Governor's Newsletter, January 2002
David C. Dale, MD, FACP
Governor, Washington Chapter
Our chapter had another excellent annual meeting October 19-20, 2001, at the Bell Harbor International Conference Center in Seattle. Dr. William J. Hall, President, ACP-ASIM, and Chief of General Medicine at the University of Rochester said this was one of the very best Chapter meetings he had ever attended. We all thank the members of the program committee, Paul Sutton (Chair), JoAnne Elmore, Doug Paauw, Linda Pinsky, Scott Ramsey, Rebecca Ruud, and Rich Tucker, for their excellent work in organizing this year's program. The speakers emphasized, "Is it Worth It?" They emphasized cost-effectiveness and practical approaches to medical care. If you were not there, do plan to attend next year. We promise it will be very worthwhile for you.
I am sure that you will agree this has been an extraordinary Autumn. The plane crashes in New York, Washington DC, and Pennsylvania on September 11 and all of the events, which have followed these tragedies, focused our attention on national security, airline safety and bioterrorism. They also prompted a strong sense of patriotism. We have all learned about the clinical features of anthrax smallpox. At the national level, the Patient's Bill of Rights, Medicare relief, patient safety, and access to healthcare have taken second place to congressional interest in spending for public health and protection. At the federal level, the government is moving toward deficit spending. Here in Washington we have rising unemployment and big budget cuts ahead. What a difference a year makes!
What are we to do? At a personal level, our primary loyalties are to our patients as well as to our families and our friends. There is a lot to do in providing good care and helping to allay the anxieties and worries of this autumn's issues. At a national level, the ACP-ASIM is very busy in working to keep our legislative leaders' attention focused on access to healthcare, reasonable oversight and regulation of the practice of medicine, and maintenance of the infrastructure which has made American healthcare so good. There is a lot for ACP-ASIM to do! On a personal note, I am now very busy getting ready to assume my role as the Chair of the Board of Governors for ACP-ASIM next Spring. By then we will probably have a new Executive Vice President succeeding Walter McDonald. By then, many of the issues, which have made this Fall so turbulent should be behind us. I hope that you are looking forward to next Spring also.
The Washington Chapter of ACP-ASIM was presented the 2000 Chapter Management Award by Dr. William J. Hall, President, ACP-ASIM for meeting the standards determined by the Chapters Subcommittee for effective chapter management.
Medicare Pay Cuts Negate Gains at the RUC
Bruce Smith, MD, FACP
The Center for Medicare and Medicaid Services (CMS) announced the 2002 Medicare Conversion Factor on Nov. 1. Next year's rate is $36.20, a 5.4% drop from the 2001 rates. This is the factor used to multiply by the Relative Value Unit (RVU) for each procedure code used to bill for physician services.
CMS uses data compiled by the AMA to determine the RVU for each procedure code. The Relative Value Update Committee (RUC) adjusts these values annually. In recent years these adjustments have generally been favorable to office-based Evaluation & Management (E&M) codes and less favorable to procedures. This year continues that trend with increases in the standard office E&M codes of 5-7% over last year's values. The lower conversion factor effectively negated any gains intended by the RUC. The higher rates were in recognition of higher overhead costs and time expectations on office-based practices. Many practices already limit access by Medicare patients due to low reimbursement and next year's lower rate may make the problem more widespread.
The Medicare Conversion Factor is calculated by an arcane equation set by the Balanced Budget Act of 1997. The formula does not adjust rates based upon the cost of providing the services, but instead links the rates to the rise or fall of the Gross Domestic Product. Emergency legislation to change the formula has been introduced in Congress and at press time Sen. Patty Murray and Sen. Maria Cantwell have signed on as co-sponsors. Please thank them for their support and encourage your other congressmen and women to support corrective legislation as well. The entire text of the 2002 RVU values and all other Medicare regulations may be found linked to the "Advocacy" section of the College web site—ACPOnline (http://www.acponline.org/advocacy/).
Patty Murray (D-WA)
173 Russel Senate Office Building
Washington, DC 20510
Phone: (202) 224-2621
Maria Cantwell (D-WA)
717 Hart Senate Office Building
Washington, DC 20510
Phone: (202) 224-3441
Ontogeny and Phylogeny, Practice and Pedagogy: Whither General Internal Medicine?
Roger W. Bush FACP
Director, Internal Medicine Residency Program, Virginia Mason Medical Center
I am trying to combine General Internist practice and Medical Education into a sustainable career. I see trouble brewing for both career interests. The ability to provide care across settings for people with many stages and types of disease-my personal definition of General Internal Medicine-seems to be dying the death of a thousand knife cuts. Poor reimbursement, onerous paperwork, the apparent failure of managed care, and now the dichotomization of General Internal Medicine into inpatient and outpatient specialties are coming together to throw me on to the phylogenetic scrap heap of medical evolution.
My introduction to evolution and embryology included the generalization "ontogeny recapitulates phylogeny". I have taken this to mean that embryonic differentiation retraces the evolutionary stages of ancestry. In this manner, the nascent organism passes rapidly through intermediary pluripotent states, which may not be adaptive to selective pressures of the postnatal environment. Some of these evolutionary waypoints are represented in life, but many are known only from the fossil record. In this manner, will training the individual internist recapitulate the history of our specialty? To the extent that this generalization is a valid metaphor for clinical education, I worry about the fate of my chosen practice style.
The phylogeny of clinical medicine includes multiple transformations: from generalist to specialty teaching, from distributed to centralized locations, and from proprietary to practice-based to research-based to business-based organizations. In the ubiquitous drive toward efficiency and financial performance, academic medical centers may tacitly reinforce stratification of General Internists into distinct inpatient and outpatient phyla, to the detriment of our patients, our trainees, and perhaps the profession.
The ontogeny of a well-trained physician includes robust preparation in biomedical science and thoughtful instruction (and modeling) by skilled, committed clinician educators. Clinical exposure across the spectra of settings of care, stages of illness, and treatment goals is integral. Just as excellence in specialty care requires familiarity with the capacity and limitations of primary care, so must hospitalists and outpatient internists (ambulists?) be keenly aware of each other's resources. Broad training is pivotal in clinical education.
Will breadth and cross-functionality be important or even tolerable in the future General Internist? Will there be physicians capable and accountable for maintaining longitudinal relationships with patients, physicians with knowledge of individual patients' values, supports, and agendas? I predict selective pressures will compel many institutions to stratify generalists into inpatient and outpatient specialists, and will render traditional General Internal Medicine practice unsustainable.
Tight monitoring of financial controls, clinical outcomes, and stakeholder satisfaction has shown the effectiveness and efficiency of hospitalists and intensivists in the short term. Well and good! Innovations such as the Hospitalist movement are the main hope for a safe, effective and affordable health care system. In a longer view, a systematic attrition of General Internists from inpatient care and teaching may occur, much as we have seen the exclusion of Family Medicine from some hospitals, and exclusion of nonintensivists from the CCU. Our colleagues in Family Medicine, with their community base for practice and education, may be buffered from total elimination. General Internal Medicine must survive among the orthodoxy of research medical schools, the guildhall of specialty hierarchy, and the vagaries of the market.
Relegation of General Internists to irrelevant, historical interest-only status in the hospital will impact patients, who stand to lose a durable relationship across diseases, settings, and functional status. It will impact clinical trainees, who will lose access to wider perspective, and lose access to valuable role models of practice outside the major teaching hospital. Loss of a cohort of physicians with system knowledge and integrative skills sufficient to manage health care will impact all of society.
Vestigial pockets of traditional General Internists may well survive, subsidized and carefully protected in a few teaching hospitals, the military, Kaisers, and the odd rural or underserved site. But the viability of General Internal Medicine, as I have known and enjoyed it, is at risk.
The challenge is clear; General Internists must stake out a patch in the center of the high ground for our nest. Efficient practice patterns, indispensable educational contributions, doctor-patient relationships and the clinical care based on the best available evidence will define the perimeter. Success will justify perpetuation of General Internal Medicine as a legitimate career, but will require hard work, creativity, and broad collaboration. In Washington State, our four excellent and diverse Internal Medicine residency programs and our progressive School of Medicine are suitable incubators. Health care delivery systems must provide habitat for the hatchlings and the practitioners and educators from whom they spring. ACP-ASIM can and should bring these elements together into a guiding coalition for a solution.
Mark Your Callendars And Save The Date!
2002 Annual Meeting
Washington Chapter ACP-ASIM
November 1-2, 2002
The Westin Hotel
An excellent meeting is being planned!
Laureate Award: Thomas Charles Reis, MD, FACP
The Washington State Chapter of the American College of Physicians-American Society of Internal Medicine has selected Dr. Thomas C. Reis as the 2001 recipient of the Chapter's Laureate Award, in recognition of his remarkable contributions to patient care and to public health; to medical education, and the improvement of the quality of medical care; and for his highly visionary leadership in Medicine and in his community.
Dr. Reis received a B.S. degree in Biology (Cum Laude) from King's College, of Wilkes-Barre, Pennsylvania in 1965, and his medical degree (AOA) from Creighton Medical School, Omaha, Nebraska in 1969. He served his internship at Nassau County Medical Center, 1969-70, followed by service in the Navy 1970-1973, rising to the rank of Lieutenant Commander. He continued his training with a residency in Internal Medicine at the University of Oregon Health Sciences Center 1973-1975, and was certified by the American Board of Internal Medicine in 1975.
Tom joined the Vancouver Clinic in Vancouver, Washington in 1975. Thus began a remarkable series of contributions to the profession and to the community. He served on many committees of Vancouver's Southwest Washington Medical Center. He had the vision to utilize the hospital's Morbidity and Mortality committees, not to do the ritual blessing of the charts, but to look at medical outcomes, and to devise methods of advancing the quality of care.
His studies of "Elective Surgery for Abdominal Aortic Aneurysm", "Carotid Artery Surgery at Southwest Medical Center", "Management of Adult Sepsis", "Postsplenectomy Studies in Southwest Washington Hospitals", "Jejuno-ileal Bypass for Morbid Obesity", and "Hepatotoxicity to Erythromycin", had the successful objective of changing the practices of colleagues, and thereby improving the quality of medical care. These were such lucid and compelling expositions of how to improve medical care that he has been sought out as a consultant in these matters.
He rose to the crisis of the newly emerged AIDS epidemic in 1983. When there were no infectious disease specialists in his community, Tom acquired the knowledge and skills to develop a community-wide approach to HIV/AIDS in Southwest Washington, while personally caring for an increasing number of such patients with great expertise and compassion. For this he received the Sixth Annual Health Recognition Award of the Southwest Washington Health District and the Clark County Medical Society Good Citizen Award. These studies not only established Dr. Reis as a competent clinical researcher, but as the guardian of the public health of his neighbors. Perhaps the ultimate measure of his endorsement and admiration by his community has been his selection as the Internist for the Portland Trailblazers and for the Portland Fire mens and womens basketball teams.
Dr. Reis has been a superb academician in a clinical community setting, a community educator, as well as a highly effective leader of his professional colleagues. He has been chairman of multiple hospital, county medical society, and Washington State Medical Association Committees. In recognition of his many innovative initiatives he has been the recipient of numerous honors and awards including:
- Doctor of the Decade Award of the Southwest Washington Medical Center
- Health Recognition Award, Southwest Washington Health district,
- Good Citizen Award, Clark County Medical Society
- Hall of Fame Award, East Vancouver Rotary
- Special Award for HIV/AIDS Education, Vancouver School District
Tom has been a highly effective and respected leader of his professional colleagues, as president of his hospital's medical staff, President of the Washington State Society of Internal Medicine, and Governor of the American College of Physicians for Washington. He reorganized and re-energized the state WSSIM and ACP chapters, though distant from Seattle. He credits his inveterate partner, Gerrie, for much of that accomplishment. He was similarly effective and respected on the Board of Governors as a member of the Post Graduate Program Task Force, developing College sponsorship and endorsement of CME activities planned by outside organizations. Tom brought great honor to his Washington internist colleagues by his service on the Board of Governors of the American College of Physicians.
We are not often blessed with such an outstanding leader and good citizen. For his lifetime of spectacular service we honor him with the Laureate Award of the Washington Chapter of the American College of Physicians-American Society of Internal Medicine.
2001 Robert J. Glaser: Distinguished Teacher Award, Alpha Omega Alpha
Douglas S. Paauw, MD, Department of Medicine, Division of General Internal Medicine, is among four physicians to receive the 2001 Robert J. Glaser Distinguished Teacher Award from Alpha Omega Alpha, the national medical honor society. Awardees are nominated by U.S. and Canadian medical schools and selected by an AOA/AAMC committee. They receive $10,000, and their institutions receive $5,000 to support teaching. Dr. Paauw, professor of medicine and attending physician at UWMC - Roosevelt, holds the Rathmann Family Foundation Endowed Chair in Patient Centered Clinical Education. He is department coordinator for student teaching, clerkship coordinator, lecturer, and member of the School of Medicine Clinical Curriculum Committee and the Task Force on Faculty Development. He has received both University and School of Medicine Distinguished Teaching Awards, a Clinician-Teacher Award of Excellence from SGIM, and the Paul Beeson Award, among other honors. He will receive this award from AOA President David C. Dale, MD (UW Department of Medicine, Division of General Internal Medicine) during the Annual Meeting of the AAMC in November in Washington, DC.
The other recipients of the 2001 Glaser Award are Walter J. Bo, MD, Bowman Gray School of Medicine; J. John Cohen, MD, University of Colorado School of Medicine; and Steven E. Weinberger, MD, Harvard Medical School.
Physician's Outpatient Antibiotic Use Target Of WSM-ERF Campaign
Did you know that a study published in JAMA in 1997 reported that physicians treating adults with viral infections prescribed antibiotics for 51% of patients with colds and 66% of patients with bronchitis? It is also accepted that inappropriate use of antibiotics contributes to the alarming problem of antibiotic resistance. With the cold and flu season rapidly approaching along with the national concern about Anthrax, physicians need to be cognizant of prescribing antibiotics for the right reasons.
The WSMA's foundation, the Washington State Medical Education and Research Foundation (WSM-ERF), has been leading since 1998 the Alliance Working for Antibiotic Resistance Education (AWARE) campaign aimed at patient and physician education regarding the appropriate use of antibiotics. The AWARE campaign is a unique collaboration between the medical profession, the Department of Health, and health plans.
AWARE kicked off a statewide education campaign in October with a call to action: Lower your use of antibiotics because these once-effective drugs are becoming increasingly ineffective. This fall expect to see TV and radio ads and articles in newspapers across the state explaining the difference between viral and bacterial infections. WSM-ERF is also mailing materials created by the CDC to individual physician offices for distribution to patients.
Working with 125 physicians around the state, AWARE has also produced a set of guidelines, which will act as a quick and simple reference for doctors to use when prescribing antibiotics for sinusitis, pharyngitis, otitis media, bronchitis, and community acquired pneumonia. Watch for these to arrive in your mailbox in within the next few weeks.
"These guidelines are imperfect, but if you use them you have a much higher probability of separating bacterial infections from viral one," said Art Sprenkle, MD, project medical director for the WSM-ERF and program director for the appropriate use campaign.
Regence, Premera, Group Health Cooperative, First Choice, Aetna, Cigna, PacifiCare, Molina, One Health Plan and Columbia United have endorsed the new guidelines in lieu of their own. Thus, physicians will need to be aware of only one set of guidelines rather than multiple versions.
Dr. Sprenkle is also giving presentations at county medial society meetings as well as specialty society meetings about the appropriate use of antibiotics and the guidelines. The program has been certified for up to two hours of Category 1 CME credit.
For more information about the AWARE campaign, contact Dr. Art Sprenkle at (firstname.lastname@example.org) or (425-891-0502).
Congratulations New Fellows!!
Stuart L Bursten-Issaquah
Clark S Coler-Seattle
Stephen N Ewer-Richland
Steven E Goodell-Spokane
Thomas H Payne-Seattle
Bruce Cameron Smith-Bellevue
Katherine R Tuttle-Spokane
WSMA Offers Physicians and their Staff Health Insurance as Additional Benefit of Membership
In partnership with Acordia, a Seattle-based insurance broker, the WSMA is now offering health insurance benefits to WSMA members, their families and their employees.
The benefit offering includes four medical plans through the Association of Washington Business and the Washington State Farm Bureau. Also available to WSMA members is a Medical Savings Account (MSA) through KPS Health Plan.
More information on the plans can be found on the WSMA Web site at www.wsma.org or by call Kallijah Paraska at Acordia at (206) 701-5226 or 1-800-876-0505.
Experience Annual Session-Philadelphia Style
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 the 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.
Experience Annual Session...
ACP-ASIM Annual Session 2002, April 11 - 14, 2002, Philadelphia, PA. You can get registration and other meeting information on the College web site by going to (http://www.acponline.org/cme/as/2002/index.html), 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.
Bioterrorism Resource Center
The September 11 terrorist attacks precipitated a wave of concern about the possibility of bioterrorism-the use of germs and chemicals as weapons of mass taking of lives. In recent weeks, the concerns have become a reality with the onslaught of Anthrax cases. In an effort to educate physicians and provide up-to-date information on biological terrorism, ACP-ASIM has developed the Bioterrorism Resource Center on the College website (http://www.acponline.org/bioterro/).
The information featured in the Bioterrorism Resource Center is broken down into the following sections:
- Therapeutic Recommendations for Exposure to or Disease Caused by Biological Weapons — Up-to-date recommendations from the CDC and other organizations regarding treatment, exposure, research, etc.
- Essential Medical Knowledge — General medical knowledge on biological and chemical weapons
- News — Current events and news releases regarding bioterrorism.
- Additional Resources — Helpful resources to assist in the gathering of information on bioterrorism; websites, journals, recordings, speakers.
- College Activities — ACP-ASIM initiatives and efforts to aid physicians in the battle against biological and chemical threats.
ACP-ASIM encourages all physicians to visit the Bioterrorism Resource Center often, as physicians are the first line of defense against bioterrorism. It is the intent of the College to be a comprehensive resource for the medical community on biological and chemical threats in an effort to prevent the sense of alarm and panic.
Education and preparation are key components in promoting an efficient, expeditious approach to bioterrorism. Visit the Bioterrorism Resource Center on the College web site at (http://www.acponline.org/bioterro/index.html) and join ACP-ASIM in the campaign to promote a "Don't panic, prepare" campaign against bioterrorism.
March 1-2, 2002 - Spokane Society of Internal Medicine's 53rd Annual Scientific Meeting to be held at the Spokane Agricultural Trade Center, Spokane, WA.
"Update In Internal Medicine"
- National Faculty
- Ten (10) Hours of CME applied for
Associated ProfessionalAnd Nurses $125
Residents $ 40
For more Information: Contact Linda Browne, Spokane Society of Internal Medicine, PO Box 8443, Spokane, WA 99203-0443, or call 509-448-2513. Brochures will be mailed January 6, 2002.
Calendar Of Events
January 10, 2002, Washington Chapter ACP-ASIM Executive Council Meeting, U/W Plaza Cafe
January 29, 2002, WSMA Legislative Summit, West Coast Olympia Hotel, Olympia, WA
March 1-2, 2002, Spokane Society of Internal Medicine 53rd Annual Scientific Meeting, Spokane Agricultural Trade Center
April 11-14, 2002, ACP-ASIM Annual Session, Philadelphia, PA
September 19-21, 2002, WSMA Annual Meeting, Tacoma, WA
November 1-2, 2002, Washington Chapter ACP-ASIM 2002 Annual Meeting, The Westin Hotel, Seattle, WA
September 18-20, 2003, WSMA Annual Meeting, Yakima, WA
April 3-6, 2003, ACP-ASIM Annual Session, San Diego, CA
How To Reach Us
David C. Dale, MD, FACP
U/W, Dept. of Medicine
Seattle, WA 98105-6422
Phone: (206) 543-7215
FAX: (206) 685-4458
Washington Chapter ACP-ASIM
2033 Sixth Avenue, Suite 1100
Seattle, WA 98121
Phone: (206) 956-3646
FAX: (206) 441-5863