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					Society of General
Internal Medicine
                                                         SGIM
                                                      FORUM
TO PROMOTE
IMPROVED PATIENT
CARE, RESEARCH,
AND EDUCATION IN
PRIMARY CARE AND
GENERAL INTERNAL MEDICINE                               Volume 28 • Number 5 • May 2005




                                      LANGUAGE ACCESS IN
                                      HEALTH CARE: STATEMENT
                                      OF PRINCIPLES
                                      Editor’s Note: Earlier this spring, the         Carolina, Tennessee, Utah and Washing-
                                      SGIM Council agreed as an organization          ton.6
                                      to support the principles outlined in this           As the number of non-English speak-
                                      document. The position statement regard-        ing residents continues to increase, so does
                                      ing language access in health care is           the demand for English-as-a-Second-Lan-
                                      provided here for your review.                  guage (ESL) classes. This heightened de-
                                                                                      mand has led to long waiting lists for ESL


                                      N
                                               early 47 million people—18% of         classes in many parts of the country.7 For
                                               the U.S. population—speak a lan-       example, in New York State, one million
                                               guage other than English at home.1     immigrants need ESL classes, but there are
                                      The 2000 census documented that over            seats for only 50,000, while in Massachu-
                                      28% of all Spanish speakers, 22.5% of           setts less than half of those who applied
                                      Asian and Pacific Island language speak-        for English classes were able to enroll.8
                                      ers, and 13% of Indo-European language               Research documents how the lack of
                                      speakers speak English “not well” or “not       language services creates a barrier to and
                                      at all.”2 Estimates of the number of people     diminishes the quality of health care for
                                      with limited English proficiency (LEP)          limited English proficient individuals.9
                                      range from a low of about 11 million, or        Over one quarter of LEP patients who
                                      4.2% of the U.S. population—who speak           needed, but did not get, an interpreter
                                      English “not well” or “not at all”—to over      reported they did not understand their
Contents                              21 million people, or 8.1% of the U.S.
                                      population—if one includes those who
                                                                                      medication instructions, compared with
                                                                                      only 2% of those who did not need an
                                      speak English less than “very well.”3           interpreter and those who needed and
1   Language Access in Health Care:
                                            As demographic trends continue to         received one.10 Language barriers also im-
    Statement of Principles
                                      evolve,4 the prevalence, composition and        pact access to care—non-English speak-
                                      geographic distribution of languages spo-       ing patients are less likely to use primary
2   On Balance                        ken will continue to be fluid and necessi-      and preventive care and public health
                                      tate the ongoing assessment of language         services and are more likely to use emer-
3   President’s Column                needs. Multilingualism is spreading rap-        gency rooms. Once at the emergency
                                      idly, in rural states and counties as well as   room, they receive far fewer services than
4   Research Funding Corner           urban environments.5 Between 1990 and           do English speaking patients.11 Language
                                      2000, fifteen states experienced more than      access is one aspect of cultural compe-
5   VA Column                         100% growth in their LEP populations—           tence that is essential to quality care for
                                      Arkansas, Colorado, Georgia, Idaho, Kan-        LEP populations.
9   Classified Ads                    sas, Kentucky, Minnesota, Nebraska, Ne-              Health care providers from across the
                                      vada, North Carolina, Oregon, South                                     continued on page 6
   SGIM FORUM
                                                      ON BALANCE
SOCIETY OF GENERAL INTERNAL MEDICINE                  Reflections on the Similarities Between
OFFICERS
PRESIDENT
                                                      Marriage and Computers in Health Care
Michael Barry, MD • Boston, MA                        Thuy Bui, MD
mbarry@partners.org • (617) 726-4106
PRESIDENT-ELECT

Barbara J. Turner, MD, MSED • Philadelphia, PA
bturner@mail.med.upenn.edu • (215) 898-2022
                                                          To my husband,                             in retrospect and that tools like clinical
                                                                                                     decision analysis are seldom used by real
IMMEDIATE PAST-PRESIDENT
                                                            As I was researching for my journal      clinicians to make real decisions about
JudyAnn Bigby, MD • Boston, MA
jbigby@partners.org • (617) 732-5759                  club presentation, I realized that I was       specific patients because the task they
PUBLICATIONS MANAGER                                  reflecting on our relationship and our         support does not match the clinicians’ task.
Bree Bowman • Washington, DC                          marriage as a whole. On some subcon-           So my love, let’s concentrate on our
bowmanb@sgim.org • (202) 887-5150                     scious level, I picked computerized            interface flaws, the technology itself that
TREASURER
                                                      physician order entry and medication           the lack of connectivity between it and
Mary McGrae McDermott, MD • Chicago, IL               errors. The story of the computer              other systems so that both of us (human
mdm608@northwestern.edu • (312) 695-8630              scientist and the doctor mirrors the rise      and computers) can cure the ills of our
SECRETARY                                             and “slow down” of computer technol-           marriage (the health care industry). Dr.
William Branch, MD • Atlanta, GA                      ogy in health care. What I am about to         Koppel said: “All systems are going to
william_branch@emoryhealthcare.org • (404) 616-6627
                                                      say comes directly from the words of           create changes and require extraordinary
SECRETARY-ELECT
                                                      Drs. Koppel, Wears and Berg.                   integration of technology and workflow. No
Wally R. Smith, MD • Richmond, VA
wrsmith@hsc.vcu.edu • (617) 732-5759                        Most computer scientists, medical        matter how good the system (our mar-
COUNCIL
                                                      informaticians and perhaps you, my             riage), constant vigilance, constant
                                                      love, view life and marriage (permit me        analysis and constant tweaking are required
Christopher Callahan, MD • Indianapolis, IN
ccallaha@iupui.edu • (317) 630-7200                   to use marriage interchangeably with           to make them function effectively.”
Giselle Corbie-Smith, MD, MSc • Chapel Hill, NC       clinical work) as a series of technical              Dr. Adubofour said: “We need to
gcorbie@med.unc.edu • (919) 962-1136
                                                      challenges requiring technical solutions. I    look at CPOE (marriage) as a journey—
Kenneth Covinsky, MD, MPH • San Francisco, CA
covinsky@medicine.ucsf.edu • (415) 221-4810           envisioned your coming into my life (the       not a destination.” Let’s continue on our
David C. Dugdale, MD • Seattle, WA                    introduction of computer technology) as a      journey a bit wiser and older….
dugdaled@u.washington.edu • (206) 598-5524
                                                      process of experimentation and mutual
Eugene Rich, MD • Omaha, NE
richec@creighton.edu • (402) 280-4184                 learning rather than one of planning,              Love, T.
Ellen F. Yee, MD, MPH • Albuquerque, NM               command and control. The biggest
eyee@unm.edu • (505) 265-1711 Ext. 4255
                                                      challenge in our relationship (a
EX OFFICIO
                                                      sociotechnical system) is the misconceptions      References
Regional Coordinator
Mitch Feldman, MD, MPhil • San Francisco, CA          about the nature of marriage (clinical            1. Koppel R. Metlay JP. Cohen A.
mfeldman@medicine.ucsf.edu • (415) 927-0181           work). There is quite a large mismatch            Abaluck B. Localio AR. Kimmel SE.
Editors, Journal of General Internal Medicine         between the implicit theories and the real        Strom BL. Role of computerized
Martha S. Gerrity, MD PhD • Portland, OR              world of marriage (clinical work).                physician order entry systems in
gerritym@ohsu.edu • (503) 220-8262 Ext. 55592
William M. Tierney, MD • Indianapolis, IN             Marriage (clinical work especially in             facilitating medication errors. JAMA.
wtierney@iupui.edu • (317) 630-6911                   hospitals) is fundamentally interpretative,       293(10):1197-203, 2005 Mar 9.
Editor, SGIM Forum                                    interruptive, multitasking, collaborative,        2. Wears RL. Berg M. Computer
Melissa McNeil, MD, MPH • Pittsburgh, PA              distributed, opportunistic, and reactive. In      technology and clinical work: still
mcneilma@upmc.edu • (412) 692-4891
Associates’ Representative                            contrast, your mind and your theories             waiting for Godot. JAMA.
Kavita Patel, MD • Los Angeles, CA                    (computerized physician order entry/              293(10):1261–3, 2005 Mar 9.
Kavitapatel@mednet.ucla.edu • (310) 794-2257          CPOE systems and decision support
HEALTH POLICY CONSULTANT
                                                      systems) are based on a different model of
Lyle Dennis • Washington, DC                          work: one that is objective, rationalized,
ldennis@dc-crd.com
EXECUTIVE DIRECTOR
                                                      linear, normative, localized, solitary, and
David Karlson, PhD                                    single-minded.
2501 M Street, NW, Suite 575                                I am not implying that I am so
Washington, DC 20037                                  complicated or irrational that we can’t
KarlsonD@sgim.org                                     work out the best technosocial system
(800) 822-3060
(202) 887-5150, 887-5405 FAX                          because as I see it, you (computer
                                                      technology) are here to stay, but you see
                                                      my clinical decisions only become apparent

                                                                           2
  PRESIDENT’S COLUMN



SWAN SONG
Michael J. Barry, MD

        “Time is the fire in which we learn,      the distinction                                                                  4. Avoid the temptation to
        Time is the fire in which we burn.”       between                                                                          blame external forces
         —Delmore Schwartz, For Rhoda             disparities in                                                                   entirely for the problem-
                                                  health care and                                                                  atic state of our health care
    “So Long, and Thanks for all the Fish.”       disparities in                                                                   system. There are indeed
          —Douglas Adams, 4th volume              health, and                                                                      many pernicious external
                 in the Hitchiker’s Trilogy       further define                                                                   forces at work making it
                                                  how the two                                                                      hard to “do the right


I
    ’m writing this last President’s              relate. Don’t                                                                    thing”, but there is much
    Column with decidedly mixed                   assume that                                                                      that physicians can and
    emotions. It’s been a great year, and         more health                                                                      should do themselves to
the annual meeting in New Orleans                 care is always better!                                               improve the care they deliver. Rome
promises to let us finish in great style.      3. Involve patients at every step in                                    may not have fallen to the barbarian
Yet for me, it feels like I’ve just learned       health system redesign. While they                                   hordes if it had been stronger within.
enough about the organization, its                may not be experts in the technical                                5. Think about the evidence base of
members, and its external challenges to           quality of medical care, they are                                     daily practice. While we teach
make a halfway-decent president—if I              experts in judging how they are being                                 evidence-based medicine, we often
could do it all over again! Oh, well.             treated, and how their treatment                                      practice tradition-based medicine.
And I fear the U.S. health care system            makes them feel. Make sure they are                                   We need to get rid of outdated and
is just as chaotic and dysfunctional as           part of setting the agenda at every                                   inefficient practices to make way for
when the year started. But SGIM and               office visit!                                                                                            continued on page 8
its members are tackling the problem,
and I am optimistic about the future. I
will leave readers of this column with a                                                       SGIM
dozen lessons I have become convinced
we must learn to make a difference in
improving American health care, in no
particular order.
                                                                                              FORUM
1. SGIM must collaborate with groups
   with similar goals for maximum effect.       EDITOR                                                                    amaio@yahoo.com • (402) 280-5178
   The various organizations represent-         Melissa McNeil, MD, MPH • Pittsburgh, PA                                  P. Preston Reynolds, MD, PhD, FACP • Baltimore, MD
                                                mcneilma@upmc.edu • (412) 692-4891                                        pprestonreynolds@comcast.net • (410) 939-7871
   ing internal medicine finally seem to
                                                                                                                          Valerie Stone, MD, MPH • Boston, MA
   be coming together, and that’s good          ASSOCIATE EDITORS
                                                                                                                          Valerie_Stone@mhri.org • (617) 726-7708
   news. Working with other organiza-           Joseph Conigliaro, MD, MPH • Pittsburgh, PA                               Brent Williams, MD • Ann Arbor, MI
                                                joseph.conigliaro@med.va.gov • (412) 688-6477                             bwilliam@umich.edu • (734) 647-9688
   tions on important projects requires         Said Ibrahim, MD, MPH • Pittsburgh, PA                                    Ellen F. Yee, MD, MPH • Albaquerque, NM
   patience and respect. While SGIM             Said.Ibrahim2@med.va.gov • (412) 688-6400 Ext. 4267                       efyee@unm.edu • (505) 265-1711 Ext. 4255
   might find it easier and faster to work      David Lee, MD • Boise, ID
                                                lee.david@boise.va.gov • (208) 422-1102
   alone, collaboration will almost             Mark Liebow, MD, MPH • Rochester, MN
   always have a bigger impact.                 mliebow@mayo.edu • (507) 284-1551
2. Carefully and forcefully address             Anna Maio, MD • Omaha, NE
   variations in health care to separate
   desirable from undesirable sources of
   variation. Desirable variation reflects      Published monthly by the Society of General Internal Medicine as a supplement to the Journal of General Internal Medicine.
   differences in patients’ values and          SGIM Forum seeks to provide a forum for information and opinions of interest to SGIM members and to general internists and
                                                those engaged in the study, teaching, or operation for the practice of general internal medicine. Unless so indicated, articles do not
   preferences, while undesirable               represent official positions or endorsement by SGIM. Rather, articles are chosen for their potential to inform, expand, and
                                                challenge readers’ opinions.
   variation reflects differences related       SGIM Forum welcomes submissions from its readers and others. Communication with the Editorial Coordinator will assist the
   to other factors, including race,            author in directing a piece to the editor to whom its content is most appropriate.
                                                The SGIM World-Wide Website is located at http://www.sgim.org
   income, and geography. Keep clear

                                                                             3
SGIM FORUM


Research Funding Corner
Joseph Conigliaro, MD, MPH

Developmental Research on Elder              rfa-files/RFA-AG-05-009.html                capacity to address and eliminate health
Mistreatment (RFA-AG-05-009)                                                             disparities.
                                               Reference                                      The primary goal of the Summer
Release Date: March 23, 2005                   1. National Research Council. (2003).     Institute Program for Increasing
Letters of Intent Receipt Date:                Elder mistreatment: Abuse, neglect, and   Diversity (SIPID) awards is to encour-
June 1, 2005                                   exploitation in an Aging America. Panel   age the development of research skills
Application Receipt Date:                      to Review Risk and Prevalence of Elder    and experience relevant to heart, lung,
June 23, 2005                                  Abuse and Neglect. Richard J. Bonnie &    blood, and sleep (HLBS) disorders to
Expiration Date: June 24, 2005                 Robert B. Wallace (Eds). Committee on     promote the competition for external
     The National Institute on Aging           National Statistics and Committee on      funding in the biomedical and behav-
(NIA) and the Office of Behavioral and         Law and Justice, Division of Behavioral   ioral sciences. The RFA also invites
Social Sciences Research (OBSSR) is            and Social Sciences and Education.        senior faculty, established researchers,
soliciting for proposals that will provide     Washington, D.C: The National             and experienced mentors to apply to be
the scientific basis for understanding,        Academies Press.                          Program Directors and Co-Directors for
preventing, and treating elder mistreat-                                                 the program. Detailed information can
ment. Broadly defined elder mistreat-                                                    be found at: http://grants.nih.gov/
ment is viewed as “intentional actions       Summer Institute Program to                 grants/guide/rfa-files/RFA-HL-04-
that cause harm or create a serious risk     Increase Diversity in Health-Related        035.html
of harm, whether or not intended, to a       Research (RFA-HL-04-035)
vulnerable elder by a caregiver or other                                                 Please contact joseph.conigliaro@
person who stands in a trust relationship    Letters Of Intent Receipt Date:             med.va.gov for any comments, sugges-
to the elder or failure by a caregiver to    August 14, 2005                             tions, or contributions to this
satisfy the elder’s basic needs or to        Application Receipt Dates:                  column. SGIM
protect the elder from harm”.1The NIA        September 14, 2005
expects to award approximately               Earliest Anticipated Start Date:
$1,700,000 annually to fund six to eight     August 1, 2006
awards using the exploratory/develop-        Expiration Date: September 15, 2005
mental award (R21) mechanism.                     To promote diversity in the
Priority areas include: (1) innovative       biomedical, behavioral, clinical and           Calendar of Events
methods for estimating incidence; (2)        social sciences research workforce the
standardization of definitions and           National Heart, Lung, and Blood                  Annual Meeting Dates
measurement; (3) elaboration of risk         Institute (NHLBI) is seeking to fund
factors; (4) methods of clinical and         five to six awards totaling up to $4.860         29th Annual Meeting
psychosocial identification of Elder         million using the R25 mechanism over               April 26–29, 2006
Mistreatment; and (5) identification of      four-years for summer institutes to                Westin Bonaventure Hotel
Elder Mistreatment in institutional          enable faculty and scientists from                 Los Angeles, California
settings. The solicitation focuses on        underrepresented racial and ethnic               30th Annual Meeting
initial steps discussed as research          groups and faculty and scientists with             April 25–28, 2007
priorities in Elder Mistreatment: Abuse,     disabilities to further develop their              Sheraton Centre Toronto
Neglect, and Exploitation in an Aging        research skills and knowledge, enhanc-             Toronto, Ontario, Canada
America (National Research Council,          ing their career development as faculty          31st Annual Meeting
2003). There was particular emphasis         members or scientists. In addition to              May 14–17, 2008
on a community-wide approach to              increase and diversify the recruitment of          Pittsburgh, Pennsylvania
designing and fielding prevalence and        talented researchers the NHLBI also
incidence studies of elder mistreatment      expects these efforts to lead to an              32nd Annual Meeting
                                                                                                May 13–16, 2009
that can be replicated at the national       improved capacity to recruit subjects
                                                                                                Miami, Florida
level. The complete RFA can be found         from diverse backgrounds into clinical
at: http://grants.nih.gov/grants/guide/      research protocols and an improved

                                                                 4
VA COLUMN
QUALITY ENHANCEMENT RESEARCH
INITIATIVES: HEART FAILURE JOINS THE LIST
Paul Heidenreich, MD and Barry Massie, MD



C
       hronic heart failure is associated                                                                  Although guideline
       with a high mortality, poor quality                                                                 compliance for some
       of life, and is the number one
                                             …there have been multiple                                     treatments (ACE
reason for discharge from the VA             large randomized trials that                                  inhibitors) is likely to be
medical service. The Veterans Health                                                                       near goal within the VA,
Administration has recently added a          have identified several                                       vulnerable populations
Chronic Heart Failure Center to their                                                                      and those with
Quality Enhancement Research
                                             therapies that improve survival                               comorbidities are likely
Initiative (CHF-QUERI). This Center          in [heart failure] patients.                                  to be undertreated.
will be based at the VA Palo Alto                                                                               CHF-QUERI’s first
Health Care System (Research Coordi-                                                                       goal will be to increase
nator, Paul Heidenreich MD) and the          Quality and Performance, the Office of        life-prolonging treatment of recognized
San Francisco VA Medical Center              Care Coordination, and other QUERI            heart failure. Of the life-prolonging
(Clinical Coordinator, Barry Massie          groups such as Ischemic Heart Disease         medical treatments, we will focus on
MD). In addition to the Research and         (IHD), Stroke, and Diabetes a top             beta-blockers given the fact that their
Clinical Coordinators, the Center will       priority. Our success also depends on our     use is suboptimal and a large number of
hire a full time implementation coordi-      affiliated investigators and advisors.        patients are candidates for therapy
nator who will design and evaluate           CHF-QUERI is in the process of                (ACE inhibitors are already used at
strategies for implementing successful       recruiting a talented and diverse             high levels for VA patients with heart
health services interventions. The           Executive Committee that includes             failure). The appropriate use of ICDs is
CHF-QUERI center is charged with 1)          expertise in health services research,        also important for several reasons. ICDs
determining best practice for heart          heart failure management, and imple-          are highly effective at preventing
failure; 2) evaluating current perfor-       mentation of disease management               sudden death, but they are an expensive
mance; and 3) selecting and possibly         programs.                                     treatment. Second, rates of appropriate
designing health services interventions            VA heart failure care is an ideal       use of procedures in general (e.g.
to improve performance, and then             candidate for the QUERI program.              coronary angiography) have often been
leading the effort to implement these        Heart failure is associated with high         lower in the VA than in the commu-
interventions system wide.                   mortality, poor quality of life, and is the   nity. Third, our CHF-QUERI will be
     The mission of our CHF-QUERI is         number one reason for discharge from          well positioned to investigate the use of
to improve survival and quality of life      the VA medical service. Furthermore,          ICDs because of the VA National ICD
for all veterans with heart failure by       there have been multiple
implementing best practices. We believe      large randomized trials
the best way to achieve this mission is      that have identified        A second goal is the reduction
through the increased use of care known      several therapies that
to prolong survival while maintaining        improve survival in         in hospitalization rates for
or improving quality of life, and through    these patients. These       patients with heart failure.
improved recognition of heart failure.       life-prolonging treat-
Thus, the goals of our QUERI center          ments include angio-
will be to implement interventions to        tensin converting enzyme (ACE)                Surveillance Center located at the San
increase the use of life-prolonging heart    inhibitors, beta-blockers, spironolac-        Francisco VA Medical Center. A related
failure treatments and to implement          tone, and intracardiac defibrillators         focus of our Center will be to improve
methods to improve the identification        (ICDs). Accordingly, heart failure            care for patients who historically have
of patients with heart failure.              guidelines both within and outside the        been undertreated. Specifically, we will
     The successful implementation of        VA recommend these treatments.                examine the impact of mental illness
this mission will require partnerships       Further, studies have indicated that          and renal insufficiency on the treatment
with other VA organizations, thus we         these treatments are not used as              of heart failure.
will make collaboration with VA’s            frequently as they should be both within          A second goal is the reduction in
Patient Care Services, the Office of         and outside the VA healthcare system.                                continued on page 10

                                                                 5
SGIM FORUM
LANGUAGE ACCESS
continued from page 1

country have reported language difficul-      5. Because it is important for providing      of Medicine, Unequal Treatment:
ties and inadequate funding of language           all patients the environment most         Confronting Racial and Ethnic Disparities in
services to be major barriers to LEP              conducive to positive health              Health Care at 70-71 (2002) (reporting
individuals’ access to health care and a          outcomes, linguistic diversity in the     that more than one in four Hispanic
serious threat to the quality of the care         health care workforce should be           individuals in the U.S. live in language-
they receive.12 The increasing diversity          encouraged, especially for individu-      isolated households where no person
of the country only amplifies the                 als in direct patient contact posi-       over age 14 speaks English “very well,”
challenge for health care providers,13            tions.                                    over half of Laotian, Cambodian, and
who must determine which language             6. All members of the health care             Hmong families are in language isolated
services are most appropriate based on            community should continue to              households, as well as 26–42% of Thai,
their setting, type and size; the fre-            educate their staff and constituents      Chinese, Korean, and Vietnamese).
quency of contact with LEP patients;              about LEP issues and help them            2. See U.S. Bureau of Census, Ability to
and the variety of languages encoun-              identify resources to improve access      Speak English: 2000 (Table QT-P17)
tered. But without adequate attention             to quality care for LEP patients.         available at http://factfinder.census.gov.
and resources being applied to address        7. Access to English as a Second              3. Id.
the problem, the health care system               Language instruction is an addi-          4. For example, from 1990–2000, the
cannot hope to meet the challenge of              tional mechanism for eliminating          “top ten” countries of origin of immi-
affording LEP individuals appropriate             the language barriers that impede         grants residing in the U.S. changed
access to quality health care.                    access to health care and should be       significantly. In 1990, the top ten were
      Those endorsing this document               made available on a timely basis to       Mexico, China, Philippines, Canada,
view it as an inseparable whole that              meet the needs of LEP individuals,        Cuba, Germany, United Kingdom, Italy,
cannot legitimately be divided into               including LEP health care workers.        Korea and Vietnam. In 2000, while the
individual parts. Each of the principles      8. Quality improvement processes              top three remained the same, three
articulated here derives its vitality from        should assess the adequacy of             countries fell off the top ten; the
its context among the others, and any             language services provided when           remaining changed to India, Cuba,
effort to single out one or another               evaluating the care of LEP patients,      Vietnam, El Salvador, Korea, Dominican
would therefore undercut the structural           particularly with respect to outcome      Republic and Canada.
integrity of the entire framework.14 The          disparities and medical errors.           5. See Peter T. Kilborn and Lynette
principles are as follows:                    9. Mechanisms should be developed to          Clemetson, Gains of 90’s Did Not Lift All,
1. Effective communication between                establish the competency of those         Census Shows, NEW YORK TIMES, A20
     health care providers and patients is        providing language services, includ-      (June 5, 2002) (finding the immigrant
     essential to facilitating access to          ing interpreters, translators and         population from 1990–2000 increased
     care, reducing health disparities and        bilingual staff/clinicians.               57%, surpassing the century’s great wave
     medical errors, and assuring a           10. Continued efforts to improve              of immigration from 1900–1910 and
     patient’s ability to adhere to               primary language data collection are      moving beyond larger coastal cities into
     treatment plans.                             essential to enhance both services        the Great Plains, the South and
2. Competent health care language                 for, and research identifying the         Appalachia).
     services are essential elements of an        needs of, the LEP population.             6. 1990 and 2000 Decennial Census.
     effective public health and health       11. Language services in health care          Limited English Proficiency refers to
     care delivery system in a pluralistic        settings must be available as a           people age 5 and above who report
     society.                                     matter of course, and all stakehold-      speaking English less than “very well.”
3. The responsibility to fund language            ers—including government agencies         7. See, e.g., National Center for
     services for LEP individuals in              that fund, administer or oversee          Education Statistics, Issue Brief: Adult
     health care settings is a societal one       health care programs—must be              Participation in English-as-a-Second
     that cannot fairly be visited upon           accountable for providing or              Language Classes (May 1998), citing Bliss
     any one segment of the public                facilitating the provision of those       1990; Chisman 1989; Crandall 1993;
     health or health care community.             services. SGIM                            U.S. Department of Education 1995;
4. Federal, state and local governments                                                     Griffith 1993.
     and health care insurers should            References                                  8. Suzanne Sataline, Immigrants’ First
     establish and fund mechanisms              1. U.S. Bureau of the Census, Profile of    Stop: The Line for English Classes, The
     through which appropriate language         Selected Social Characteristics: 2000       Christian Science Monitor (Aug. 27,
     services are available where and           (Table DP-2), available at http://          2002).
     when they are needed.                      factfinder.census.gov. See also Institute                       continued on next page

                                                                   6
LANGUAGE ACCESS
continued from previous page

   9. See, e.g., Flores G, Barton Laws M,         Difference an Interpreter Can Make at 7,     and Alyse Freilich, The Urban Institute,
   Mayo SJ, et al.., Errors in medical            The Access Project (Apr. 2002).              Washington, DC). See also Institute of
   interpretation and their                       11. E.g. Judith Bernstein et al., Trained    Medicine, Unequal Treatment: Confront-
   potential clinical consequences in pediatric   Medical Interpreters in the Emergency        ing Racial and Ethnic Disparities in Health
   encounters, Pediatrics 2003, 111(1):6–14;      Department: Effects on Services, Subse-      71–72 (2002) (describing recent survey
   Ghandi TK, Burstin HR, Cook EF, et al.         quent Charges, and Follow-up, J. OF          finding 51% of providers believed
   Drug complications in outpatients, Journal     IMMIGRANT HEALTH, Vol. 4 No. 4               patients did not adhere to treatment
   of General Internal Medicine 2000,             (October 2002); IS Watt et al, The health    because of culture or language but 56%
   15:149-154l; Pitkin Derose K, Baker DW,        care experience and health behavior of the   reported no cultural competency
   Limited English proficiency and Latinos’ use   Chinese: a survey based in Hull, 15 J.       training).
   of physician services, Medical Care            PUBLIC HEALTH MED. 129 (1993); Sarah         13. For the purposes of this document,
   Research and Review 2000, 57(1):76–91.         A. Fox and J.A. Stein, The Effect of         “providers” includes health care
   See also, Jacobs, et. al., Language Barriers   Physician-Patient Communication on           institutions such as hospitals and nursing
   in Health Care Settings: An Annotated          Mammography Utilization by Different         homes; managed care organizations;
   Bibliography of the Research Literature,       Ethnic Groups, 29 MED. CARE 1065             insurers; and individual clinicians and
   The California Endowment (2003),               (1991).                                      practitioners.
   available at http://www.calendow.org/          12. Kaiser Commission on Medicaid and        14. It is anticipated that this document
   pub/publications/LANGUAGE                      the Uninsured, Caring for Immigrants:        will be disseminated to other interested
   BARRIERSAB9-03.pdf.                            Health Care Safety Nets in Los Angeles,      stakeholders, Congressional and
   10. See Dennis P. Andrulis, Nanette            New York, Miami, and Houston at ii-iii
   Goodman, and Carol Pryor, What a               (Feb. 2001) (prepared by Leighton Ku                               continued on page 9




                      YOU’RE INVITED TO VISIT
                          THE SGIM WEBSITE
                              Portal & Pathway
                                                                    TO

                               Professional Effectiveness & Satisfaction
       KNOWLEDGE ❖ NETWORKING ❖ CAREER DEVELOPMENT

                                        Featuring Links to Resources & Tools
                                                              INCLUDING :

                       Meetings ◆ Publications ◆ Job Listings ◆ Funding Sources
                               ◆ Residency & Fellowship Directories ◆

                                        Government Agencies
                 Located at http://www.sgim.org

                                                                    7
SGIM FORUM
SWAN SONG
continued from page 3

                                                             we must remember that              just better patient care at academic
Embrace current efforts at                                   what we do as “core                medical centers, but everywhere.
                                                             business” is care for              Just publishing a paper about an
quality measurement, but                                     complex, chronically ill           innovation, no matter how satisfy-
                                                             people in the context of           ing it can sometimes be, seldom
develop more global measures                                 their families and their           changes the world. We need to
of quality for the future.                                   society.                           implement and advocate!
                                                             10.         Remember                I finish the year immensely grateful
                                                             general internal medi-         to all SGIM’s members who have
     new things that have better evi-                        cine is international; we      volunteered their time to make the
     dence of an impact on outcomes.             have much to learn from our                organization stronger and more effec-
     Think about how much gratuitous             colleagues in other countries, and         tive, as well as to our dedicated and
     lung listening and guaiac testing of        can share many problems and                hardworking staff in the Washington
     stool from office digital rectal exams      potential solutions with each other.       office. I’ll look forward to working with
     doctors do in patients with no                                                                           you all again in the
     respiratory or GI complaints!                                                                            future!
6.   Embrace current efforts at quality       Continue to diversify the health                                     I’d also like to thank
     measurement, but develop more            care work force in the United                                   all those friends and
     global measures of quality for the                                                                       colleagues who read and
     future. These days quality measures      States so it is more reflective of                              commented on drafts of
     focus primarily on the delivery of                                                                       these columns this year,
     effective care, which is very impor-     the great and increasing                                        including Al Mulley,
     tant. However, we must also              diversity of the general                                        Tim Ferris, Mary
     measure the patient’s view of their                                                                      McNaughton Collins,
     care, the nondelivery of ineffective     population.                                                     Elliott Fisher, Gene
     care, and decision quality. And                                                                          Rich, David Karlson,
     quality measurement without serious                                                                      Bob Centor, Gregg
     efforts at quality improvement is        11. Continue to diversify the health          Meyer, the Concrete Lady, Susan
     wasted energy.                               care work force in the United States      Edgman Levitan, and Jean Barry (who is
7.   Involve our students, residents, and         so it is more reflective of the great     more than a friend and colleague).
     fellows in our efforts to revitalize         and increasing diversity of the           Nevertheless, responsibility for all errors,
     general internal medicine. Although          general population. This job is for       misquotes, lame pop culture references,
     fewer people are being attracted to          everyone, whether in the majority         and sloppy syntax are mine alone! And
     the primary care specialties right           or minority, and our progress on his      bless everyone who read a column, and
     now, the ones that are, despite the          front has been much too slow.             especially those who emailed me, whether
     environment, are fabulous, and they      12. Remember that medical education           with brickbats or kudos.
     are our future!                              and medical research, which SGIM               Good luck, be careful out there,
8.   Continue to work toward adequate             members do so well, are not ends          and if the opportunity to serve SGIM
     health insurance for all. In my own          themselves. They are means to the         comes your way, I advise you to seize
     mind, that will eventually require a         end of better patient care. And not       it! SGIM
     single-payer system. Although at
     times it may seem like we’ll never
     get there, remember what Winston                                        SGIM National Office
     Churchill said, “The Americans will                       Executive Director: David Karlson, PhD • KarlsonD@sgim.org
     always do the right thing... after                Director of Membership & Operations: Kay Ovington • OvingtonK@sgim.org
     they’ve exhausted all the alterna-                         Director of Education: Sarajane Garten • GartenS@sgim.org
     tives.”                                                    Director of Development: Tracy McKay • McKayT@sgim.org
9.   Keep general internal medicine a                Director of Finanace and Project Management: Leslie Dunne • DunneL@sgim.org
     “big tent.” There is room for many                     Director of Regional Services: Juhee Kothari • KothariJ@sgim.org
     different people in GIM, whether                          Publications Manager: Bree Bowman • BowmanB@sgim.org
                                                       Administrative Support Specialist: Christina Charlton • CharltonC@sgim.org
     their interests are in primary care,
                                                          Member Services Administrator: Nina Goldman • GoldmanN@sgim.org
     hospital medicine, geriatrics…or
                                                            Director of Information Technology: May Wang • WangM@sgim.org
     even prostate diseases (like me)! Yet

                                                                  8
LANGUAGE ACCESS
continued from page 7

   Administration staff, and the media           National Asian Pacific American Legal                  National Partnership for Women and
   solely to raise awareness of this issue and    Consortium                                              Families
   to support policies consonant with these      National Association of Community                      National Respite Coalition
   principles. However, endorsement of            Health Centers                                        National Senior Citizens Law Center
   these principles by an organization           National Association of Mental Health                  National Women’s Law Center
   should not be interpreted as indicating        Planning and Advisory Councils                        Northern Virginia Area Health
   its support for, or opposition to, any        National Association of Public                           Education Center
   particular legislation or administrative       Hospitals and Health Systems                          Physicians for Human Rights
   proposal that may emerge.                     National Association of Social Workers                 Presbyterian Church (U.S.A.)
                                                 National Council of La Raza                              Washington Office
Endorsing Organizations                          National Council on Interpreting in                    Summit Health Institute for Research
American Civil Liberties Union                    Health Care                                             and Education
American College of Physicians                   National Family Planning and                           USAction
American Counseling Association                   Reproductive Health Association                       Welfare Law Center
American Hospital Association                    National Health Law Program
American Medical Student Association             National Immigration Law Center
Asian Pacific Islander American Health           National Hispanic Medical Association
  Forum                                          National Latina Institute for
American Psychological Association                Reproductive Health
Association of Asian Pacific                     National Mental Health Association
  Community Health Organizations
Association of Community
  Organizations for Reform Now
Association of Language Companies
Association of University Centers on               CLASSIFIED ADS
  Disabilities
Bazelon Center for Mental Health Law
California Healthcare Association                   Positions Available and Announcements are $50 per 50 words for SGIM members and $100 per
                                                    50 words for nonmembers. These fees cover one month’s appearance in the Forum and appear-
California Healthcare Interpreting
                                                    ance on the SGIM Website at http://www.sgim.org. Send your ad, along with the name of the
  Association                                       SGIM member sponsor, to ForumAds@sgim.org. It is assumed that all ads are placed by equal
Catholic Charities USA                              opportunity employers.
Catholic Health Association
Children’s Defense Fund
Center on Budget and Policy Priorities           HOSPITALIST. The Division of General Internal          of 3 references to W. J. Many, Jr., Program Director,
Cuban American National Council                  Medicine, Department of Medicine at the Univer-        UAB MIMRP, 4371 Narrow Lane Rd, Ste 200,
District of Columbia Language Access             sity of Pittsburgh is building a large academic        Montgomery, AL 36116 or to hope@uab
  Coalition                                      hospitalist program. The positions provide excit-      montgomery.com. Inquiries accepted until position
                                                 ing opportunities for long term careers in patient     is filled. No phone calls please.
District of Columbia Primary Care                care or a combination of patient care, teaching and
  Association                                    research. Starting salary of $150,000 or higher de-    MASSACHUSETTS. UMass Memorial Health
Families USA                                     pending on qualifications/experience. Send letter      Care has openings for a General Primary Care phy-
Family Voices                                    of interest and CV to Wishwa Kapoor, MD, 200           sician at two of our well-established practices in
HIV Medicine Association                         Lothrop Street, 933 West MUH, Pittsburgh, PA           Worcester County. Provide quality patient care in
                                                 15213 (fax 412 692-4825) or e-mail                     an office-based independent private practice set-
Institute for Reproductive Health                Noskoka@upmc.edu. The University of Pittsburgh         ting, but enjoy the benefits of being a hospital-based
  Access                                         is an Affirmative Action, Equal Opportunity Em-        employee. Work in collegial surroundings where
Joint Commission on the Accreditation            ployer.                                                clinical care and education are valued and multiple
  of Health Care                                                                                        career opportunities exist! Academic appointment
La Clinica del Pueblo                            HOSPITALIST-EDUCATOR: Residency Program                at UMass Medical School, commensurate with
                                                 is recruiting ABIM board certified Hospitalist         training and experience. Excellent benefits and
Latino Coalition for a Healthy                   trained M.D., as an Instructor of Medicine, and a      compensation package. Send CV or contact: Wil-
  California                                     tenured- earning position. Responsibilities include    liam Corbett, M.D., Physician Recruitment, UMass
Medicare Rights Center                           inpatient care and resident teaching with additional   Memorial Health Care, 15 Belmont Street-Morgan
Mexican American Legal Defense and               opportunities for clinical investigation and aca-      Bldg., Worcester, MA 01605, 508-334-8755,
  Educational Fund                               demic pursuits. UAB is an Affirmative Action/          danshirh@ummhc.org, fax (508)-334-5054.
                                                 Equal Opportunity Employer. Send CV & names
Migrant Legal Action Program

                                                                         9
SGIM FORUM
VA COLUMN
continued from page 5

hospitalization rates for patients with
heart failure. Most of the interventions                                   Director for the Center for Health Outcomes and
that prolong survival also have been                                                   Chief of the Division of General Medicine and
shown to reduce hospitalization, thus                                                           Geriatrics School of Medicine/Department of Medicine
our first two goals will likely be                                                                         Case Western Reserve University
achieved in tandem. There are addi-                                                                                                      The successful candidate will be
tional interventions, often part of                                                                                                      an MD or MD/PhD Physician-
disease management programs such as                                                                                                      Scientist with a significant and
home monitoring, that primarily reduce                                                                                                   sustained nationally funded re-
hospitalizations. We will collaborate                                                                                                    search program. He/She should
                                                                                                                                         qualify for the rank of tenured As-
with the VA’s Office of Care Coordina-                                 sociate or full Professor of Medicine at Case and be board certified in Internal Medicine. The
tion to evaluate and standardize the                                   Center Director/Division Chief will be provided substantial resources including an Endowed Chair
different VISN approaches to home                                      to develop the research, educational and programs within General Medicine and Geriatrics at
monitoring for patients with heart                                     Case and to synergize with existing programs in Health Outcomes, Health Policy and Clinical
failure.                                                               Epidemiology in the Department of Epidemiology and Biostatistics, Family Medicine and Pediat-
                                                                       rics at Case and Case-affiliated hospitals at MetroHealth Medical Center and the Wade Park
     A third goal is the prevention of                                 Veterans Administration hospital. Interested candidate’s curriculum vitae and nomination of
symptomatic heart failure by identifying                               potential candidates should be forwarded to Jackson T. Wright, Jr., MD, PhD, Chair Search
patients in the asymptomatic stage of                                  Committee, Case Western Reserve University, Department of Medicine, University Hospitals
the disease (reduced left ventricular                                  of Cleveland, 11100 Euclid Avenue, Cleveland, OH 44106-6053, jackson.wright@case.edu
ejection fraction), or with risk factors                               (preferred electronically). Case Western Reserve University is an equal opportunity employer. Women
                                                                       and minorities are encouraged to apply.
for development of heart failure
                             continued on next page



                         Health Services Researcher In Aging/Palliative Care
                               Center for Healthcare Research and Policy Case Western Reserve University —MetroHealth Medical Center

       The Center for Health Care Research and Policy and the Division of Geriatrics and Palliative Care – Department of Medicine, CASE at MetroHealth
   Medical Center, is seeking a physician investigator to join the Programs for Research and Education on Aging (PREA). The successful candidate will
   work alongside Ph.D. researchers from sociology, economics, and statistics, as well as physician researchers who also practice internal medicine, geriatrics,
   palliative care, neurology, and rehabilitation. A majority of professional time may be protected for research.
       Current Center research includes work pertaining to palliative care and life limiting illnesses, quality of care, post acute care outcomes, patient prefer-
   ences, quality of life among persons with disabilities, and the evaluation of community-based long term care. Center faculty also lead education programs
   related to aging both at CASE and as part of the statewide Geriatric Education Center.
       The Center is located at MetroHealth Medical Center, a primary affiliate of CASE, and one of the premier public hospitals in the nation. Opportunities for
   clinical practice in a range of clinical venues are available. Opportunities for teaching and advising exist in graduate programs in health services and clinical
   research supported by AHRQ and the NIH, in programs leading to Ph.D., M.D.-Ph.D., and M.S. degrees.

   Qualifications: A demonstrated strong potential for external, competitive grant funding in aging/palliative care, teaching/mentoring students, and a
   history of successful collaboration with research teams. A commitment to methodologically rigorous work that contributes to clinical care and/or public
   policy issues relevant to older adults/palliative care. Physicians BC/BE in Internal Medicine preferred. Faculty rank will be commensurate with the candidate’s
   training and experience.

   For information about the position contact:
   Randall D. Cebul, MD, Director, Center for Health Care Research and Policy
   Patrick Murray, MD, MS, Co-director, PREA
   Julia Rose, PhD, MA, Co-director, PREA
   Elizabeth O’Toole, MD, Director, Division of Geriatrics and Palliative Care
   2500 MetroHealth Dr.
   Cleveland, OH 44109
   216-778-3901
   email: pkmurray@metrohealth.org
   URL: http://www.chrp.org/index_sub.html
   An Affirmative Action/Equal Opportunity Employer • Women and Minorities are Encouraged to Apply




                                                                                                 10
VA COLUMN
continued from previous page
                                                                                  Clinic
(ischemic heart disease and hyperten-       nurse-based clinic to             Medical Director
sion). Current guidelines recommend an      initiate and titrate       Full time position available for an internist or family
evaluation for possible left ventricular    beta-blockers. In          physician as Site Medical Director for a large, University
dysfunction in patients with ischemic       addition, we will assist   affiliated, substance abuse treatment clinic in the Bronx, NY.
                                                                       This dynamic opioid pharmacoptherapy site provides on-site
heart disease and those with symptoms       in the development         primary medical care, including HIV care, integrated with
suggestive of heart failure (unexplained    and standardization of     substance abuse treatment and psychiatric services.
dyspnea). We will work with other           home-monitoring            Relationship to Montefiore Medical Center and academic
QUERI groups (e.g. IHD-QUERI) to            protocols for patients     departments within Albert Einstein College of Medicine are
promote the importance of evaluating        with heart failure that    very well established.
patients for reduced left ventricular       are already being          This position requires direct patient care along with a
ejection fraction (echocardiography).       implemented by the         clinical administrative role, including quality improvement,
                                                                       medical staff oversight, and opportunities for teaching and
     Another important role for CHF-        Office of Care             research. Experience in ambulatory care is essential.
QUERI is to identify several interven-      Coordination.              Experience in substance abuse treatment and HIV care
tions that are, or will soon be ready for         Only through         preferred. Clinical administration is also a plus. Board
widespread implementation. We have          collaboration with         eligibility required.
identified several interventions that are   other VA organiza-         Please send CV and cover memo to: Roy Cohen, MD, Medical
ready for promotion through collabora-      tions and investigators    Director, AECOM/Division of Substance Abuse, 1500 Waters
                                                                       Place, Betty Parker Bldg, 6th Floor, Ward 20, Bronx, NY
tive efforts with different VA organiza-    will CHF-QUERI
                                                                       10461, (718) 409-9450, Email: rcohen@dosa.aecom.yu.edu
tions. The interventions for implemen-      fulfill its mission of     EOE
tation are: 1) a performance measure for    improving the quality
beta-blockers; 2) a toolkit for inpatient   of VA heart failure                         ALBERT EINSTEIN
                                                                                        COLLEGE OF MEDICINE
heart failure care based on the Ameri-      care system                                 Advancing science, building careers
can Heart Association “Get-with-the-        wide. SGIM
Guidelines” project; and 3) use of a

                                                               11
SGIM
FORUM
Society of General Internal Medicine
2501 M Street, NW
Suite 575
Washington, DC 20037

				
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