Summer 1999 Governor's Newsletter

Governor's Notes
June

In the last couple of years, we have witnessed unprecedented changes in our profession. From a fee for service environment, we are asked to switch our mindset to capitation and managed care. This challenges our profession generally and internal medicine particularly. The Chinese blessing "May you live in interesting times" would be considered a curse by many physicians today. Some of our colleagues are very angry and discouraged as they experience erosion of autonomy and their professionalism. The major driver producing change has been the economics of financing medical care both in the private and public sectors. Preceding the National meeting in New Orleans, one of the major issues discussed by the Board of Governors and the Board of Regents was to define and discuss in rank order, the threats and opportunities to internal medicine using the current environmental assessment as a point of departure.

Threats

  • A key element of the infrastructure of medicine, medical education no longer enjoys public support. Immediate symptom is the reduction in GME funding of the Medicare and a threat to withdraw GME funding from Medicare and make it simply another item in the annual federal budget setting process.
  • Physicians have less time for individual patient visits and yet the patient's health plans and payers all have added new expectations of the physician to satisfy during the time the patient/physician visit.
  • Internists, especially general internists are experiencing increased competition from other health professionals. The number of people entering the fields of nursing and pharmacy has remained constant or increased at a time when automation or use of less educated professionals has reduced the need for their services.

Opportunities

  • The growing sophistication of computer support to medical practice has created nearly boundless opportunities to improve the practice of medicine.
  • The signs of practice management have grown but physicians remain far behind the cutting edge at the time when there is a high premium on effective management of the business and organization of a clinical practice.

Hamlet's question " To Be Or Not To Be" was overshadowed by the question of "PAC Or Not To PAC". There are two major schools of thought. On one hand, the ACP-ASIM without the PAC (Political Action Committee) has been effective with our national leaders in the role of advisors and promoters of humanistic ideas. The College did manage to advocate effectively and support new ideas. On the other hand, PAC can clearly identify goals and win support in a more organized way. The latter group believes that the modern approach to influence decision making in the government , organized sponsor lobbying opens otherwise closed doors. At the recent Board of Regents meeting, decision was made to gather more information from the membership regarding this issue. As your Governor, I sit on the Board of Governors of the College and in that capacity, have the ability to represent you and bring to this body for discussion, any issues and concerns you may have. Again, I hope that you will work with us to address those issues during this critical time of health system reform.

There were over 6,000 MD's in attendance at our National meeting in New Orleans and a group of 187 were from our state. The program was outstanding and the "Multiple Feeding of the Mind", a new form of learning was very successful. The fact that the Jazz Festival took place during the same time clearly did not hurt attendance.

I was very proud to participate in convocation and walk down the isle with 25 new fellows from Michigan:

Suresh Ann, MBBS
Gary G. Bill, MD
Albert M. Brady, MD
Ronald A. Charles, MD
Delmer J. Dehart,MD
Richard D. Dryer, MD
Manoharan W. Eustace, MBBS
Gwendolyn R. Graddy-Dansby, MD
Suhasini Gudipati, MD
Curtis L. Hunt, MD
Naji M. Khairallah, MD
Augustine K. Kole-James, MD
Karen W. Merritt, MD
Frederick P. Michael, DO
Iman E. Mohamed, MBchB
Hem P. Mohindra, MD
Eliezer Monge St. Laurent, MD
Anthony F. Ognjan, DO
Paul T. Porter, MD
Pablo Reyes, MD
Yvonne T.Sesi, MD
Nabil Sultani, MD
Andrew CG Uprichard, MD
Ralph E. Watson, MD
Douglas R. Woll, MD

By the confirming of Fellowship, you have been recognized by your peers for your outstanding accomplishments, achievements and expertise in medicine and most importantly, for your contributions to your patients, communities, the College and to those students and physicians who have benefited from your teaching. Fellowship of course does not delineate an end, but is a beginning of a new period of your professional life and offers an opportunity for you to become involved in the leadership of the College, both on the chapter and national level.

Congratulations again and I am sure a number of you will go on to serve on regional—national ACP/ASIM committees and attain leadership positions including governor for your region.

I would like to take this opportunity to congratulate two new Masters of the College — Dr. Michael Lesch who in the meantime moved to Chair the Department of Medicine at St. Lukes Roosevelt in New York and Dr. Robert Narins, Dept. of Nephrology/Hypertension of Henry Ford Hospital, Detroit. Mastership is awarded to those few individuals who have made major contributions to the field of internal medicine. In the past, designation was reserved for department chairs and other "giants" in the field. More recently however, community service and major contribution to the local community were taken into consideration.

I think you will be pleased to learn that the Michigan Chapter was nominated for the Evergreen Award and was awarded the Chapter Management Award for 1998. Congratulations to all of you who helped us to achieve that.

At the time of this writing, the Awards Committee headed by Dr. Gilbert Bluhm is considering your nominations for Laureate as well as Mastership. The Laureate Awards will be presented in Traverse City in September. In the same vain, I would like you to also notify Dr. Ken Fisher, Chairman of the Program Committee for our Scientific Meeting of your expectations. You can email him at: kfisher@KCMS.MSU.edu. Ken is working very hard with his program committee and I can reassure you that the attendees will not be disappointed in this year's program.

I am a member of the program committee for the national meeting in Philadelphia in the year 2000 and needless to say, the expectations are very high. My contribution will be organizing the "cardiology part". Any suggestions?

A very important successful event took place in Southfield on May 7, 1999 where the OHEP Center for Medical Education (OHEP) organized an outstanding meeting for our Associates. OHEP is the largest community based medical education consortium in the Midwest. There are 96 accredited residency and fellowship programs in 50 specialties and subspecialties responsible for about 40% of the GME in the State of Michigan. Attendance was at an all time high with 210 registrants. We were very pleased with the overwhelming participation by our associates. The academic quality of the posters and clinical vignettes improves every year. It was great to exchange ideas with our younger colleagues. It really "made my day". I wish to salute the program committee for creating such an outstanding program and also Dr. Ernie Hammel, Director, OHEP, Dr. Louis Saravoltz, Chairman of the OHEP Internal Medicine Committee and Residency Program Director, St. John Hospital and Medical Center and Dr. Dennis Malloy, Vice Chairman, OHEP Internal Medicine Committee and Associate Program Director, Department of Internal Medicine, St. Joseph Mercy Hospital. Our featured speaker was Dr. John Tooker, Deputy Executive Vice President of ACP-ASIM and his topic was" Medicine in the New Millennium". Awards in four different categories were presented and are listed below. The winners of the categories were invited to present at the ACP-ASIM's regional meeting in Traverse City in September 1999. The winners of the competition were as follows:

First Place Case Report (Oral)—Susan Bannon, MD-MSU/Kalamazoo
Second Place Case Report (Oral)—Behzad Molavi, MD, MSU, East Lansing
First Place Research (Oral)—Elie Hage-Korban, MD, MSU, East Lansing
Second Place Research (Oral)—Fareha A. Kazi, MD, MSU, East Lansing

First Place Case Report (Poster)—David P. Solvut, MD, PHD, U of M
Second Place Case Report (Poster)—Abdia Zafar, MD, St. John Hospital & Medical Center
First Place Research (Poster)—Behzad Molavi, MD, MSU, East Lansing
Second Place Research (Poster)—Nasser Bayati, MD, William Beaumont, Royal Oak

Congratulations to all participants on a job well done. The first place winners were awarded an engraved plague and $100 with the second place winners receiving a certificate and $50.00. Should any of the first place winners listed above so choose to submit their winning papers for consideration and are approved for presentation at Annual Session in Philadelphia April 13-16, 2000, the Chapter will pay their expenses.

It is never too early to start thinking about our next Associates Day which will be organized and hosted by Michigan State University, Lansing, MI. for the year 2000. Look for details in our Fall Newsletter.

Michigan Scientific Meeting
September 23- 26, 1999
Grand Traverse Resort
Theme: Ambulatory Approach to Chronic Diseases

Now is the time to mark your calendar to insure your attendance at our Scientific Meeting in September. Topics to be covered will include Rheumatology, Infectious Disease, Neurology, Chronic Obstructive Lung Disease, Congestive Heart Failure, and Hypertension. Highlights will include a Medical Student Program, Associates' Program with Clinical Vignettes, Posters and Research Competitions, Women Resident/Student Roundtable Discussion, Minority Physician Breakfast, Kids Program Saturday Evening, Prize drawings during Banquet, Laureate Awards. I am sure all attendees will once again be pleased to have Dr. David Scrase return from Albuquerque, New Mexico to conduct the very popular Thieves Market.

Joel Appel, DO, FACP, Chair, Mi. ACP-ASIM Medical Student Program: This is the Sixth Annual Medical Student Retreat sponsored by the MI. Chapter of ACP-ASIM. I urge medical students in Year II, III and IV interested in a career in Internal Medicine to attend. This will consolidate your interest in Internal Medicine with a weekend of educational and social activities in a collegial setting with your counterparts from Michigan State University, U of M, Case Western and the Membership of ACP-ASIM. The ACP will reimburse you for hotel expenses, plus provide registration fees and most meals. For further information or to request a reservation (deadline August 20, 1999), contact: Sue Murphy, Administrative Assistant or myself, at (313) 966-4960 or email at: aa6469@wayne.edu. A limited number of slots are available, so please notify us as soon as possible.

Vanessa L. Robinson, MD, FACP, Co-Chair, Minorities—Once again we are able to meet and discuss our concerns during our Scientific Meeting in Traverse City. Please join us on Saturday September 25th at 7:15 am. We encourage each one of you to email either Dr. Barbara McIntosh or myself with your thoughts so that our meeting will be a rewarding experience. Email: vrobin1@hfhs.org or Dr. McIntosh at bmcinto1@hurleymc.com.

Jan Rival, MD, FACP- The time spent at the meeting is not only a learning experience but an opportunity to bring your family and enjoy the Traverse City area. Should you have any questions or need any information regarding our meeting, please call or email our office. Also, for your convenience, look at the Chapter's Web Site at www.acponline.org/chapters/mi. A copy of the program, registration form and hotel accommodations are available on line.

Our success depends on our membership to accomplish our mission so please get involved.

Leadership Day On Capitol Hill
Joseph J. Weiss, MD, FACP and John P. Papp, MD, FACP

On Tuesday May 25th, 200 ACP-ASIM physicians from throughout the United States assembled at the Washington Court Hotel, just strides away from Capitol Hill. Representing Michigan were Drs. Jan Rival, Joseph J. Weiss, Howard Goldberg and John Papp.

Our purpose was to lobby the next day on Capitol Hill for issues ACP-ASIM leadership considered important to American internists. Issues at hand included 1) tax credits for low to moderate income uninsured Americans 2) electronic medical records confidentiality legislation 3) patient protection legislation 4) Medicare restructuring 5) funding for graduate medical education 6) pain management-end of life care 7) collective bargaining. Written information on the bills to support, where ACP-ASIM stands on the issues including what to expect in rebuttal and ways in which to respond were given to each of us for review. The following morning, representative Greg Ganske on the Ganske-Dingell Patient Protection Act and Representative Ben Cardin on his bill for reform in GME funding spoke with the ACP-ASIM leadership in attendance on their bills. Following their presentation, we left for Capitol Hill to visit with Brandi LaPerriere, Senator Spencer Abraham's legislative assistant on health care policy and subsequently we visited with Congressman Vernon Ehlers (Republican-Third District) and his legislative assistant, Sandra LaGrand , Congressman Sander Levin, (Democrat-Twelfth District) and Congressman Joseph Knowlenberg (Republican 5th District) .

In summary, the trip to Washington and our lobbying was very worthwhile. The preparation of ACP-ASIM is outstanding and participating in politics in Washington, even briefly, gives one a sense of the activity that cannot be equaled by reading newspapers or watching CNN. It was an exciting and informative time for all of us attending. We appreciated the leadership of Dr. Jan Rival and also the opportunity of having this chance to visit Capitol Hill regarding matters of concern for all of us.

GME Funding
Eric J. Scher, MD, FACP, Chair, Mi. ACP-ASIM Residency Program Director's Committee

Academic Health Centers (AHC) that carryout graduate medical education throughout our country are under pressure to reduce costs and become more efficient in delivering health care services to their patients. AHC's care for large numbers of indigent patients and have broader social and societal missions relative to their non-teaching hospitals. As a result of reduced reimbursements, increasing denials and slow payments by HMOs, reductions in Medicare reimbursements due to the BBA (Balanced Bude Amendment), and increasing numbers of uninsured patients these missions are now threatened. In late April of this year, the AAMC called for restoration of BBA Medicare cuts to teaching hospitals and stated that these cuts have gone too far and are threatening the long-term financial stability of U.S. teaching hospitals. The BBA, through reductions in IME (Indirect Medical Expenses) over a five-year period and caps on the number of residents and DME (Direct Medical Education) dollars affixed to those resident FTE's (Full time equivalent), has caused significant financial difficulties for most AHC's and now threaten the quality of graduate medical education in many centers. More recently, the now defunct Bipartisan Commission on the Future of Medicare supported a proposal to remove DME from the Medicare trust fund and place it into the appropriations process. This would lend further uncertainty to the GME funding process and make it even more vulnerable to the political vagaries of Congress. There is also new talk of more drastic reductions in IME than stipulated by the BBA.

U.S. teaching hospitals are where 44% of all indigent care in the country is provided, 75% of all residents are trained and a vast majority of the clinical research is performed. These missions are clearly threatened by the financial instability caused by the Balanced Budget amendment and more recently by proposals put forth by the Bipartisan Commission on the Future of Medicare.

The ACP-ASIM opposes removing funding for the direct cost of GME from the Medicare Trust Fund. Furthermore, the ACP-ASIM supports an All-Payer system for funding graduate medical education. The rationale is that all health care payers, not just Medicare, depend on high quality medical graduates, medical research, and technical advances from teaching facilities. All payers also derive value from this system and should share in the requisite investment in medical education.

As program directors, we all have a vested interest in ensuring stability in GME financing and we need to become more proactive in making our concerns known to our legislators through organizations like ACP-ASIM.

I wish you a nice summer and look forward to seeing you in September at our regional meeting. As mentioned previously, Dr. Ken Fisher is doing a yeoman's job to insure that it will be a learning, teaching experience second to none with social interaction, which is an integral part of our program. I would like to close with a poet's corner and several suggestions—

How to keep peace:

  1. Listen more and argue less
  2. Show your appreciation wherever possible
  3. Greet people with a smile on your face
  4. Let your virtues speak through your deeds
  5. Accept criticism graciously
  6. Express criticism healthfully
  7. Use your own common sense with goodwill as your guide
  8. Plan your objectives and work with a plan
  9. Do your best in whatever you try
  10. Encourage, congratulate, sympathize, understand; in short, treat others as you wish to be treated
  11. Win acquaintances and keep friends

Just a reminder— it is very easy to get in touch with us. If you would like to include any of your thoughts in a future Governors letter, give us your fax/email address. We need to hear of your concerns/suggestions/proposals. Our door is open to all.

Ways to Contact Your Governor

Write:

Michigan Chapter ACP-ASIM
C/0 Henry Ford Hospital
2799 West Grand Blvd.
Detroit, MI. 48202
ATT: Room B-1540, K-15

Call: 800-247-2485 (Michigan residents only) or (313) 876-1403
Fax: 313-876-1409
E-mail: Jrival1@HFHS.org

Please let me know of your ideas, concerns, criticisms