American College of Physicians: Internal Medicine — Doctors for Adults ®

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Report of the Executive Vice President 1995-96

From the July/August 1996 ACP Observer, copyright 1996 by the American College of Physicians.

Editors note: This report was presented to the membership this April at Annual Session in San Francisco. This is an edited version.

The year in review—highlights

  • Membership climbed to 89,000—plus 6,000 student members. Over the past five years the College has grown by about 25%, or, counting medical student members, by 33%.
  • An all-time record number of 6,200 members pre-registered for the 1996 Annual Session in San Francisco.
  • Revenues exceeded expenses. The new Research and Development Fund began with $3 million of College reserve funds and almost $1 million dollars in member contributions.
  • Key leadership posts have been filled: John Tooker, FACP, a former ACP Governor, is the new Deputy Executive Vice President. Herbert S. Waxman, FACP, with superb credentials in both academic and clinical medicine, heads the education division.
  • ACP spearheaded the new FCIM curriculum project, believing that the residency curriculum for the next decade needs an overhaul if the profession is to survive.
  • ACP leadership and staff used the College's strengths in education, information and health policy to address changes wrought by managed care.
  • Results of ongoing meetings with subspecialist societies and discussions about referral guidelines or patterns that will maximize the skills of both generalist and subspecialist internists are showing promise.
  • The College renewed its commitment to working closely and in harmony with other medical organizations for the benefit of health care professionals and the public.
  • The Board of Regents set up a task force to examine the College's guidelines program (CEAP) to see whether it is meeting members' needs, is cost-effective and actually changes practice.

ACP will be the foremost comprehensive education and information resource for all internists.

Internists look to ACP for education to keep them at the competitive edge of medicine. ACP offers internists educational opportunities to fit a variety of needs:

  • The In-Training Exam for Associates looking toward board certification.
  • Board preparation and update courses at sites across the United States.
  • Locally planned CME presentations at ACP chapter meetings throughout the United States.
  • Annual Session, where internal medicine's best faculty offer hundreds of CME courses in one location.
  • Self-assessment programs in both general and subspecialist internal medicine.

Statistics show the value of the College's education programs to members:

  • 38,000 internists have subscribed to Medical Knowledge Self-Assessment Program 10 (MKSAP 10) since its introduction in September 1994.
  • 27,000 internists have subscribed to the nine Subspecialty MKSAPs, first published in February 1993.
  • A record 18,006 physicians registered for the 1996 In-Training Examination.

ACP expands traditional educational programming

The ACP Initiative on Lyme Disease, funded by a cooperative agreement with the Centers for Disease Control and Prevention, combines state-of-the-art CME programming with research and evaluation activities. The project developed a clinical practice tool kit, a user's guide, a clinical practice survey, a monograph and "train the trainer" workshops.

The Women's Health Initiative, sponsored by ACP's Special Task Force on Women's Health, completed a policy statement that "delivering primary care to women is one of the core competencies of internal medicine, " commented on drafts of a curriculum report prepared by FCIM and sponsored a dozen courses at Annual Session.

Other new education products:

  • The Postgraduate Subcommittee reviewed the board preparation curriculum and developed a core curriculum for all board preparation courses.
  • MKSAP 10 Electronic, an interactive CD-ROM developed in collaboration with Mosby medical publishers, delivers easy electronic searching of the 17 sections and animation and video to enhance learning.
  • MKSAP 11 is in the works, with new sections to help internists prepare for the recertification exam and adapt to changes in the practice environment.

The College selected a new senior vice president for education, Herbert S. Waxman, FACP. Dr. Waxman brings strong experience in both academic and clinical medicine. He was chair of the department of medicine and residency program director in internal medicine at Albert Einstein Medical Center in Philadelphia, and he was also senior associate chairman of the department of medicine at Temple University School of Medicine. He is certified in hematology and recertified in internal medicine.

ACP will be the foremost information resource for internists.

For more than 80 years, ACP has been known as the most reliable information resource for internists. Annals of Internal Medicine, today the most widely cited medical specialty journal in the world, leads the College's publications, followed by ACP Journal Club and, this year, a new publication, Evidence-Based Medicine.

Annals innovates; new publications debut

This year, Annals of Internal Medicine:

  • Introduced a new, more reader-friendly design.
  • Organized a new readership advisory panel to explore editorial ideas and changes.
  • Published special supplements on diabetes and on the prevention of opportunistic infections.
  • Sold a record number of advertising pages, for the first time exceeding those sold by JAMA.

New print titles this year:

  • Evidence-Based Medicine, in collaboration with the BMJ Publishing Group. This journal reviews more than 50 international journals and from these selects evidence-based articles on general surgery, pediatrics, obstetrics, gynecology, psychiatry and general practice.
  • "Computers in Clinical Practice: Managing Patients, Communication and Information." This book contains chapters on practice management, medical record systems, medical literature management, diagnostic and therapeutic decision support, full-text information retrieval and portable computing devices. More than 4,000 copies have been sold, and copies have been distributed to all U.S. medical school deans and internal medicine program directors.
  • "Ethical Choices: Case Studies for Medical Practice." This book shows how medical ethics apply to physicians' daily practices and patients' health, welfare and rights.
  • "Medical Care of the Nursing Home Resident: What Physicians Need to Know." This book addresses general internists and primary care physicians, who provide most of the medical care to nursing home patients. The College distributed 40,000 free copies to internal medicine and family practice residents and fourth-year medical students, courtesy of a grant from the Merck Company Foundation.

ACP journals moved into the electronic arena:

  • The Annals' table of contents and the full text of selected articles from each issue are posted on the College's new World Wide Web site.
  • ACP Journal Club is now available on disk.

College education and information products begin integration

This year, the College continued efforts to integrate its education and information offerings into useful forms for busy internists.

Among the first products is ACP Library on Disk, which integrates important ACP clinical information into one searchable database on CD-ROM. Included are the texts of all current MKSAP programs: ACP's "Clinical Practice Guidelines," "Common Diagnostic Tests," "Common Screening Tests," "ACP Guide for Adult Immunization" and "Diagnostic Strategies for Common Medical Problems," and all issues ofACP Journal Club.

Extending the reach of ACP information, the College launched a homepage on the World Wide Web (address: http://www.acponline.org). The site features information about CME courses, ACP publications and products, selected articles from Annals of Internal Medicine and prepublication selections from ACP Journal Club and Evidence-Based Medicine. ACP members and faculty posted daily reports on the site from Annual Session in San Francisco.

The number of subscribers to ACP Online grew to more than 2,000. New forums allow members to discuss managed care and clinical issues.

Clinical information management tools are an important piece of the arsenal ACP believes members will need in the future. At Annual Session, ACP offered some 40 computer-related sessions, a pre-Session course and a medical informatics resource room within the ACP Learning Center. The courses help members use the new powerful computer-based clinical information systems in offices, clinics and hospitals.

ACP will advocate responsible positions on health and public policy to benefit the public, our patients, the medical profession and our members.

\Policy analysis and development

This year, ACP:

  • Produced policy statements on health insurance reform, the impact of managed care on education and the work force, Medicaid state waivers, Medicare managed care, and antitrust reform.
  • Participated in the five-year review of RBRVS.
  • Reviewed and recommended changes in practice expense calculation, CPT coding and ICD-9.
  • Answered members' questions about complex payment issues.
  • Responded to proposed rules from federal agencies on issues such as Medicare payment proposals, regulation of tobacco, and informed consent requirements for emergency research.

Advocacy

Using written testimony, staff-to-staff meetings, letters and other communications, ACP staff and leadership:

  • Opposed Medicare/Medicaid spending reductions.
  • Supported liability reform efforts and the reduction of certain CLIA requirements.
  • Supported congressional appropriations for the Agency for Health Care Policy and Research and health professions education.
  • Met with the Health Care Financing Administration on the single conversion factor and requirements for provider-sponsored organizations.
  • Met with the Federal Trade Commission on antitrust changes.
  • Issued recommendations on payment issues to individual Medicare carriers.

The fourth ACP Leadership Day on Capitol Hill attracted some 90 leaders and members representing 34 ACP chapters from around the country. ACP leaders were briefed on the status of health care legislation by two congressional representatives and then met with key legislators.

ACP will serve the professional needs of the membership.

With more and more pressures on medicine—the rising costs of education, the growth of managed care, the squeezes on physician clinical autonomy and income—ACP members want their organization to look out for their interests and for the profession. As a professional organization, ACP is positioned to handle many national issues more effectively than can individual, unaffiliated physicians.

Addressing managed care issues

The growth of managed care is perhaps this decade's major health care development. Most ACP members will work with managed care organizations (MCOs) as more Medicaid and Medicare recipients move into managed care. The College used its traditional strengths in education, information and health policy to deal with these changes. ACP:

  • Organized a coordinating team to monitor and plan managed care-related activities throughout the College.
  • Established a resource center to link members with experienced business, management and legal advisors.
  • Developed a series of position papers that:

* outline quality standards for MCOs that enroll Medicare and Medicaid patients;

* address issues of physician-run plans and antitrust law;

* assess the impact of managed care on medical education and the physician work force;

* explore voluntary purchasing pools.

  • Offered a dozen courses at 1996 Annual Session for physicians working in and among managed care organizations.
  • Began a regular question-and-answer column in ACP Observer to explore managed care issues.
  • Surveyed members to learn about their experiences and needs in the managed care arena.
  • Described ACP's current resources on a special page of the College's new World Wide Web site.
  • Refocused an ACP Online member forum toward managed care issues.

ACP leadership and staff are identifying and establishing relationships with managed care consultants, organizations and professional societies. Because MCOs will play such a large part in medicine in the future, ACP is exploring collaborative relationships and mechanisms to structure internal medicine referral patterns to benefit physicians and patients.

Recertification

Recertification of practicing internists began in July 1995. To help members prepare for the new examinations, ACP offered a track of courses at Annual Session and is incorporating relevant questions into the upcoming MKSAP 11.

Retraining

In 1994, ACP set up a Career Change Task Force to explore potential needs of members for retraining. The task force sponsored a collaborative needs assessment with Albert Einstein Medical Center, surveying a group of New York internal medicine subspecialists on their needs and desires for retraining for primary care. In December 1995, ACP sponsored an invitational conference with the support of the Bureau of Health Professions. The group recommended that, in light of changing practice demands, ACP assess educational needs for all internists and consider establishing a learning center to teach skills in communication, procedures and clinical management.

Generalist and subspecialist relationships

The relationship between internal medicine specialists and subspecialists is a top priority. Both groups have been pinched by managed care's market expansion.

The College sponsors and funds two professional committees in which internists come together to share information and work on common issues. The Council of Subspecialty Societies (CSS), formed in 1975, shares information on governmental and regulatory issues and provides input to the Board of Regents and Board of Governors. The Council of Medical Societies (CMS), formed in 1979, is a broader forum for exchange of information among medical organizations related to internal medicine.

The College held two national meetings with representatives from subspecialist disciplines and societies. The second, in cooperation with the Agency for Health Care Policy and Research, attempted to identify productive practice relationships and referral guidelines, particularly in managed care situations. These meetings have led to ongoing talks with an independent guideline developer about co-sponsoring a book of referral guidelines.

Office practice assessment program

In an era of managed care "report cards," the ACP Office Practice Assessment Program (OPAP) provides a way for physicians to measure their patients' perceptions accurately and use the information to improve practice. OPAP uses the Patient-Centered Care Questionnaire, the most rigorously tested tool of its kind. ACP Governors helped identify the geographically representative pool of more than 70 physicians who administered this tool as part of the Patient-Centered Care Project (funded by the Commonwealth Fund).

Professional needs of special groups

Guided by its diversity plan, the College continues to work to attract and keep minority members.

  • At 1996 Annual Session, the College organized focus groups for Asian and Hispanic physicians, an African-American physician reception, International Medical Graduate (IMG) networking forum, a cultural competence event and an event on leadership for women physicians.
  • The Membership Enhancement Subcommittee is finishing a position statement on International Medical Graduates.
  • Staff is disseminating College information at minority and women's medical organization meetings.

Working with other medical organizations

ACP continues to work with the American Society of Internal Medicine (ASIM). Although no merger talks took place this year, leaders worked on joint committees, and local ACP chapters and ASIM societies held joint meetings.

A founding member of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), ACP has three seats on the Commission and sends representatives to JCAHO's Professional and Technical Advisory Committees on ambulatory care, hospital accreditation, long-term care and health care network accreditation.

The College sends representatives to nearly 30 other organizations. ACP representatives explain College policies and positions at these organizations' meetings and report back to staff or the Board of Regents on relevant activities of the organizations.

ACP and the AMA

ACP has worked on achieving closer relations with the AMA this year. ACP has representatives in the AMA House of Delegates, the CPT advisory committee, the RBRVS update committee, the National Advisory Council on Family Violence and the Specialty Society Medical Liability Project.

ACP sends a full delegation to the semi-annual meetings of the AMA House of Delegates. The delegation reviews all reports and resolutions to come before the House of Delegates and identifies corresponding ACP policy positions. Delegation members are each assigned to a reference committee, where they discuss and debate issues of importance to internal medicine.

At the meetings, the ACP delegation (which includes all members of the ACP Executive Committee of the Board of Regents and the Executive Vice President) meets with the ASIM delegation and internal medicine specialty societies to discuss issues of mutual concern. In 1995, ACP chaired the Section Council on Internal Medicine at the AMA.

At the June 1995 meeting, ACP introduced three resolutions:

  • A resolution on professionalism and medical ethics, which was approved with only a minor editorial change.
  • A resolution, co-sponsored with the American Academy of Pediatrics, that asked the AMA to ensure that any restructuring of Medicaid would preserve the safety net function. This resolution was adopted after amendment to combine a similar resolution from the American Association of Public Health Physicians.
  • A resolution that sought AMA opposition of efforts to weaken FDA authority over evaluation of drugs and devices for both safety and efficacy. In lieu of a group of resolutions on the FDA, the House of Delegates approved a Board of Trustees Report, recommending that the AMA continue to monitor the FDA, work with the FDA on controversial issues, support an adequate budget for the FDA and respond appropriately to legislation.

ACP submitted two resolutions for consideration at the December 1995 Interim Meeting:

  • A resolution urging the AMA to help develop uniform criteria for monitoring changes in Medicaid programs was adopted, with the addition that Medicaid managed care programs be monitored for their impact on all eligible groups.
  • A resolution urged the AMA to get all parties involved in the financing of health care and/or graduate medical education to develop mechanisms to equitably share in the financing of graduate medical education. The House of Delegates adopted a substitute resolution committing the AMA to undertake a comprehensive study of the options for financing graduate medical education.

ACP Governors represent the membership

ACP Governors continue to play an increasingly important role in the College. This year, Governors:

  • Took the lead in examining the College's communication efforts with members.
  • Participated in the annual College environmental assessment, which provides the platform for the year's strategic plan.
  • Commented on draft policy papers via ACP Online, which improved turnaround time for Governor input into College positions.
  • Revised the resolutions process to have councils and committees comment on proposed resolutions.
  • Established their own online forum to exchange ideas and opinions expeditiously.
  • Contacted small groups of generalists, specialists, academicians, Associates, and physicians in the armed services to learn what they want from the College, and reviewed these data at its April meeting.

Last year, 58 regional meetings were held, with attendance increasing by 21% over the past year. Thirty-two regional meetings were held in conjunction with local ASIM organizations.

ACP will establish and promote the highest clinical standards and ethical ideals.

Evidence-based practice guidelines

The College was one of the first medical organizations to systematically develop evidence-based practice guidelines for physicians. To date, ACP has published more than 200 guidelines to help members practice efficient and high-quality medicine. This year, ACP published three new screening guidelines: for hypertension, for ovarian cancer and for cholesterol. Guidelines on prostate cancer screening and Lyme disease have been approved and have been submitted for publication in Annals of Internal Medicine. Ten other papers have been commissioned.

In March, the Board of Regents approved a special task force to set priorities for the Clinical Efficacy Assessment Project (CEAP) and examine how changes in the practice environment have affected the need for guidelines. In recommending improvement to the CEAP process, the task force will consider how CEAP should relate to other guideline developers and how ACP guidelines can meet the needs of guideline users.

The geriatric care project will produce guides combining evidence-based recommendations and geriatric practice principles on topics such as conducting the initial visit, assessing drug use and assessing and managing altered mental status. The project, under development by the ACP Task Force on Aging, responds to major population/medical care trends.

Ethics and human rights committee

Continuing its commitment to uphold the highest ethical standards, the ACP Ethics and Human Rights Committee began work on the fourth edition of the ACP Ethics Manual. The committee oversees the development of case studies and statements on issues such as ethics and managed care, physician participation in execution, embargoes of humanitarian aid and war crimes.

ACP will advance internal medicine as a career.

The College promotes internal medicine as an exciting, rewarding career and endeavors to attract the best and brightest medical students to internal medicine.

Community-based teaching project

The Community-Based Teaching Project (CBT) helps medical schools and internal medicine residency programs give future internists training in community settings. To recognize and encourage member participation in this important and rewarding project, the program awards certificates to practitioners who participate.

During the year, CBT sponsored faculty development programs in six regions of the country and a national symposium that attracted representatives from 60 medical schools in 36 states.

CBT encourages and supports practicing internists to be successful educators and trainers. ACP Governors in each state lead efforts to recruit and support outstanding internists practicing in the community. ACP Governors' Class of 1996 compiled a guide, "Learning from Practitioners," which has sold 2,000 copies.

FCIM curriculum project

ACP played a major role in the FCIM curriculum project, which takes a fresh look at the internal medicine residency curriculum and offers recommendations for program directors developing residency curricula. A first draft was presented to academic and practitioner representatives of FCIM at a meeting in November 1995. The project is supported by grants from the Robert Wood Johnson Foundation and the Josiah Macy Jr. Foundation.

Associate and student memberships

The Council of Associates has been expanded from 11 to 13 members, with new districts based on the number of training programs within geographic regions to provide more equitable representation. More than 1,000 Associates submitted abstracts for the Associates' Competition. Finalists and winners presented their abstracts at Annual Session.

The new ACP student membership, introduced in 1994, has attracted nearly 6,000 student members to date. A new benefit of student membership this year is a free $25,000 accidental death and dismemberment insurance policy.

This year, more than 45,000 U.S. medical students received a colorful new brochure, "Meet Internal Medicine," produced by the Career Counseling Project and distributed through a grant from Bristol-Myers-Squibb.

ACP will recognize individual excellence and distinguished contributions to internal medicine.

ACP membership included 262 Masters, 23,047 Fellows and 137 Honorary Fellows, as of March 31, 1996. Last year:

  • ACP chapters presented more than 50 ACP Fellows with Laureate Awards.
  • Seven projects from among 30 nominations received Evergreen Awards at the spring Board of Governors meeting.
  • Twenty-nine chapters received the new Chapter Management award.
  • The Honorary Fellowships Program was restructured to provide a broader and more equitable approach to awarding honorary fellowships.

Membership reaches 89,000 MDs; 6,000 students

College rolls stand at more than 89,000 physician members and 6,000 student members. Membership has grown steadily by about 25% over the past five years.

Other statistics about College membership:

  • College members comprise 55% of Board-certified internists.
  • Half practice general internal medicine and half are subspecialists.
  • Half spend most of their professional time in direct care of patients, according to a 1995 survey.
  • 80% are male.
  • 2.6% are African-American, 8% are Asian/Asian-American and 8% are Indian/Pakistani.

New international activities office

In February, the College established an international activities office to oversee College-wide activities. An advisory network of ACP members familiar with medicine in other countries will provide input on new and existing products for international markets and will participate in international outreach at Annual Session.

College staff today

ACP has about 250 employees in Philadelphia and Washington, D.C. Many work behind the scenes in support functions. A few facts from the past year attest to the quality of their work:

  • Under a new director, the customer/member service department reorganized for speed and efficiency.
  • The information services department upgraded the member database to improve telephone turnaround time for members ordering College products and services.
  • The convention services department set up arrangements for update and board review courses, handled more than 300 meetings at College headquarters and supervised planning and operation of Annual Session, including selling exhibit space and managing audiocassette production and sales.
  • A new marketing department was set up to analyze existing promotional programs, reduce costs, increase effectiveness, coordinate cross-disciplinary marketing and identify new markets, products and opportunities.
  • The distribution center processed more than three million pieces of mail in the last seven months.
  • The graphic services department provided design, production, printing and copying services to all departments of the College and managed more than $6 million in contracts to print Annals, ACP Observer and other journals and College print products.
  • The archives department has continued to preserve historically important ACP information and corporate records to serve leadership, governance and planning needs and to protect the College in legal and regulatory matters.

Financially, the College is sound, with revenues of $43,458,000 and expenses of $40,700,000 during the last audit period (July 1994 to June 1995).

Research and development fund

In 1995, the Board of Regents established a research and development (R&D) fund with $3 million of College reserve funds. To date, members have contributed an additional $928,000.

The College believes that to address the needs of its members in future years and to remain financially sound, part of College revenue each year must come from new products and services. As it is rarely possible for the College's operating budget to sustain start-up costs for new initiatives, the R&D fund has been established to support start-up costs for new programs and products judged essential to sustain and enhance the practice of medicine and fulfill the College's mission. R&D funds will initiate programs that would otherwise be difficult or impossible to implement; they are not to extend established programs in open-ended fashion.

To be approved for funding, a project must meet at least one of three criteria: 1) it must provide a foundation for future revenue development; 2) it must meet an important member need, identified through systematic research; or 3) it must contribute to knowledge about members, which can be used for revenue development and meeting member needs.


Dr. McDonald: 'Our College'

It has been an honor to serve as the Executive Vice President of the American College of Physicians for the past year. Seldom have I enjoyed any experience to the degree I have enjoyed this. It has been an opportunity to test my belief that the way for our College to flourish is to ensure that it is perceived by all internists, and especially the members of the College, as our College rather than the College.

This will happen if everything that is done in the name of the College is consonant with our missions and goals. I believe that you will agree that they are as relevant today as they might have been in 1915 when the College was founded.

In helping to set our College's agenda, I have tried to promulgate the concepts that we must be knowledgeable of, but unfettered by, our rich history; we must be cognizant of, but not frightened by, risk; we must be aware of past successes, but be boldly innovative; and we must not only acknowledge, but also occupy, the moral high ground.

There have been some notable staff additions this year. Two experienced and respected physicians, Dr. John Tooker and Herb Waxman, have been recruited as the Deputy Executive Vice President and the Senior Vice President for Education, respectively. Their contributions have already been substantial.

The governance of our College is both strong and evolving. The Board of Regents has developed the flexibility and facility to deal with the growing complexities of our College. The popularly elected Board of Governors continues to evolve as a powerful and influential voice of the membership. The evolution and adopting of electronic means of communication have assisted greatly in streamlining and facilitating the development of participatory governance.

Our College's accomplishments this year are outlined in this document. I believe that upon reviewing this document you will be as pleased as I am.

What lies ahead? Next year, our College will emphasize continuing educational innovation, communicating the value of the internist to the public and expanding our capabilities to assist our members in dealing with the complexities of managed care. We will bring together internists from all backgrounds to develop referral guidelines. Whatever we accomplish, we will continue to be guided by the mission and goals which have served as so well for so many years. Your continued support and input are highly valued.

Walter J. McDonald, FACP
Executive Vice President


ACP's mission and goals statement

Mission

To enhance the quality and effectiveness of healthcare by fostering excellence and professionalism in the practice of medicine.

Goals

  • To establish and promote the highest clinical standards and ethical ideals;
  • To be the foremost comprehensive education and information resource for all internists;
  • To advocate responsible positions on individual health and on public policy relating to health care for the benefit of the public, our patients, the medical profession and our members;
  • To serve the professional needs of the membership and advance internal medicine as a career; and
  • To recognize individual excellence and distinguished contributions to internal medicine.

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