Kennedy. We urged our legislators to support patient protection legislation in the form of the Norwood-Dingell bill passed by the House last year. We also discussed prescription coverage for Medicare beneficiaries, the Institute of Medicine report on patient safety, and joint negotiation by physicians.

Throughout the day, we were impressed by how easily we were able to access our elected officials and how interested they were in hearing what we had to say (in fact, Senator Reed was tied up in floor deliberations at the time of our appointment, but rather than have us speak to his legislative aide, he asked her to bring us to the reception room adjoining the Senate chamber so he could meet with us). Our Senators and Representatives may not necessarily agree with everything we say nor support all of our proposals, but it is still important that they year from us. This doesn't require a trip to Washington - telephone, paper mail, or e-mail (see the article on the Legislative Action Center in this newsletter) works fine. Also, a visit to the district office to meet with the Senator or Representative during recesses can also be effective.