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November 2011 Kenneth E. Olive, MD, FACP, ACP Governor


From the Governor

Dr. Olive

Monique Forskin-Bennerman, MD, FACP and her colleagues on the scientific program committee (Elizabeth Bray, MD, FACP, Jason Hayes, MD, FACP, Victor Kolade, MBBS, FACP, Reena Kuriacose, MD, FACP, Ayo Oso, MBBS, FACP, Mukta Panda, MD, FACP, Mario Ray, MD, FACP) deserve kudos for organizing an outstanding chapter meeting last month. If you did not attend the 2011 Tennessee Chapter Scientific Meeting, you missed an excellent continuing medical education experience and the opportunity to network with about 150 colleagues of all ages from across the state. Highlights of the meeting included a lively debate on cancer screening, a thought-provoking discussion related to the distressed physician, and an update on the Washington DC political landscape by Robert Doherty, ACP Senior Vice President for Governmental Affairs and Public Policy. Robert Centor, MD, FACP, one of the Regents of the College served as the College representative to the meeting. Dr. Center facilitated discussion of the College strategic priorities at both the luncheon and Town Hall meeting. Other presentations provided excellent updates in radiology for the internist, treatment of hepatitis C, interventional stroke management, diabetes care, and management of resistant hypertension. Participants also had the opportunity to participate in workshops on pain management, smoking cessation, dementia management, and ECG interpretation. Jim Lewis, MD, FACP and Catherine Clark, MD, FACP presented two modules in the Self Evaluation Program (SEP) for maintenance of certification. Mark your calendars for the 2012 program to be held at the Chattanoogan Hotel in Chattanooga October 19-20. Daphne Norwood, MD, FACP of Knoxville will chair the program committee for the 2012 meeting. This issue of the newsletter features several photos from the meeting. More photos will be posted at the chapter website in the near future..

•••

Charlene Dewey, MD, FACP of the Center for Professional Health at Vanderbilt University was our speaker on the distressed physician. She and her colleague William H. Swiggart, M.S., L.P.C./MHSP have kindly agree to contribute the feature article for this issue of the Governor’s Newsletter entitled Professionalism and the Professional Health and Wellness of the Internist. Since all of us work with distressed physicians and many of us have been distressed physicians, I would encourage you to take the time to read this article.

•••

After sharing some personal reflections related to my wife’s death in the October 2010 issue this newsletter I have been the beneficiary of many well wishes from colleagues across the chapter. Many of you have spoken to me at meetings and emailed me to express kind thoughts. I am happy to share that I was married to Janine Richardson on October 29, 2011 and we are doing very well. Below is a photo of us enjoying the Mayan ruins at Tulum Mexico during our honeymoon.

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Professionalism and the Professional Health and Wellness of the Internist

Charlene M. Dewey, M.D., M.Ed., FACP and William H. Swiggart, M.S., L.P.C./MHSP October 2011
Dr. Dewey

The Center for Professional Health (CPH) at Vanderbilt University School of Medicine in Nashville, TN, defines professional health and wellness (PHW) as the maintenance of the physician’s mental, emotional, physical and spiritual being. This allows him/her to perform in a professional manner. Professional health and wellness is not separate from one’s general health and wellness; it encompasses how health and wellness influences behaviors in the professional environment, thus affecting professionalism. According to Stern, “Professionalism is demonstrated through a foundation of clinical competence, communication skills and ethical and legal understanding, upon which is built the aspiration to wise application of the principles of professionalism: excellence, humanism, accountability, and altruism.”1 (See figure 1.) Professionalism requires both the understanding of the rules that govern our professional practices and the appropriate demonstration of behaviors expected of a physician. It is not enough to just “know.” We are judged or deemed professional by our behavior; not our motives or our knowledge. The authors adopted Stern’s model to emphasize the role of professional health and wellness as the foundation to professionalism while emphasizing that the professional culture/environment also plays a significant role. Both individual factors (internal system) and external system factors influence professional behaviors. When these two systems function well, personal and institutional vitality exists, but when low functioning or unhealthy, they create the “perfect storm” that can be associated with disruptive physician behavior. (See figure 2.)

Figure 1

Figure 2

Physicians face many challenges in training and yet have little education on maintaining professional health and wellness. Self-awareness is an important element in understanding how we behave under both normal and stressful conditions. Physicians need education in self-awareness, emotional intelligence, conflict management, and coping mechanisms to better equip themselves with skills needed to thrive in the healthcare environment. Medical education should inform and provide learning opportunities related the individual’s health and wellness related to the rewards and challenges of practicing medicine.

Poor self-care can be the tipping point influencing physicians to cross boundaries, demonstrate unprofessional behaviors, or abuse a substance. Unfortunately, such behaviors have significant consequences including loss of patient trust, reputation, family relations and/or friendships, and loss of licensure or careers. The most unfortunate outcome is physician suicide. Evidence on physicians’ health and wellness informs us that:

  • Up to 30-60% of physicians have some distress or burnout.2
  • It is estimated that one physician commits suicide every day in this country and that number is considered an underestimate.2,3
  • Physicians commit suicide more than any other profession and at higher rates than the general population.4 2
  • Women physicians suffer from anxiety, depression and burnout and commit suicide more than male physicians.2 3
  • Mental health issues (depression and substance use) increase the risk of suicide.2
  • Physicians, especially men, underutilize the health care system. Stigma around physicians’ health and mental health issues remains a significant barrier to physicians seeking help.2 4
  • Physicians who practice in academic medicine appear to work longer hours and take less vacation than physicians practicing in the community. Academic and community practicing physicians have similar rates of anxiety (27%) and depression (10%).4,5
  • Williams et al. described the potentially negative impact of the work environment on a physician’s health and wellness.6
  • In 2008, the Joint Commission identified disruptive behaviors as a sentinel event. This is due to the consequences of disruptive behaviors on team function, communication, patients and family, visitors, increased chance of medical errors and legal liability, staff turnovers, financial losses, and loss of reputation.7-13
  • Physicians can learn resiliency skills through training.14

Our goal is to educate physicians on PHW so they can self-assess their risk. The left side of our PHW spectrum describes physicians who are both healthy and well. These physicians are generally better able to care for patients, cope with stress, handle adversities, manage burnout and maintain professional boundaries than those on the right of the spectrum.15 (See figure 3.) Moving to the right of the spectrum, physicians experience stress, burnouts, failed coping skills, and are at greater risk for mental health problems, substance use, and suicide. Personal/family issues often arise first, while declines in function at work can go unnoticed for quite some time.16

Figure 3

There are several risk factors or etiologies at the root of disruptive behaviors. These include personality types, psychological factors (substance use, physical/mental/sexual abuse in childhood, rigid beliefs, etc.), mental health issues (personality disorders, compulsive disorders, depression, bipolar, and narcissism), stress reactions, burnout, family of origin issues, and reduced health and wellness.17,18 Several protective factors have been identified that help physicians improve their wellness, resiliency, and coping ability. Table 1 describes protective factors, tips on managing energy, and Maslach’s six sources of burnout that should be evaluated and addressed.20

Table 1

Several resources exist to provide education, training and/or counseling. These include employee assistance programs (EAP) and most states have physician health programs (PHP) located through the Federation of State Physician Health Programs (FSPHP).21 The Center for Professional Health lists articles and presentations for your review on their web-page covering topics of professional health and wellness.22 Personal coaches, professional counselors, and clergy are also good sources for advice and guidance. A significant number of physicians are stressed and distressed; some will burnout, and a few will exhibit disruptive behaviors, and less will commit suicide. Because physicians are human, we must tend to our professional health and wellness if we are to care for others. Make your professional health and wellness a priority – starting today!

The medical academy's primary ethical imperative may be to care for others, but this imperative is meaningless if it is divorced from the imperative to care for oneself. How can we hope to care for others, after all, if we ourselves, are crippled by ill health, burnout or resentment? …medical academics must turn to an ethics that not only encourages, but even demands care of self.”2

References:

  1. Stern D. Measuring Medical Professionalism: Oxford University Press; 2006.
  2. Cole T, Goodrich TJ, Gritz, ER. Faculty Health in Academic Medicine: Physicians, Scientists, and the Pressures of Success: Humana Press: Totowa, NJ; 2009.
  3. High physician suicide rates suggest lack of treatment for depression. MD Consult News; June 11, 2008.
  4. Linn LS, Yager J, Cope D, Leake B. Health status, job satisfaction, job stress, and life satisfaction among academic and clinical faculty. JAMA. Nov 15 1985;254(19):2775-2782.
  5. Schindler BA, Novack DH, Cohen DG, et al. The impact of the changing health care environment on the health and well-being of faculty at four medical schools. Acad Med. Jan 2006;81(1):27-34.
  6. Williams E, Konrad, TR, Linzer, M, McMurray, J, Pathman, DE, Gerrity M, Schwartz, MD, Scheckler WE, Douglas J; SGIM Career Satisfaction Study Group. Physician, practice, and patient characteristics related to primary care physician physical and mental health: results from the Physician Worklife Study. Health Serv Res. 2002 Feb;37(1):121-43.
  7. Joint Commission 2008, JC. Issue 40 July 9, 2008.
  8. Dayton E, Henriksen K. Communication failure: basic components, contributing factors, and the call for structure. Jt Comm J Qual Patient Saf. 2007 Jan;33(1):34-47
  9. .
  10. Gawande A, Zinner, MJ, Studdert, DM, Brennan, TA. Analysis of errors reported by surgeons at three teaching hospitals. Surgery 133, pp. 614–621. 2003
  11. .
  12. White A, Pichert, JW., Bledsoe, SH., Irwin, C., Entman, SS. Cause and Effect Analysis of Closed Claims in Obstetrics and Gynecology. Obstetrics & Gynecology: May 2005; Volume 105 - Issue 5, Part 1 - pp 1031-1038.
  13. Lingard L, Espin, S., Whyte, S., Regehr, G., Baker, GR., Reznick, R., Bohnen, J., Orser, B., Doran, Grober E. Communication failures in the operating room: an observational classification of recurrent types and effects. Qual Saf Health Care 2004;13:330-334
  14. Samenow CP, Swiggart W, Spickard A, Jr. A CME course aimed at addressing disruptive physician behavior. Physician Exec. Jan-Feb 2008;34(1):32-40.
  15. Sutton R. The No Asshole Rule: Building a Civilized Workplace and Surviving one that Isn’t. Business Plus, New York; 2007.
  16. Sood A, Prasad K, Schroeder D, Varkey P. Stress management and resilience training among Department of Medicine faculty: a pilot randomized clinical trial. J Gen Intern Med. Aug 2011;26(8):858-861.
  17. Dewey CM, Swiggart, WH. Center for Professional Health – Vanderbilt University School of Medicine. 2009, Pediatric Grand Rounds – Vanderbilt University School of medicine “Professionalism and the Health and Wellness of Physicians: Managing Stress, Burnout and Energy” Last Accessed 10/19/2011.
  18. Swiggart WH, Dewey CM, Hickson GB, Finlayson AJ, Spickard WA, Jr. A plan for identification, treatment, and remediation of disruptive behaviors in physicians. Front Health Serv Manage. Summer 2009;25(4):3-11.
  19. Spickard AJ, Gabbe, SG, Christensen, JF. Mid-career burnout in generalist and specialist physicians, Table 2. JAMA. 2002;288(12):1447-1450.
  20. Gabbard G, Nadelson C. Professional boundaries in the physician-patient relationship. Journal of the American Medical Association. 1995;273(18):1445-1449.
  21. Schwarts T, McCarthy, C. Managing Your Energy, Not Your Time. Harvard Business Review. 2007.
  22. Maslach C, Leiter, MP. The truth about burnout: How organizations cause personal stress and what to do about it1997.
  23. Federation of State Physician Health Programs (FSPHP). Last accessed October 17, 2011.
  24. The Center for Professional Health. Vanderbilt University
  25. .

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Associates and Medical Students at the Chapter Meeting

Tracey Doering, MD, FACP and Mukta Panda, MD, FACP coordinated an expanded program for associates and medical students at the 2011 Chapter meeting. Thursday evening, prior to the beginning of the main meeting on Friday morning, thirty-six residents and nine medical students participated in a poster competition. While most were in the clinical vignette category, several were research posters. The Council of Young Physicians coordinated judging for the event. Following a buffet dinner residents participated in an animated Doctor’s Dilemma competition (medical Jeopardy). Victor Kolade, MD, FACP conducted this activity with Dr. Doering. The UT Nashville (Baptist Hospital) residency program team won the competition.

Jeopardy 2011

Jeopardy moved so fast it can make your head spin

Jeopardy Baptist Team

Tracey Doering and the winning resident team from UT Nashville (Baptist Hospital)

Bray & Hayes judging

Elizabeth Bray, MD, FACP and Jason Hayes, MD, FACP judging posters

Associates Clinical Vignette Competition Winners

First Place – Ahmad Alazzeh, MD, ETSU, Not Quite an Acute ST Segment Elevation MI. Second Place – Hetalben Patel, MD, Meharry, Rapidity of ADAMTS 13 Autoantibody Production in a Case of TTP. Third Place – Savita Fanta, MD, Vanderbilt, Heterophile Antibodies: An Explanation for the Inexplicably Elevated TSH.

Dr. Ahmad Alazzeh

Dr. Ahmad Alazzeh

Dr. Hetalben Patel

Dr. Hetalben Patel

Dr. Fanta

Dr. Savita Fanta

Dr. Wilson

Dr. Jessica Wilson

Fabunmi

Abayoni Fabunmi

Henderson

Armen Henderson

Panda

Nikhil Panda

Research Poster Competition Winners

First Place - Jessica Wilson MD, Vanderbilt, The Association of Kynurenine Pathway of Tryptophan Metabolism with Acute Brain Dysfunction During Critical Illness.

Second Place - Abayoni Fabunmi, Meharry, Biochemical characterization of a single amino acid change in the VP1 unique region of AAV1 and AAV6.

Medical Student Poster Competition Winners

First Place - Armen Henderson, Meharry, Molecular Cardiac Surgery with Recirculating Delivery (MCARD) in Treatment of Heart Failure.

Second Place - Nikhil Panda, UT Chattanooga, An Uncommon Cause for a Common Symptom Complex.

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Awards Presented at Chapter Meeting

Mastership (MACP) is the highest honor awarded by the College to Fellows who have been selected because of “personal character, positions of honor, contributions towards furthering the purposes of the ACP, eminence in practice or in medical research, or other attainments in science or in the art of medicine.” Masters must be highly accomplished individuals. Evidence of their achievements can come from many types of endeavors such as research, education, health care initiatives, volunteerism, and administrative positions. The Master must be distinguished by the excellence and significance of his or her contributions to the field of medicine. This year the Tennessee Chapter is proud to have three of its members recognized. Fred Ralston, MD, MACP and Steve Miller, MD, MACP were awarded their masterships at the internal Medicine 2011 Convocation. Due to extenuating circumstances Burgein (Gene) Overholt, MD, MACP was unable to attend the Convocation and his Mastership was awarded by at the chapter meeting by ACP Immediate Past President Fred Ralston, MD, MACP.

Overholt

Dr. Gene Overholt accepting his Mastership

Mukta Panda, MD, FACP, was recognized with the Laureate Award. Dr. Panda has consistently served the chapter over many years as a member of the Governor’s Council and as a leader of the Associates program. Dr. Panda has served as a mentor for numerous students and residents and is a recognized leader in medical education.

Pandalaureate

Dr. Mukta Panda accepting her Laureate Award

Clif Cleaveland, MD, MACP, received the Volunteerism and Community Service Award. Despite being a senior physician who has accomplished as much as might be expected in the College as both a Master and former ACP President, Dr. Cleaveland continues to make major volunteer contributions to both the College and community. Dr. Cleaveland has been the driving force behind the Chapter Reading Retreats and ACP Annual Meeting literature in medicine workshops for many years.

Dr. Centor

Robert Centor MD FACP, Regent discussing ACP Strategic Priorities

Doherty

Robert Doherty, ACP Senior Vice President for Governmental Affairs and Public Policy emphasizes a remark

Three Presidents

Ben Hall, MD, MACP (former ASIM President), Fred Ralston (immediate past ACP President) and Clif Cleaveland, MD, MACP (form ACP President) all continue to be involved in Chapter activities.

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Tennessee Council of Young Physicians

Reena Kuriacose MD, FACP, TCYP Chair

The Tennessee Council of Young Physicians (TCYP) has been very active in the 2010-2011 year. In the fall of 2010, a new Chair and four new members were elected. In 2011 when two of the founding members completed their terms, two more new members were elected – including a subspecialist which is a first for the council. A young physician chaired the Tennessee Chapter scientific program committee in 2011 and three other members of the TCYP served on the planning committee. The Associates’ and medical students’ poster judging at the Chapter meeting was coordinated by the council with 14 judges. A well attended Jeopardy session was conducted by a council member. Three members currently serve on the Tennessee Chapter Governor's Council

The Council was involved in National ACP activities. Three members attended Internal Medicine 2011 and two were involved in the poster judging session. One member attended the 2011 Leadership Day on Capitol Hill.

TCYP encourages developing leadership skills and attaining fellowships for young physicians. Two members received the LEAD certificate at San Diego and another member has currently achieved all the requirements of the LEAD certificate. All members of the 2010-2011 council except one are fellows of ACP and the remaining person is working towards advancement to fellowship. The newly selected members (2011-2013) are also working on advancement to fellowship.

A dinner talk on coding held in the western region of Tennessee was well attended, A Spring fling social event for young physicians and families was held in the middle region of Tennessee. Two more talks are being organized for 2011 and 2012 on coding and the distressed physician.

TCYP had its own Facebook and Twitter page established in 2011

The residency program at Chattanooga has a collaboration with the College – (designated as 'non-financial sponsors') – to have their departmental Grand Rounds as an ACP event and regularly present a message from the Governor of the Chapter. This has been linked to the Chapter Young Physicians Facebook page to increase ACP visibility.

The TCYP encourages more young physicians to take advantage of the opportunities ACP offers in building a satisfying personal and career life by becoming actively involved in ACP activities at both the chapter and national levels

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Hospitalist Medicine

John W. Fowler, Jr., MD, FACP, Hospitalist Committee Chair

Hospital practice has been an important feature of internal medicine practice since its inception. Now the hospitalist model, with its mix of benefits and drawbacks, has become established an important style of practice for internists. Recognizing the value of high-quality hospital work in our patients' overall care and the important role our hospitalist members play in the life of the chapter, chapter members met at the annual meeting Hospitalist Breakfast to discuss issues surrounding hospitalist care.

Topics covered in that discussion provide a window into the concerns and perceptions of ACP members about the state of hospitalist medicine:

Scheduling
Workload
Seamless care
Getting to the top level
Doing both office and hospital
Stipends from hospitals
Ethics
Commitment to one hospital system
Relationships between inpatient and outpatient physicians
Improvement in transitions of care including use of technology
Readmissions
Teaching hospitalists Primary care physicians influence on hospitalist decisions
Involvement of hospitalists in hospital committees
Surgical co-management

These topics serve only as a beginning of discussions we should have going forward about the hospitalist model, with the goal of optimizing health care for patients. To facilitate further discussion, we have posted this topic list to the chapter newsgroup at the ACP website, accessible under Discussion Groups.

In addition, Tennessee Chapter is exploring ways to engage hospitalists and other internists involved in care of hospitalized patients. In the spring of this year, Tennessee ACP co-sponsored a successful meeting of hospitalists and primary care physicians on the topics of successful hospital discharges as well as heart failure care. We are looking for further opportunities to sponsor educational opportunities of this type, in collaboration with hospitals or other appropriate groups. I invite you to look over the newsgroup and share your further thoughts about the role of hospitalists in ACP and the role of ACP in hospital medicine, and particularly your ideas about engaging hospitalists in the work of ACP.

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2012 Reading Retreat

Mark Anderson, MD, FACP

The 2012 Tennessee-ACP Reading Retreat (Retreat #25) will take place March 2 – 4, 2012 at Fall Creek Falls State Park. The theme will be “Against Fatality”. We will be discussing the struggle our patients have – the struggle that, in fact, all of us will have at sometime – against mortality. Courage in this struggle is much admired but it can be both helpful and hurtful.

To help us understand how best to help our patients in this struggle “against fatality”, we will be using the following works: Vanity Fair pieces by Christopher Hitchens concerning his own fight against incurable cancer; the play W;t by Karen Edson; the novel Everyman by Philip Roth; the film “Indestructable” by Ben Byers; and poems by Shakespeare, John Donne, Emily Dickenson and Dylan Thomas.

Our teacher will be Dr. Greg O’Dea, UTC Foundation Professor of English and Director of the Honors Program at University of Tennessee, Chattanooga. For information, contact Mark Anderson, MD, FACP in Chattanooga.

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Contact Information

Richard G. Lane, MD, FACP,
Governor, Tennessee Chapter

Renee Arnott
Executive Director
Ph: 615-460-1657
E-mail: renee.arnott@tnmed.org