• rss
  • facebook
  • twitter
  • linkedin


January 2012 Alan D. Forker, MD, MACP, Governor

Message from the Governor

Dr. Fleming

The most fun I’ve had being your Governor in the past 4 months was watching Dr. David Fleming receive the Missouri Chapter Laureate Award at out Annual Chapter Meeting in September, 2011. He richly deserved it since he was our Governor from 2007-2011 and now is the Chair, Board of Governors, meaning in administrative charge of all chapter Governors. And in his spare time he is Chairman, Department of Medicine, University of Missouri-Columbia (joke). We thanked David for the richness of his leadership expertise for ACP, in addition to the daily role model he provides for the current and next generation of internists. Thank you, David, for all the time and effort you have given to ACP and internal medicine.

Congress averted a 27.4% decrease in Medicare reimbursement as of January 1 with a two month delay. This means on March 1, 2012, physicians are in danger of an even greater cut in reimbursement for their services, leading to potential closure of their practices, limiting how many Medicare patients that can be seen, laying off staff, and postponing investment in their practice for improved patient coordination and care, such as funding purchase of electronic medical records.

ACP asks Congress to make a course correction: support the proposed bill offered by Rep. Allyson Schwartz (D-PA), which ensures patient access to physicians while promoting efficiency, quality and value in health care delivery, exactly what ACP stands for. Some of the key points are:

  • permanently repealing the SGR
  • aggressively testing and evaluating new payment and delivery models, such as the Patient Centered Medical Home (PCMH), and insuring access to primary care
  • stabilizing the current payment system for both primary and subspecialty providers, ensuring long-term stability
  • identifying best practices, and rewarding providers for high-quality, high-value care.

More than ever we need your support in voicing our concerns, responsibly and competently, at the state and national level. I hope you would join me at the next Leadership Day in Washington, DC, June 6-7, 2012.

I think this is a good time to mention the interesting article in the Kansas City Star on November 6, 2011 regarding Hal Holbrook. As most Missourians know, Hal has dedicated the bulk of his professional life to performing Mark Twain, probably Missouri’s most famous writer. He was in KC to discuss his new book and memoir, Harold: The Boy Who Became Mark Twain. In an interview he made a key point: Mark Twain had unusual understanding of us, human beings, why we think the way we do, and “What he says about people is the truth.” Further, that currently “nobody is telling the truth,” referring to the news media and politics.

I think it is time for us, all of medicine, but especially internal medicine and ACP, to speak forcibly about the truth for what is best for our patients. We need to stand up and speak out. We should lead the way in telling the truth, leaving out all conflicts of interest, especially financial conflicts of interest. We should discuss with patients how we are reaching a reasonable diagnosis, based on a thorough history and physical exam, not an unnecessary battery of expensive tests. If tests are needed, explain why they are needed and their value. We should not be afraid to discuss costs and cost/benefit ratios plus risk/benefit ratios. For those of you who have not read Dr. Jerome Groopman’s book, HOW DOCTORS THINK, I urge you to read it, since he discusses multiple different types of physicians and their frequent deficient thought process. One of his key points: don’t be afraid to say “I don’t know.” Let’s be a modern Mark Twain and speak the truth.

Further, you should read Dr. Abraham Verghese, et al, article in October 11, 2011 issue of Annals of Internal Medicine, entitled “The Bedside Evaluation: Ritual and Reason. We need to avoid the total attention to the computer and the “iPatient,” and focus on the actual patient. As he points out, too often patients complain “my doctor never touched me.” This is a ritual experience of deepening engagement with the patient, “conveying a symbolic centering of attention on the body.” Plus, for teachers this is an opportunity to get rid of the “hidden curriculum” that hands-on care is not important. Hands-on teaching and care should not only provide added satisfaction to experienced physicians, but also bring about a change in the attitude of young physicians: Hey, this is fun.

Alan Forker, MD, MACP Governor


Joplin Tornado, May 22, 2011 and Japanese Earthquake, March 2011

For those who didn’t see it, the front cover of ACP Hospitalist, September 2011, showed a picture of a destroyed room/entrance to St. John’s Regional Medical Center. The inside article describes the mobilization of patients (5 died, but 183 were successfully evacuated) and care of those patients because of the prompt response and competence of the Joplin medical community. We applaud our colleagues in Joplin for their service and dedication to our profession.

A key benefit of belonging to ACP is meeting physicians outside your practice, hospital, and community; I have thoroughly enjoyed making friends with internists all over Missouri, an opportunity I would have missed if I hadn’t joined ACP and volunteered my time over the past 37 years. And if you attend the national ACP meetings, such as coming up in New Orleans, April 17-21, 2012, you will meet physicians from around the USA and the world. I now consider him my friend, Dr. Shotai Kobayashi, MACP, Governor of Japan. His Governor’s Letter of October, 2011, thanks Americans for our support, but also encloses a story by Jinrou Ishizuka, FACP, regarding his and other physicians providing patient care over five months.

Initially, “my town, 38 km away from Fukushima was chaos: people in my town panicked. Food stores, banks, post offices, most businesses were quickly closed. My staff were absent without giving notice. More than 150 patients visited us every day, many did not carry their medical information with them, and we had minimal food and medical supplies.” Many physicians abandoned their usual daily life, and stayed at these evacuation clinics for the next 5 months. Wow! What dedication to service our colleagues in Joplin and Japan have demonstrated. We thank you from the depths of our hearts.


Board of Governers, September, 2011, San Antonio Meeing, and Dr. Sanjeev Arora, FACP, and Hepatitis Echo Project

All of the Governors from all chapters meet twice a year to discuss current issues in medicine, especially internal medicine. Included at this meeting was a core curriculum on the Accountable Care Organization (ACO), which you will hear more about from multiple sources, including ACP. But the highlight for me was the fantastic talk by Dr. Sanjeev Arora, gastroenterologist/hepatologist from the University of New Mexico.

Dr. Arora started a project entitled “Extension for Community Healthcare Outcomes” or ECHO because in 2003-2004, patients could wait up to 8 months to be seen at the University , and not a single primary care physician was treating hepatitis C in all of New Mexico. He established a disease management model, utilizing videoconferencing and the Internet, with emphasis on case based learning. The specialists at the University never saw the patients with increasing knowledge and independence of the primary care physicians, many in rural areas of New Mexico. Eventually, hundreds of patients were seen and treated; and guess what: who got the best care—University specialists or the rural primary care physicians? When percentages of patients with a sustained virologic response and adverse events were compared, the results were equivalent, meaning the primary care physicians did just as well as the subspecialists. I refer you to: ACP Internist, September, 2011; and the June, 2011 issue of NEJM, ie Arora, etal: Outcomes of treatment for hepatitis C virus infection by primary care providers. N Engl J Med: 2011; 364, 2199-2207. If you interested for your own patients, he said “Call us.” Contact information for project ECHO is available online at http://echo.unm.edu. What a model for education and quality patient care!


Annual Missouri Chapter, ACP, Meeting, September, 2011, and Dr. Donna Sweet, MD, MACP, and Hepatitis C

Another excellent Annual Scientific Session was held at Tan-Tar-A. For those of you who didn’t attend, I’m sorry since the learning experience was exceptional. And can you believe it, a week after hearing Dr. Arora talk, Dr. Donna Sweet, a master clinician and teacher from Wichita, gave a keynote presentation on hepatitis C that was outstanding. As a physician who has never treated hepatitis C (since I have spent most of my professional life as a cardiologist), the learning curve was steep. I learned that 4 million Americans have been infected with hepatitis C and 76% are undiagnosed. WOW. In 2007 there were 15,106 deaths attributed to hepatitis C and complications vs. 12,734 deaths due to HIV/AIDS. Even more attention gathering was the case she presented: a 50 year old physician with a chief complaint of fatigue with an AST=65, ALT=44. And yes, after a liver biopsy to quantitate the degree of inflammation vs. fibrosis (response better with the former), he responded with clearance of his hep C . With this double dose of hepatitis C over those 2 weeks, I was appropriately awakened and alarmed by this clinical and societal challenge.

Before I close this fireside chat (Baby, it’s cold outside), I want to remind you of 3 key dates:

  • National ACP Meeting/scientific sessions in New Orleans, April 18-21, 2012
  • Leadership Day in Washington DC, June 6-7, 2012
  • MO Chapter Annual Meeting/scientific sessions, September 13-16, 2012 at Tan-Tar-A, Lake of the Ozarks.

We need your support for internal medicine and ACP. I hope to see you at these meetings. Stay warm.


Doctors Dilemma

doctors dilemma

Drs Lishmanov, Smitherman, and Chennamaneni

The University of Missouri IM Residency Program won the Doctors Dilemma contest held during the Missouri Chapter annual meeting. Other programs competing were St Luke’s (Chesterfield), Saint Louis University, and Washington University. The Missouri winners (Anton Lishmanov, Venu Chennamaneni, and Sarah Smitherman) will compete at IM 12 in New Orleans in April. The Chapter will have its 2012 Doctors Dilemma contest Friday, September 14 during the chapter meeting at Tan Tar A.


Associate and Student Poster Competitions

The Missouri Chapter again had over 100 posters in the Associates competition. The Chapter will be sending three Associate members to IM 12 in New Orleans to present their posters which were selected as winners of their respective categories during the contest at the chapter meeting. The Chapter also had a Student member poster contest for the first time from which two winners will also be advanced to IM 12.

Clinical Vignette - Associate
Sanjay Maniar - Washington University
The Myocardial Bandit: A Case of Left Internal Mammary Artery Steal Phenomenon

Research - Associate
Mayank Mittal - University of Missouri
Inhibition of Vascular Smooth Muscle Cell Migration by a Novel Tiplaxtinin Eluting Stent

Patient Safety & Quality Improvement - Associate
Delene Etwaru Musielak - University of Missouri
Quality Improvement of ANCA Testing: Review of appropriateness in a consecutive 12-month cohort at MU.

Clinical Vignette - Student
Megan Rau - University of Missouri
Recurrent Pleural Effusion following Radical Cystectomy and Ileal Conduit Surgery

Research - Student
Seth Bloom - Washington University
Commensal Bacteroides species induce colitis in host-genotype-specific fashion in a mouse model of inflammatory bowel disease.


Chapter Meeting Exhibitors and Sponsors

The Missouri Chapter appreciates the support of our sponsor and exhibitors at the 2011 meeting. The Chapter relies on exhibitors and sponsorship to produce approximately half the revenue for the annual meeting. This revenue helps cover costs which would otherwise be included in the physician registration fee. We thank the following for their support, including the sponsorship of the exhibit hall food and drink by MPM.

Cox Health / Ferrell Duncan
Eli Lilly
KIG Healthcare Solutions
McKesson Practice Partner
Missouri Army National Guard
Missouri Professionals Mutual (MPM)
Novo Nordisk
Optimer Pharmaceuticals
PDS Cortex
sanofi Aventis
St Luke's Health System


Clerkship Award

clerkship award

Left to right: Stephanie Moore Canham – WU, Matthew Strand – MU; Katie Ward – SLU; and Danny Burakovsky - UMKC


ACP Physical Diagnosis

physical diagnosis

Left to right: Jason Curtis – WU; Andrew Valleroy - MU; Christopher Brett - UMKC; and Stacy Stieren - SLU



If you don’t recognize this acronym yet you will in the near future. The NCQA has a new certification plan for Patient Centered Medical Homes for practices who are interested in achieving additional reimbursement from MO HealthNet and Anthem. ACP resources are online.



This acronym for Quality Resource and Use Report will enter your Medicare lexicon in 2012. All physicians in Missouri, Iowa, Nebraska and Kansas who billed Medicare fee for service in 2010 will receive a report measuring cost and quality. This four state region is being used as a focus group by CMS in their Physician Feedback Program to identify improvements to the QRUR before rolling it out nationwide. CMS will use 2013 data to implement the 2015 value based payment modifier for physicians on a budget neutral basis. The modifier will apply to all physicians by 2017. More online at: www.cms.gov/physicianfeedbackprogram


Health & Public Policy Committee

Bill Fogarty, MD, FACP has served as chair of the HPPC for the past few governors and has decided to pass the reins to Peggy Barjenbruch, MD, FACP. Dr Fogarty has provided superior leadership to the Chapter during Hill visits, Leadership Day, and communicating with Congress. As Dr Barjenbruch is just getting started, she is seeking additional committee members to help track federal and state legislation. If you have an interest in participating on the HPPC, email pmills@msma.org.


Chapter receives Excellence Award

chapter excellence

The Missouri Chapter is in receipt of the 2011 Chapter Excellence Award. The award recognizes chapters which successfully meet the standards for managing a chapter. In order to achieve the Chapter Excellence Award, chapters must meet all basic criteria and seven optional criteria. Criteria include such activities as formulating an effective Governor’s Council and committees, communicating frequently with membership, providing educational opportunities, recruiting and advancing members and celebrating membership through local awards. The Chapter has received this award every year since the ACP-ASIM 1998 merger.


2012 Chapter Meeting Speakers & Topics

  • ABIM SEP – Hospital Medicine – Brent Beasley

  • ABIM SEP – Office Based Internal Medicine – Melvin Blanchard & Ernie-Paul Barrette

  • End of Life Issues / Palliative Care / pain management (Saturday AM - Hospitalist topic) – Miguel Paniagua & Richard Butin

  • Broken Heart syndrome (Saturday AM - Hospitalist topic) – Kevin Bybee

  • Management of chronic wounds (Saturday AM - Hospitalist topic)– David Thomas

  • Interventional Radiology capability and evolving embolization procedures – Nasir Siddiqi

  • PQRS / quality measurement – Michael Barr

  • Management of Acute Low back pain – Tom De Fer

  • Community acquired pneumonia & review of pneumonia guidelines – Will Roland

  • Headache – Richard Sohn

  • Differential diagnosis of arthritis & importance of early diagnosis of Rheumatoid arthritis – Anne Winkler

  • Management of dementia – use of medications & nonpharmacologic management – John Morley

  • New CSF & Imaging tests to diagnose dementia: what is real vs PR – David Carr

  • The Adventure of Domestic Volunteer Medicine – Bridget McCandless

  • Thyroid nodule work up & Hyperthyroidism Cases – Uzma Kahn

  • Non-Alcoholic Fatty Liver Disease, recent update and current management – Ghassan Hammoud

  • Workshop: EKG reading – Richard Whiting

  • Diabetes Management – David Gardner

Why I attend the ACP meeting:
"Being a subspecialist, I can always count on superb pointers about all the other parts of Internal Medicine, from experts in the field, who know at what level to aim. It is universally helpful, and makes for a very enjoyable, stimulating long weekend."
Mary Muscato, MD, FACP (Hem/Onc)

Hospitalist Saturday
The Chapter meeting will have a Hospitalist focus on Saturday, Sept 15. The morning lectures will be focused on in patient medicine; the lunch discussion will be management and follow up of patients who have had interventions but need continued outpatient care, appropriate transition of care with a hospitalist and a non-hospitalist; and the afternoon session will be a non-CME session on hospitalist related administrative issues.


Chapter Council Ballot - due January 30

The following have completed one term and are re-nominated for a second term (vote for three):

  • ___ Bridget McCandless, MD, FACP – Kansas City

  • ___ Tracy Norfleet, MD – St Louis

  • ___ Megan Wren, MD, FACP – St. Louis

Nominated for a first term to the Council are (vote for four):

  • ___ Tom Allen, MD – Kansas City

  • ___ Ahmed Awad, DO – Kansas City

  • ___ Peggy Barjenbruch, MD, FACP – Mexico

  • ___ Richard Burns, MD, FACP – Columbia

Fax your ballot to: 573-636-8552 or mail to: ACP; PO Box 1028; Jefferson City, MO 65102 or email to: pmills@msma.org



April 19-21, 2012 IM 12 in New Orleans
Sept 13-16, 2012 Missouri Chapter meeting at Tan Tar A in Osage Beach
April 11-13, 2013 IM 13 in San Francisco
Sept 26-29, 2013 Missouri Chapter meeting at Tan Tar A in Osage Beach
April 10-12, 2014 IM 14 in Orlando
Sept 11-14, 2014 Missouri Chapter meeting at Tan Tar A in Osage Beach



[PDF] Acrobat PDF format. Download Acrobat Reader software for free from Adobe. Problems with PDFs?