In the News
for the Week of 5-20-08
Special Internal Medicine 2008 issue
Leadership Day 2008
- ACP presses its case on the Hill with record with record turnout of physicians
ACP Regents and Governors
- Governors discuss impact of drug and imaging preapprovals
- Regents approve clinical guidelines on fractures, consider hospital-acquired infections
Scientific sessions of note
- Racial, ethnic disparities: Use patient-centered care, not stereotypes
- Worry when prostate cancer tissue reaches the pathologist
- How to survive private practice and have a life
Cartoon caption contest
- May's winning entry
Leadership Day 2008.
ACP presses its case on the Hill with record turnout of physicians
“Who’s taking care of America?” Sen. John Kerry (D-MA) joked upon entering his Capitol Hill office on Wednesday and finding it crowded to capacity with internists.
The College’s annual Leadership Day, held for the first time during Internal Medicine week, brought more than 500 physicians to Capitol Hill on Wednesday to lobby their elected representatives in person. It was the College's largest Leadership Day ever, with physicians coming from all 50 states, the District of Columbia and Puerto Rico to encourage their elected officials to support the College’s legislative priorities.
Requests focused on three major areas: preventing pending Medicare physician payment cuts, funding pilots of the patient-centered medical home, and expanding access to primary care. The doctors told real-life anecdotes to convince politicians of primary care’s precarious situation.
“I’m $60,000 in debt. I live with four people. I don’t go out that much,” University of Washington medical student Gabriel Fine told Sen. Maria Cantwell (D-WA). He went on to explain how the prospect of declining reimbursements is pushing many students toward careers in more lucrative subspecialties over general internal medicine.
Ms. Cantwell was one of the most sympathetic ears that the internists found. Just before Leadership Day, she agreed to sponsor legislation proposed by the College. The “Patient Access to Primary Care Act” would expand scholarships, provide payment for care coordination, and institute loan-forgiveness programs for young physicians who practice primary care in underserved areas.
Ms. Cantwell, along with many of her colleagues, also expressed support for the College’s efforts to halt the Sustainable Growth Rate cuts scheduled for July 1, 2008. Legislators from both sides of the aisle assured the internists that Congress was working hard to avert the cuts, but expressed less certainty about whether they would be halted for a full 18 months, as the ACP is urging.
“It’s not a foregone conclusion that we can get this done, so the physician community really needs to get active on this,” said Chris Dawe, a legislative aide to Mr. Kerry.
Legislators and their aides also repeatedly asked the visiting physicians for their help crafting more comprehensive reforms of the U.S. health care system. “We really need your input. We need your help to do a reality check about the things that look good on paper,” said Sen. John Cornyn (R-TX).
“We’re looking for ideas of what will attract people to primary care … so you don’t have to become a boutique dermatologist with your own line of skin care,” said Mr. Kerry.
The physicians urged legislators to support just such a real-world test of proposals for improving primary care, by approving $500 million to fund a Medicare pilot of the patient-centered medical home. It was one of the toughest sells of the day, as legislators were reluctant to commit the financially strapped federal government to a new expenditure.
The physicians emphasized how the outlay of money could be recouped by the cost savings provided by comprehensive primary care—such as regularly consulting with a diabetic patient about his diet to avoid an amputation.
“Recognizing that there are budget issues, what would the cost be if we don’t do something? We’re looking at a pound of prevention,” said Washington internist Carrie A. Horwitch, FACP.
The politicians supported the College’s ideas about funding medical homes and education, but were consistently pessimistic about the money. Rep. Louise McIntosh Slaughter (D-NY) noted the difficulty that Congress has faced even over funding of higher education for veterans.
“This is a government that’s broke,” she said. “I imagine that it would be harder to get loan forgiveness for people with the possibility of good income.”
ACP members were unwavering in their focus on the importance of these issues for society as a whole, as well as physicians, however. “The patient-centered medical home is a last-ditch effort to save primary care from oblivion and destruction,” said New York Upstate Governor Edward A. Stehlik, FACP.
It was just that sort of intensity which ACP Executive Vice-President and CEO John Tooker, FACP, praised at the White Coat Rally that ended the day. After the group gathered outside the Capitol building finished some demonstration-style cheering (“When do we want SGR fix? NOW!”), Dr. Tooker encouraged the attendees to continue their efforts to persuade legislators beyond Leadership Day. “Wear them down until they give you their commitment,” he said.
ACP Regents and Governors.
Governors discuss impact of drug and imaging preapprovals
The Board of Governors voted last Wednesday to recommend that the Regents evaluate the impact of drug and medical imaging preauthorization requirements; endorse electronic prescribing of controlled substances; establish benchmarks for reasonable health insurance administrative costs; and publicize misleading and/or fraudulent representations by health insurers.
Though the matter was ultimately referred for further study, the governors also vigorously debated whether to advocate for certain standards in relationships with drug companies and other medically related industries. Those standards might include banning gifts at medical meetings, banning industry-sponsored meals, disallowing drug trade names in medical promotional materials, and discouraging physicians from ghostwriting articles for academic journals.
College members have, on occasion, been offered money to sign on to articles slated for publication in peer-reviewed journals, even though they were not involved in writing or researching the paper, Governor Jay Butler, FACP, of Alaska noted in discussing the provision on ghostwriting.
Also referred for further study was the possibility of offering a reduced ACP membership rate to members who elect to receive all communications electronically; and of making Key Contact enrollment an automatic benefit to which members could opt out if they desired.
In addition, the Governors voted to ask that the Regents:
- Monitor the national news for negative articles and broadcasts about primary and general internal medicine care, and launch a prompt media response that explains the limitations posed by the current system of primary care, as well as the patient-centered medical home concept.
- Support legislation specifically funding National Institutes of Health or Agency for Healthcare Research and Quality research that serves to further characterize primary care practice patterns in regions that provide high-quality healthcare at lower cost.
- Advocate for an amendment to the Controlled Substance Act to allow electronic prescribing of controlled substances with the same security standards as non-narcotics, and incorporate this into the existing system for electronic prescribing rather than in a separate mechanism.
- Work to ensure that a patient’s provider has access to all his/her health care records from the Veterans’ Health Administration.
- Advocate for an evaluation of the impact of pharmaceutical and advanced medical imaging preauthorization programs on cost savings, patient satisfaction and the work of the physician office, and for compensating providers for the cost of the preauthorizations.
- Study how to promote further expansion of the number of Federally Qualified Health Centers in order to decrease health care disparities.
- Publicize to College members the potential dangers of signing ambiguous forms from health insurers, and explicitly identify companies that implement misleading or fraudulent policies, as well as work with other medical societies to ensure that such actions are brought to the attention of regulators.
- Establish benchmarks for reasonable health insurance administrative costs and explore means for reducing and controlling these costs, as well as for setting guidelines on the appropriate percentage of premium that needs to be spent on patient care delivery.
- Call upon the American Board of Internal Medicine to develop further pathways for recertification that allow more options for achieving board certification—in particular, the substitution of additional non-ABIM-developed, high-quality continuing medical education in place of ABIM-developed modules.
- Explore hiring and supervising individuals to serve as “virtual” executive directors for several chapters at a time—or as regional executive directors shared among chapters. Chapters who elect this service would pay the national office for the associated costs.
Regents approve clinical guidelines on fractures, consider hospital-acquired infections
The Board of Regents on Tuesday approved clinical practice guidelines aimed at preventing fractures, as well as a measure that could lead to ACP's first guideline on reducing hospital-acquired infections.
The Regents also agreed to form a group of physicians and other health professionals to advise College members on practice management issues; to set policies on the employment of International Medical Graduates in the U.S.; and work with the American Medical Association to establish business practice benchmarks for health insurance companies that will be given to providers, purchasers, patients and policymakers.
The following items also were approved at the meeting:
- A practice guideline, “Pharmacologic Treatment of Low Bone Density or Osteoporosis to Prevent Fractures in Men and Women,” which is expected to be published in the Annals of Internal Medicine by September.
- A measure recommending that the Agency for Healthcare Research and Quality (AHRQ) commission an evidence-based review on making hospital-acquired infection a quality improvement measure—an effort that could potentially lead to development of a clinical guideline by the Clinical Efficacy Assessment Subcommittee. In the meantime, the Regents will inform ACP members of strategies to reduce hospital-acquired infection rates via education at annual meetings and possibly other venues.
- Establish a Practice Support Advisory Group, staffed by member physicians as well as nurses, laboratory technicians and other staff, which would advise College members by phone and e-mail on practice management issues.
- Provide an ongoing assessment of the projected costs—such as completing coursework and paperwork—to large and small practices of meeting the requirements for being a patient-centered medical home (PCMH). A research team is currently working with various practices to determine the costs of complying with each element of the PCMH, with the goal of advocating to Medicare and other payers that they provide adequate payment.
- Work with the Society of General Internal Medicine, the Society of Hospital Medicine and the Association of Program Directors in Internal Medicine on developing recommendations on the impact of resident duty hours on clinical and teaching responsibilities of faculty.
- A policy on the role of international medical graduates (IMGs) in the U.S. physician workforce. Under the policy, ACP supports:
- streamlining the process for obtaining J-1 and H1B visas for IMGs who want postgraduate medical training or to practice in the U.S.;
- expanding J-1 visa waiver programs to help alleviate physician shortages in underserved urban and rural areas;
- exempting from the H-1B visa cap those physicians trained in specialties that are facing shortages;
- collaborating with medical schools and teaching hospitals in less developed countries to improve their medical education and training; and
- developing a Global Health Corps or other entity that could facilitate opportunities for U.S. physicians to serve in less developed countries.
Scientific sessions of note.
Racial, ethnic disparities: Use patient-centered care, not stereotypes
Based on existing research, how should you treat an older hypertensive woman if she happens to be Hispanic?
The same as any other hypertensive patient, said Michael J. Bloch, ACP Member, during his Thursday session “Racial and Ethnic Disparities in Cardiometabolic Risk: Lessons for Clinical Practice.”
While research has shown that the prevalence of certain cardiovascular risk factors varies based on race and ethnicity—and this should affect one’s approach to screening-- it doesn’t affect the therapies one should recommend.
“These differences…don’t affect the management or care of individual patients,” Dr. Bloch said. “What may change, however, is how you deliver that care.”
Studies have shown that race and ethnicity affect healthcare outcomes, even when researchers control for income, education, occupation and insurance coverage. The root causes of this are complex, and may include inequities in the health care delivery system, difference in patient behaviors and preferences, and problems with the provider-patient relationship, he said.
Indeed, an observational study published in a 2004 American Journal of Public Health article found that physicians were 23% more verbally dominant, and engaged in 33% less patient-centered communication, with African-American patients than with white patients, regardless of the provider’s own race, Dr. Bloch said.
Some cultural competency programs have used this kind of data as a basis for educating physicians on specific values, customs and beliefs that are thought to be unique to different racial and ethnic groups. But focusing on stereotypes is not the best solution to altering provider behavior, Dr. Bloch said.
“These programs are well-meaning but run the risk of over-simplifying,” Dr. Bloch said. “So we use a patient-centered approach to improve communication between the practitioner and patient.”
Dr. Bloch noted that Joseph Betancourt, MD, et al. have developed a patient-centered approach, called the ESFT (Explanatory, Social, Fears, Treatment) Model, that works well for cross-cultural communication with patients, he said. The model's components involve the patient's:
- Explanation and conceptualization of his/her illness. The provider may ask the patient:
- What do you call your problem?
- What do you think is causing it?
- How does it affect your life? How does your family feel about it?
- What kind of treatment do you think will work?
- Social and financial barriers to adherence
- Does your insurance cover your medications?
- Do you have access to a pharmacy?
- Is it difficult to afford your medications or copayments?
- How are your medications organized at home? Do you have a pill box?
- Fears and concerns about the treatment or its potential side effects
- How do you feel about taking the medication?
- What have you heard about this medication?
- What worries do you have about side effects?
- Do you think the medication will interfere with your life?
- Understanding of his/her treatment regimen
- How do you plan to take the medications?
- How do you feel about your treatment plan?
- Can you repeat the (treatment) instructions back to me in your own words?
“You may not ask every single question, but you can use it as guide in deciding which questions are the most meaningful in a given situation,” Dr. Bloch said. “Best of all, this model works for majority and minority populations.”.
Worry when prostate cancer tissue reaches the pathologist
Better detection of prostate cancer means that diagnosis has become inevitable in most men, reported Oliver Sartor, MD, of Tulane University.
Dr. Sartor, a professor of cancer research in the departments of medicine and urology at Tulane, led two Thursday sessions on “Controversies in Prostate Cancer: Screening, Evaluation of the Rising PSA, and Effects of Anti-Androgen Treatment.”
Improved detection—prostate-specific antigen (PSA) testing and core biopsies instead of a digital rectal exam (DRE)—created a higher “incidence rate” of prostate cancer starting by 1992, Dr. Sartor said. The biggest risk associated with cancerous prostate tissue, he quipped, is its finding its way to the pathologist’s microscope.
“A lot more men have the disease than are ever destined to die from it,” Dr. Sartor said.
Autopsy results show that more than half of men over age 50 have prostate cancer. Clinically, about 17% of men over age 50 are diagnosed with it and about 3% die from it. (Despite the impact of early diagnosis on lowering mortality, prostate cancer is the second-leading cause of cancer death in men, behind lung cancer.)
A comparison of transurethral resection of the prostate and biopsy detection among more than 18,000 men with normal PSA and DRE results—“a low-risk group”—showed that 25% of that population had prostate cancer [N Engl J Med. 2003;349:213-22].
Dr. Sartor's take-home message addressed ways to approach diagnosing patients at risk for prostate cancer.
- PSA can be used to diagnose prostate cancer earlier, but many patients may never need treatment.
- Debate continues on the proper PSA level to trigger biopsy, but over 4.0 ng/mL in a patient with a life expectancy of greater than 10 years is reasonable. Lower PSA cutoffs are justified in men younger than age 50. PSA in serum at age 40 predicts future risk of prostate cancer.
- Treatment must be highly individualized.
- Prognostic tables are available to guide decisions. A Google search can find them easily.
Risk factors include:
- increasing age
- sub-Saharan African ancestry
- having brothers and fathers with prostate cancer
- genetic mutations: 8q24, 17q12, 17q24 SNPs, RNASEL mutations and a novel (XMRV) retrovirus, and the breast cancer gene, BRCA2.
How to survive private practice and have a life
How do busy physicians in private practice find time for their personal lives? Should small-practice doctors perform procedures to enhance revenues and if so, how do they balance that with seeing patients? What are the pros and cons of partnership? These were some of the many questions posed by young physicians and others at last week's panel discussion, "Surviving as a young physician in private practice."
Perhaps one of the most important rules of thumb is not being afraid to ask questions, said panel moderator Ryan D. Mire, FACP, a general internist in a 63-physician multispecialty practice. "At first I felt that I had something to prove as the new kid on the block," said Dr. Mire, "but now I ask for help. Remember that these are your colleagues and the bottom line for everyone is providing good patient care."
Also keep in mind, said panelist Rex S. Morgan, ACP Member, that medical school prepares you to care for patients, not to run a business. Dr. Morgan, a geriatrician in private practice with his wife, said he relies on a strong support staff and hires consultants to advise him on the business issues and technology.
Jennifer A. Jackson, ACP Member, an internist in a small Kansas community, advised physicians starting out to decide what salary they will accept and then come up with ways to achieve it. "My overhead is high and I can't change that, so I had to hone my skills and increase revenue in other ways," she said.
While low reimbursements and hectic schedules make it difficult to survive in private practice, the three panelists said that, for them, the positives still outweigh the negatives.
"I love being my own boss," said Dr. Morgan, adding that tax breaks can make up for some of the deficiency in reimbursement. Dr. Jackson added that there's no substitute for "owning" her schedule. "I take my kids to school and I meet them at them at the end of the day," she said.
The panelists offered several other strategies for making private practice work:
- Hire part-time, mid-level practitioners to take notes during visits so the physician is freed up to move to the next patient and spends less time tending to charts after hours.
- Learn how to perform in-office procedures, such as echocardiograms, stress tests or skin tag removal, that can add revenue to the practice. But do your homework first: Calculate how many procedures you would have to do per month at the current reimbursement rate to make it worthwhile. If one procedure takes the same time as seeing four patients, for example, it might not make financial sense.
- Diversify your practice by doing part-time hospice or palliative care or participating in office-based research. Dr. Jackson, for example, oversees physician assistants in the emergency department at the local hospital. "Don't pigeon-hole yourself," said Dr. Morgan. "You need to be able to transition your practice if things change over the next five years."
- Explore potential partnership opportunities but balance the up-front costs against the potential long-term benefits. For example, do partners share revenue from ancillary services and will the extra revenue make up for the cost of partnership? How important is it for you to have decision-making power?
Cartoon Caption Contest.
May's winning entry
ACP InternistWeekly has compiled the results from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.
This issue's winning cartoon caption was submitted by Dave Johnston, a medical student at the Brody School of Medicine at East Carolina University in Greenville, N.C. He receives a $50 gift certificate good toward any ACP product, program or service.
ACP readers cast 240 ballots online to choose the winning entry. Thanks to all who voted!
The winning entry:
"No doc, this time I fell down a spiral staircase!"
The winning caption received 44.2% of the votes cast. The two runners up were:
“I know it looks bad, so just give it to me straight.” (35.8%)
“Another one falls victim to the Hokey Pokey.” (20%)
About ACP InternistWeekly
ACP InternistWeekly is a weekly newsletter produced by the staff of ACP Internist. It is automatically sent to all College members who have an e-mail address on file with ACP.
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Copyright 2008 by the American College of Physicians.
A 67-year-old man is evaluated for a 6-month history of worsening exertional dyspnea. He has severe COPD, previously with minimal exertional symptoms, but now notes activity-limiting shortness of breath when walking short distances. He does not have chest pain, gastrointestinal symptoms, or sleep-related symptoms. Medical history is otherwise unremarkable. Medications are a twice-daily fluticasone/salmeterol inhaler and an as-needed albuterol/ipratropium metered-dose inhaler. He has a 55-pack-year smoking history but quit when COPD was diagnosed. Following a physical exam, chest radiograph, and transthoracic echocardiogram, what is the most appropriate diagnostic test to perform next?
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