Association of Chiefs of General Internal Medicine

VOLUME 2, ISSUE 3: JUNE 9, 2003

FROM THE EDITOR
Greetings to all! I thought the meeting was a great success. Bill Moran organized a wonderful institute. As usual the Chief's dinner brought great camaraderie. I always enjoy seeing everyone, and hearing about their successes and concerns.

Jeff Whittle and Karen DeSalvo have joined me on the communications committee. They will make regular contributions to the newsletter and to our soon to be upgraded Listserve.

As editor of Chief's Alert, I am making a personal plea. Like most physicians I have great concern about the current malpractice crisis. Recently, I have learned about Common Good - a nonprofit organization dedicated to reforming America's lawsuit culture. They have recently sent a petition to congress:

An Urgent Call for a Reliable System of Medical Justice

"Current reform proposals to "cap" one category of damages are not nearly ambitious enough. Providing relief to doctors squeezed by insurance premiums is important, but will not heal the deep distrust of justice that skews daily decisions. Nor will it provide incentives to overhaul outdated practices.

America needs an entirely new system of medical justice. Its first goal is to be reliable?reliable to protect patients against bad practices, reliable to protect caregivers who act reasonably, and reliable to interpret standards of care so that all participants know where they stand, and where they must improve.

We call upon Congress immediately to initiate hearings on the broad effects of litigation on healthcare, not just on the immediate litigation insurance crisis, and to consider recommendations on how to create new systems of medical justice that will promote better care, not undermine it. The health of all Americans depends upon it."

In looking at the list of signees, I was pleased to see that my dean was among the original signees (you will recognize many academic leaders on this list). I am using my editor's prerogative to suggest that you visit the web site (http://ourcommongood.com/) and examine their statement. I have signed the petition, and only suggest that you consider this seriously.

Thanks for your indulgence.
Bob Centor

PRESIDENT'S CORNER
James Byrd

ACGIM, the third year begins with 108 members! Some of us joined the organization before we were officially launched, others became members in the past month. We have Chiefs with over 20 years experience, others who have been on the job for just weeks. What holds us together as a new and vibrant organization? What can ACGIM do to advance academic GIM and enhance the jobs of the Chiefs?

    I am excited to serve as President of ACGIM following Bob Centor and Mark Linzer. As we start our year, it is valuable for me to look back to where we have been, and look forward to where we will go this year. Since two organizational meetings in Chicago, one at the annual meeting in 1998, and the other over two delightful (really) winter days in January 1999, ACGIM has remained focused on our core values and goals:

1)    To advocate for academic GIM.
2)    To support each other as a geographically disparate network of like-minded colleagues facing similar challenges.
3)    To train future leaders and develop ourselves as leaders.
4)    To articulate the value of academic GIM to department chairs, medicine specialists, and non-medicine faculty and leaders.

In support of goals one and four, last year we joined the Association of Subspecialty Programs (ASP) and had a special session with the executive council of the Association of Professors of Medicine (APM). We are at the table. We have the opportunity to communicate, not compete with specialty division chiefs and fellowship directors. We have the chance to educate and influence chairs about the vital role that GIM plays in Departments of Medicine. To advance the second goal, Chief's Alert was initiated under the editorship of Bob Centor. He has added two dynamic, relatively new Chiefs to his Communications Committee, Karen DeSalvo and Jeff Whittle. They will work on the newsletter and assist with the ACGIM listserve, which from my perspective, justifies our dues. Bob, Karen and Jeff will collate and summarize our important discussions and post them on our web site for future reference. We have been working on goal three each year at the SGIM annual meeting, where we have a Management Institute, which was directed this year and will be next year by Bill Moran.

    What can we do this year? We must consolidate our early achievements and continue to grow. Hopefully, by next spring we will include over 90% of medical school GIM Division Chiefs. We will seek out for membership faculty who lead GIM Divisions in affiliated academic programs. Keith Doram, our Secretary-Treasurer is leading this effort. We will also seek the "Harry Selkers," that is, academic generalist leaders of research and educational programs. We will develop our relationship with ASP with Mark Linzer as our representative.

    By the annual meeting in Chicago, a return to our roots, I want us to have a formal mentoring program. It has been my wish that each new GIM Chief can be readily matched with a more senior ACGIM member for at least one year, maybe two or three. Rich Gross is leading this effort. He had made great progress, and we held him back so as to not compete with the new year long mentoring program offered by SGIM. We hope to recruit senior Chiefs to share their wisdom, knowledge and experiences with new Chiefs. Our organization, like SGIM, needs to utilize the talents of our wise senior faculty. So, please participate in this program. The other program that will be completed is a Chief's curriculum. Peter Rudd is leading this effort. One product of his work may be a new Chief's half-day workshop at the annual meeting.

    We need you to continue to give us feedback, participate on the listserv, and participate in committees and work groups when asked. I expect ACGIM to have another outstanding year.

    Speaking of feedback, at our recent monthly teleconference, David Karlson asked ACGIM to give formal comment to the SGIM Council by the summer retreat concerning the Future of General Internal Medicine Report and Recommendations as presented in the Forum in May and discussed in a plenary session at the SGIM annual meeting. A number of major internal medicine organizations have participated in reviewing the Report. How will the eight recommendations impact academic GIM and our Divisions? Bob Centor will place a query on the ACGIM listserv this week. Your responses will be summarized and I will present the ACGIM review at the SGIM retreat. If requested, we will prepare a formal written report. The ACGIM council wants our report to reflect the collective views of our members.

JEFF WHITTLE'S REPORT ON THE INSTITUTE

The ACGIM Management Institute was held at the Pan Pacific Hotel Vancouver on April 30, 2003. Over 30 paid attendees and several visitors heard William Moran, President Elect of ACGIM, moderate sessions led by Drs. Mark Linzer, Mary Nettleman, and Mark Williams.

Dr. Linzer, the immediate past president of ACGIM, described a study that identified the proportion of the time that physicians in General Internal Medicine would be expected to be unable to perform clinical duties because of predictable events, including maternity leave, moves to part time status, and retirement. He described several staffing approaches to the resultant shortfall. These include the use of faculty physicians whose primary job is to cover planned absences. These physicians may be attracted by a reduced but flexible workweek, with compensation proportional to hours worked. Other approaches include cultivating emeritus faculty, who oftentimes are willing and able to provide experienced, flexible backup in exchange for maintenance of their benefits. Finally, greater use of part time physicians more generally may allow for increased flexibility when full time physicians must cut back, especially when these times of reduced activity are predictable. Particularly if their value to the Division is acknowledged by words and actions, such physicians are likely to be willing resources in times of stress.

On a related topic, Dr. Linzer presented information about physician work-life issues illustrated in a survey of his own division of GIM. The survey highlighted the division's success in making the environment friendly to female as well as male faculty, but also emphasized unmet needs for mentoring, especially among the primarily clinical members of the faculty. He suggested ACGIM members might well consider implementing the survey in their own divisions.

Dr. Nettleman presented a comprehensive review of the problems in identifying primary care clinical practice in academic centers. She identified lack of income from ancillaries (EKGs, radiology, etc.), relatively poor payer mix, and inefficient working environments as contributors to the apparent paradox that academic internists are unable to cover their costs while private sector internists can do so despite earning more in salary and benefits than academics. Perhaps surprisingly, given the increasing financial sophistication of academic medical centers, it appears that unfavorable contracting also contributes. This may be because the contracts are structured with an emphasis on maintaining adequate subspecialty and inpatient reimbursement, even if at the cost of poor reimbursement for primary care services.

Dr. Nettleman emphasized the importance of making a sound business case for the value of the primary care providers to the whole enterprise, based on data regarding downstream revenue generated by primary care referrals. In addition, it is important to demonstrate that primary care providers come as close to profitability as possible. For example, at Virginia Commonwealth University, the numbers of work RVU's per internists FTEE is at or above MGMA standards. This makes it clearer that the income shortfall is due to the factors mentioned above, rather than poor productivity. Similarly, information regarding costs can be compared to benchmarks to show that the clinic staffing is not excessively expensive. Similarly, she emphasized the importance of attending to all steps in the billing process. She and members of the audience provided examples of where this process can break down. These included not using codes that are appropriate to the complexity of the services provided, poor performance by the billing office, and failure to submit bills for services provided. None of these are obvious from simply looking at collection rates or total dollars billed.

The final presentation was by Dr. Williams, immediate past president of the Society for Hospital Medicine (formerly the National Association of Inpatient Physicians). He related the meteoric growth of the specialty through the 90's, including the fact that the number of hospitalists now exceeded the number of practitioners of several traditional specialties, including allergists, infectious diseases specialists, and even geriatricians. His brief review of the history of hospital medicine pointed out that it arose from an identified need in the community, rather than from a specific academic focus. As such, hospital medicine entails diverse activities in different settings. This has led to an organization that has not fully defined its distinct competencies. However, a core set of competencies that is emerging includes end of life care, ensuring systems are supportive of efficient and high quality patient care, and participation in hospital strategic planning as well as the clinical care of patients ill enough to be hospitalized.

He reviewed the data suggesting that hospitalists improve length of stay, costs and quality of care compared to models where office based physicians cared for patients in the hospital as well as in the office. He acknowledged that these studies did not meet the standard of a randomized clinical trial and that the mechanism by which the difference occurred was unknown. He noted that despite the growth of hospital based physicians, there was still lingering concern about how best to manage the transfer of care back to a physician who will care for the patient over time. This is one important argument for keeping the academic home of hospital physicians in the Division of General Internal Medicine. The rest of his talk and the discussion focused on the issue of the natural academic home for hospital medicine. Another factor supporting this approach was historical precedent - most academic hospitalists are currently based in GIM divisions and the few existing hospital medicine fellowships are in based in GIM. Moreover, the training of internal medicine residents is heavily hospital based, leading to the common practice of entering hospital medicine straight out of internal medicine residency. Academically, many of the identified distinct competencies of hospital medicine - for example, system based care, and quality of care - are domains where general internists have been the leading researchers. Arguments against basing hospital medicine in general internal medicine included the dangers of marrying two groups which both typically required external support to cover the cost of clinical care. Discussion among those in attendance indicated that hospital medicine is most often based in the division of general internal medicine, but that some places had already moved to a more or less separate hospital medicine group.

THE LISTSERVE

We are currently working on developing our own Listserve method. We specified several characteristics:

1. Responses to the Listserve would default to the Listserve rather than to the author.
2. We will archive all Listserve posts on a secure web page - allowing members to search back through questions and answers.
3. We will have digesting available - either daily or weekly. Digesting allows one to request one daily email which includes all posts from that day (rather than multiple posts during the day).

Let us know if there are any other Listserve features that we should include.

BOOK REVIEWS

Leadership and Self-deception
(Reviewed by Bob Centor)
Recently I was browsing at a Border's book store and saw this book displayed. I admittedly reacted positively to this quote from Stephen R. Covey (author of the 7 Habits of Highly Effective People), "Profound … engaging … packed with insight. I couldn't recommend it more highly."

It is a small book, and looked like a quick read. The advertising and packaging convinced me to buy it and read it.

Reading the book took about 90 minutes. It is a short book, but it has already started to change how I view myself and others.

The book's author is The Arbinger Institute. They have a web page - www.arbinger.com. I recommend the web site to explore whether you might want to read this book.

The book explores a single concept, which they call self deception. Quoting from their web page:

"To give you an idea of what's at stake, consider the following analogy. An infant is learning to crawl. She begins by pushing herself backward around the house. Backing herself around, she gets lodged beneath the furniture. There she thrashes about-crying and banging her little head against the sides and undersides of the pieces. She is stuck and hates it. So she does the only thing she can think of to get herself out-she pushes even harder, which only worsens her problem. She's more stuck than ever.

If this infant could talk, she would blame the furniture for her troubles. She, after all, is doing everything she can think of. The problem couldn't be hers. But of course, the problem is hers, even though she can't see it. While it's true she's doing everything she can think of, the problem is precisely that she can't see how she's the problem. Having the problem she has, nothing she can think of will be a solution.

Self-deception is like this. It blinds us to the true cause of problems, and once blind, all the "solutions" we can think of will actually make matters worse. That's why self-deception is so central to leadership-because leadership is about making matters better. To the extent we are self-deceived, our leadership is undermined at every turn-and not because of the furniture."

Reading this book has given my some insights as to how my decisions affect how I view others. I think that this book offers a paradigm shift in my leadership exploration. You may like it.


The Tipping Point
By Malcolm Gladwell
ISBN 0316346624
Published by Back Bay Books (January 2002)
(Reviewed by Karen DeSalvo)

Yawns are infectious. So are fads. So was the information that Paul Revere was carrying on his fateful ride. And so go the seemingly unconnected analogies in Malcolm Gladwell's book, The Tipping Point. This book is one of those that will forever change the way you see and interpret the world. Importantly, it is also a quick and entertaining read. The 304 page book requires only a few hours of dedicated reading. It is relevant and useful on both a personal and professional level.
In his book, Gladwell develops a framework for explaining how information, ideas and cultural change are transmitted in society. Using the model of infectious disease epidemics, he deconstructs the way that information, ideas and culture change spread through society. He argues each change has a "tipping point" - usually a small event, that given the right context, personalities and momentum, can make a big difference.

One of the key tenets of his theory is that the spread of such "epidemics" in society is dependent upon the "Law of the Few" referring to three key personality types: connectors, maven, and salesmen. Connectors are those individuals who seem to "collect" people. They know many people, across much geography and many walks of life. Mavens are those individuals who gather knowledge and are considered a source of accurate, timely and abundant information. This is the person who we go to if we want to purchase a new computer - they will have all the insight into who, what, where, when and why. The last group of individuals key to the successful transmission of epidemics is the Salesmen. These are those in our society who are able to sell new ideas to the population and show great ease in convincing people, either directly or indirectly, to change.
This book was passed to me and on by me to many others. All have found it rewarding and useful in all aspects of their life. I hope you will also.

Review by Karen DeSalvo

ARTICLES OF INTEREST

Use of the Internet and E-mail for Health Care Information Results From a National Survey - JAMA http://jama.ama-assn.org/cgi/content/abstract/289/18/2400.

Systematic review of scope and quality of electronic patient record data in primary care - British Medical Journal http://bmj.com/cgi/content/full/326/7398/1070.

Doc: Clinicians Must Go Beyond Buy-In - Health Data Management
http://www.healthdatamanagement.com/html/news/NewsStory.cfm?DID=10162

Group Pitches E-health Definition - Health Data Management http://www.healthdatamanagement.com/html/news/NewsStory.cfm?DID=10182

MEMBER NEWS
Mary Nettleman will soon move from Virginia Commonwealth University (where she has been GIM division chief) to take the position as Chair of Medicine at Michigan State. Dick Wenzel (Chair of Medicine at VCU) has named Betty Anne Johnson interim division chief.