1996-97 report from ACP's Executive Vice President
Editor's note: This report was presented to ACP membership in March at the Annual Session in Philadelphia. This is an edited version.
The year in review—key events
- Membership climbed past the 100,000 mark and now includes more than 8,000 medical students.
- Affirming the need for ACP clinical guidelines, the College took a hard look at the way we select our topics and the process for disseminating the information to our members and others.
- The College developed closer working relationships with other medical organizations, gained two seats in the AMA House of Delegates and collaborated with ASIM on many practice issues.
- We sharpened our look at managed care, surveying members and following up with focus groups to determine what we should be doing to meet the diverse needs of members when it comes to managed care.
- We saw the final approval of the Federated Council for Internal Medicine (FCIM) report, "Graduate Education in Internal Medicine: A Resource Document," which ACP has been working on for several years.
- The College launched its first public information campaign to promote internal medicine, "The Internist of Today—Toward a National Public Identity."
- We continued full-steam ahead to integrate ACP information and publications in print and electronic formats.
- It was a healthy year financially, with revenues of $41,733,000 and expenses of $40,434,000 for fiscal year 1995/96. From July 1996 to January 1997, members have generously contributed almost $1 million to the Research and Development Fund.
- ACP released new papers on graduate medical education, quality in Medicare managed care, Medicare reform, medical savings accounts and antitrust implications for physician-run health plans.
MKSAP. The Medical Knowledge Self-Assessment Program (MKSAP)—innovative when it was introduced in 1968 and still a best seller—widened its scope to include 10 subspecialty MKSAPs. This year MKSAP 10 became available on CD-ROM; more than 2,200 members subscribed to the MKSAP 10 Electronic.
In-Training Examination. The In-Training Examination, produced by ACP in collaboration with the Association of Program Directors in Internal Medicine and the Association of Professors of Medicine, is now used by almost all internal medicine training programs and residents. More than 19,000 residents registered for the program this year.
Electronic products. Increased emphasis on electronic educational products revealed that we need more precise terms to search medical databases optimally. To facilitate reliable and consistent electronic retrieval of specific information, ACP's clinical information management team created a workable thesaurus that will be incorporated into future ACP education and information products.
To meet the needs of recertification, ACP again offered a full track of programs at Annual Session and is building recertification into the syllabus of MKSAP 11.
Clinical guidelines. ACP is a leader in the development of clinical practice guidelines. The College has published more than 200 guidelines evaluating medical screening, practice issues and diagnostic tests.
Because ACP guidelines are based on clinical evidence—not consensus —we often make conservative recommendations, producing guidelines that are not always popular with the public. Today many other medical societies, public health groups and managed care organizations—even for-profit companies—are developing guidelines. Should the College continue to develop guidelines? The Board appointed a group to look at the College's guidelines effort, known as the Clinical Efficacy Assessment Project (CEAP), and make recommendations.
The group reported that CEAP guidelines fill a need not covered by other types of guidelines. However, it also suggested that future guidelines be more user friendly, clearer and more sensitive in "gray areas" where evidence is weak or conflicting. The group recommended the College develop its guidelines more quickly and disseminate them more efficiently and possibly include physician education materials. It recommended that topics chosen for guidelines relate to themes that promote improved quality in medical practice, and that the College seek opportunities for collaborative guideline development with other organizations both within and outside internal medicine.
Community-based teaching program. ACP's community-based teaching program (CBT) is moving residency training into the ambulatory setting. During the year, the "CBT Guidebook" was completed (it will be published in the fall) and the CBT clearinghouse of existing resources was expanded. ACP published and distributed proceedings of the national symposium, "Community-Based Teaching: State of the Art and How to Get There," and offered three programs on community-based teaching at Annual Session.
FCIM collaboration. Expanding community-based teaching programs created the need for programs for community-based faculty. ACP held a CBT faculty development symposium and, with other FCIM organizations, submitted a grant application to the Health Resources and Services Administration to support ambulatory education.
The College participated in the report of the FCIM Task Force on the Internal Medicine Residency Curriculum. ACP will publish the report, "Graduate Education in Internal Medicine: A Resource Document," later this year. ACP will design medical education programs to complement the recommendations.
ACP Research Center
The College reorganized the ACP Research Center to consolidate existing research efforts under one roof, saving money and improving efficiency.
The center completed an important research project on the health effects of gun violence, a topic that has concerned the Board of Governors and Board of Regents for some time. With funding from the Joyce Foundation and the National Head Injury Foundation, ACP polled a sample of ACP members and members of the American College of Surgeons about their feelings and experiences with gun violence. Complete results of the survey have been submitted to Annals of Internal Medicine.
Managed care activities
Many ACP members are concerned about aspects of managed care. To assess needs, the College surveyed members about their experiences working in the managed care environment, their satisfaction with medicine as a career and the role the College should take in managed care. Member groups in four cities suggested managed care initiatives for the College.
ACP's Managed Care Resource Center currently provides consultant referrals and is expanding to develop new tools and materials to help internists meet the demands of managed care.
A Managed Care Advisory Group advises the College on relevant issues. This group, composed of clinicians, managed care medical directors, and physician/consultants, represents the internal medicine constituencies in the managed care marketplace. It is developing a curriculum for managed care education for the 1998 Annual Session.
Annals of Internal Medicine. Annals of Internal Medicine, the College's flagship publication, continues to be one of the Big Three medical publications in the United States. Annals continues to refine and develop new services while retaining the clinical content that has kept readers loyal for years. This year Annals did the following:
- Expanded its editorial staff.
- Created a printed Update Series of the popular update programs at Annual Session.
- Began a news section, "Currents."
- Inaugurated a systematic review series.
- Enhanced the structure and presentation of its information on the ACP Web site.
ACP Observer. ACP Observer reported on nonclinical issues, such as changes in the medical marketplace and computerization of medical practice, and included more coverage of managed care and integrated health systems. ACP Observer continued its popular ethics case study series developed by the ACP Ethics and Human Rights Committee. The membership publication won editorial awards from the American Society of Business Press Editors and a first-place award for newswriting from the Society of National Association Publications.
ACP Journal Club. ACP Journal Club continues to get high ratings from internists and is ranked second only to Annals in popularity. Its related publication, Evidence-Based Medicine, completed its first full year of publication with an expanded international audience. A new ACP electronic product, Best Evidence, is an easily searchable database of both publications, with material from 1991 onward reviewed for its timeliness.
Library on Disk, books, ACP Online. ACP Library on Disk, the College's first integrated information product in electronic form, contains MKSAP programs, publications and guidelines. The expanding ACP Books Program publishes in both electronic and print forms. This year it offered four new titles:
- "Who Has Seen a Blood Sugar? Reflections on Medical Education"
- "How to Report Statistics in Medicine: A Guide for Authors, Editors, and Reviewers"
- "Medical Meanings: A Glossary of Word Origins"
- "Bedside Diagnosis: An Annotated Bibliography of Literature on Physical Examination and Interviewing"
ACP Online, the College's Web site (http://www.acponline.org), offers a number of new services for College members. The members-only features of the Web site include ACP Journal Club Archive, a searchable collection of all issues since 1991; the MKSAP Quiz, which allows members to answer selected MKSAP questions and compare their responses to those of other online users and subscribers to the print version; "Washington Report," which focuses on legislation, regulations and other public policy developments affecting internal medicine; and Virtual Annual Session 1997, which offered reports on selected presentations by member correspondents.
ACP relies on its core values to develop thoughtful position papers that put the health of our patients and the public first. At the 1996 Annual Session, the College released a position paper renewing our commitment to work for universal health care coverage. At the 1997 Annual Session, with the goal of getting access to care back on the public agenda, we released a position paper, "Inner City Health Care," citing the high incidence of infectious and chronic disease, which is compounded by poverty, unsafe housing, exposure to violence, lack of educational opportunity, joblessness and economic decline.
ACP also works on the details of practicing medicine in the United States. Our Washington office works with regulatory agencies and legislators on broad issues such as universal health care coverage, and intricate issues, such as HCFA payment policies. Increasingly in these endeavors, the College collaborates with the American Society of Internal Medicine (ASIM) and other medical organizations. This year, for example, we collaborated on workforce issues, Medicare physician payment issues and fraud and abuse provisions of insurance reform.
In 1996-97 we targeted:
- Access to health care, by supporting and working for passage of the Kassebaum-Kennedy bill, which makes health coverage portable from job to job. This bill was the focus of ACP's fourth annual Leadership Day on Capitol Hill, which attracted chapter leaders from all over the United States for a day of Congressional advocacy in Washington.
- Medicare reform, by conducting a thorough analysis of Medicare, including a cost analysis of proposed reforms, and issuing a paper calling for changes in fee-for-service and managed care plans to increase the quality and efficiency of Medicare-funded care.
- Growth of managed care and its implications for physicians who want to form their own provider networks. A new position paper, "Physician-Driven Integration: A Response to the Corporatization of Medicine," guides members who want to take on this challenge.
- Public health consequences of smoking, by advocating regulation of tobacco as a drug, and health consequences of gun violence, by undertaking a survey of members of ACP and the American College of Surgeons.
- Physician workforce restructuring, by tackling some of the complex issues such as reapportioning residency slots to reflect real-world needs.
- Graduate medical education, by issuing a position paper that examines all-payer funding in the context of managed care and promotes out-of-hospital or ambulatory training.
Ethics and human rights. Building on the College's well-respected work in medical ethics, the Ethics and Human Rights Committee:
- Developed and published new ethics case studies on health care restrictions covering undocumented immigrants (California's Proposition 187), confidentiality and the documentation of sensitive information and futile care.
- Continued human rights policy work by speaking out on the health effects of economic embargoes, land mines, female genital mutilation and the role of health professionals in the protection of human rights.
- Began development of a fourth edition of the "ACP Ethics Manual."
End-of-life care. In January 1997, the Board of Regents voted to undertake an initiative to improve end-of-life care. It asked for research to help physicians deliver palliative care and promote compassion for the dying.
Collaboration with others
ACP members look to the College to work productively with other medical organizations to increase their influence and eliminate duplication of efforts. For example, the National Coalition on Health Care advocates universal coverage of health care and supports efforts to improve quality of care. Health Professionals for Diversity seeks to expand educational opportunities for minorities.
ACP and the AMA. The College has taken an increasingly active role in the AMA in the last few years, working to highlight internal medicine's role and needs. At the December AMA House of Delegates meeting, ACP, in collaboration with ASIM and internist members of many AMA state delegations, successfully represented the voice of internal medicine.
ACP and AMA leaders met several times this year. AMA Executive Vice President P. John Seward, MD, and other AMA leaders visited the College in Philadelphia.
Internal medicine received a boost in the recent ballot by AMA members to re-align the AMA House of Delegates. Previously, each specialty society was entitled to one delegate. The balloting increased specialty society representation and gave AMA members an opportunity to choose one specialty society to represent them in the House of Delegates. As a result, ACP gained an additional two delegates and ASIM one additional delegate. This gives internal medicine five votes in the AMA House of Delegates and a stronger platform for our case.
Internal medicine public education campaign
This spring the College kicks off a multiyear, multimillion dollar public awareness campaign designed to educate consumers about why, when and how to seek the care of an internist.
"The Internist of Today—Toward a National Public Identity" has the following goal: "To raise the level of public awareness and understanding of the internist's unique role in medicine, thereby helping the patient make an informed decision when selecting a physician." The general public, particularly men and women 40 to 60, is the primary audience; the secondary audience is managed care executives.
Independent research, comprising 10 focus groups of consumers in five cities and a nationwide telephone survey of 1,900 consumers, confirmed that the public has little knowledge of what internists are or do and has difficulty distinguishing internists from other physicians. Only one quarter of the respondents correctly identified internists as specialists of internal medicine, while another quarter said that internists were "interns" or "just out of school." Other frequent responses ranged from "surgeons with primary care responsibility" to "someone who works in a hospital."
A random telephone survey of members revealed 88% favor a public awareness program. Seven College members serve on the steering committee that guides the campaign.
Just recently, College membership passed the 100,000 mark. As of Feb. 1, 1997, our membership profile is 287 Masters; 23,649 Fellows; 44,150 Members; 23,563 Associates; 152 Honorary Fellows; and 8,222 Medical Student Members.
Honors and achievement. Recognition of professional achievement and honors is an important ACP function. At the 1997 convocation, we welcomed 38 new Masters and more than 600 new Fellows. During the year, ACP Governors presented 47 Laureate and local chapter awards to members in recognition of outstanding commitment to medical care, education and service to their communities and the College.
Diversity. To celebrate and encourage a diverse membership, the College sponsored several special events at the 1997 Annual Session:
- The African-American physicians' networking reception.
- The international medical graduates networking forum.
- A cultural competence course focusing on the needs of Latino and Islamic patients.
- A leadership course for women physicians.
The Board of Regents approved a position statement on international medical graduates, written by the Membership Enhancement Subcommittee. Several ACP Chapters have special programs devoted to issues relating to women, minorities and international medical graduates.
Board of Governors and chapters. The Board of Governors serves as an advisory board on matters of policy to the Board of Regents, and as a forum for members to express their views on matters affecting the College and their local chapters. This year the Board of Governors:
- Forwarded 12 resolutions to the Board of Regents, recommending action.
- Reviewed and commented on 10 draft ACP policy papers, with changes incorporated into final versions considered by the Board of Regents.
- Held elections in 16 chapters to replace ACP Governors in their final year of office.
- Voted to accept changes in chapter financing developed by the financial restructuring task force.
- Participated in the College's strategic planning process by analyzing and providing extensive input on the environmental assessment.
- Kept current on College activities by communicating electronically in the Governors Forum on CompuServe.
Governors held 63 chapter/regional meetings during the year. An Officer or Regent of the College attended meetings to share with the membership issues affecting the College. More than half of these meetings were cosponsored with ASIM. Associate members held eight separate meetings.
The New York Chapter broke new ground by developing the College's first chapter Web site. Other chapter Web sites are under development.
Council of Associates. The Council of Associates considers matters of concern to our resident members. This year it surveyed Associates in the military regarding military service managed care (TriCare). The Council also asked Associates about their community service during medical school and residency training programs. A resource book on community service programs nationwide will be compiled for future ACP Associate chapters. Associates submitted more than 1,000 papers for the 1997 Associates' Competition, the 15th anniversary of this Merck-sponsored competition.
Medical student membership. ACP medical student membership, started in 1994, has burgeoned to more than 8,000 members. This year the student newsletter was reformatted, drawing on the rich content of MKSAP, Annals of Internal Medicine, ACP Journal Club and ACP Observer.
Financially the College is healthy, with revenues of $41,773,000 and expenses of $40,434,000 during the last audit period of July 1995 through June 1996. Independent auditors confirmed that the College ended the fiscal year financially sound, with increased net assets. New investment firms have been obtained to manage the College reserve fund portfolio under the watchful eye of our professional evaluation service.
Research and development fund. Member contributions to the Research and Development Fund, now in its second year of operation, total almost $2 million. These contributions are supporting the development of new College products and services, such as the Office Practice Assessment Project, the Physician Information and Education Resource (PIER) project and the "Internist Today" public education campaign.
The College relies on more than 275 employees in its Philadelphia headquarters and Washington, D.C., office to maintain the level of innovation, quality and service members have come to expect.
This year the College commissioned an independent employee opinion survey; 91% of staff participated. A key area of strength identified is the pride and commitment staff take in their work. Eighty-eight percent of staff reported "I am proud to work for the College," and 93% said "I am committed to the success of the College."
The College's mission and goals
To enhance the quality and effectiveness of health care by fostering excellence and professionalism in the practice of medicine.
- 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;
- To promote and conduct research to enhance the quality of practice, the education of internists and the attractiveness of internal medicine to physicians and the public;
- To recognize individual excellence and distinguished contributions to internal medicine.
Approved by the Board of Regents in July of 1991; revised in October of 1996.
A letter from Dr. McDonald
I feel privileged to be in a position to provide you with this year's report. It covers the activities of our College over the past 12 months. I believe that you will find that our organization is as active and vibrant as it has ever been. As I write this letter, nonetheless, I have several conflicting emotions.
A major source of pride for me is the role that ACP has assumed in bringing practicing physicians and medical students together. In less than two years, more than 8,000 students have joined the College. Many of our members not previously engaged in providing medical education are now actively helping teach medical students and residents. It is of significance that when our College achieved the milestone of having 100,000 members, the record-breaking member happened to be a fourth-year medical student. Our leadership roles in outlining quality standards in Medicare managed care, in achieving antitrust relief, in renewing the call for universal access and in addressing the medical plight of the urban poor are other activities that I shall remember with pride.
I am pleased with our College's improved and updated educational offerings, and I am particularly excited that we could use a portion of the research funds provided by members to work on an exciting educational concept that will bring our medical libraries to the exam room and the bedside. Once again, we have relearned the lesson that working in concert with other organizations is the best way to enunciate the message of internal medicine. We are also taking that message to the public, defining what we do and why we do it well. All of the above has been accomplished with a financially sound budget.
The staff and elected leadership of the College have made a major effort this year to keep in touch with you. It is the success of this effort that leads to some of the conflicting feelings alluded to earlier. We still have a great deal of work to do.
We hear of frustration with the patient-physician interaction, paperwork and bureaucracy, and restricted access to subspecialists. You tell us about loss of autonomy and inadequate time to see your patients. The message differs somewhat, depending on the region and often on the penetration and type of managed care.
We hear that while you are pleased with the College's efforts to educate the public about the role of the internist, eliminate gag rules, relieve antitrust pressures and advocate for universal access to health care, you feel that medicine and our patients need more help from the College.
We hear that you need more scientifically based guidelines, definition of workforce needs and advocacy for medical education, research and for physicians and their patients when and if managed care entities cross ethical boundaries.
While we have had a good year, much remains to be done. ACP will step forward to represent physicians, their patients and quality care. This can be accomplished with teamwork and in a proactive fashion. I hope you will take a few minutes to read about and celebrate this year at our College. Then we must work together to accomplish the rest of what must be done.
Walter J. McDonald, FACP
Executive Vice President
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