Steven A. Schroeder, MD, to Receive the 11th Annual by skt71486

VIEWS: 13 PAGES: 8

									                                            SOCIETY OF GENERAL INTERNAL MEDICINE




SGIM FORUM
Vol. 19, No. 4          To Promote Improved Patient Care, Research, and Education in Primary Care                                                     April 1996


Steven A. Schroeder, MD, to Receive the 11th Annual
Robert J. Glaser Award at SGIM Annual Meeting
                                   At the Spe-                 Dr. Schroeder is a founding member of                  leadership of the Pew/Rockefeller Health of
                               cial Awards                 SGIM who is nationally and internationally                 the Public Program. The number of distin-
                               Ceremony on                 recognized for his leadership in medicine.                 guished lectures that he has given testify to
                               Friday, May 3,              As president, 1985-86, he led the Society                  his international recognition. His respon-
                               1996, at 4:00               through its transitional year with the                     sibilities as President of the Robert Wood
                               PM, Steven A.               American College of Physicians. Under his                  Johnson Foundation, the nation’s largest
                               Schroeder, MD,              leadership, membership and attendance at                   health care philanthropy, have placed him
                               will receive the            the annual meetings boomed. His fiscal acu-                into one of American medicine’s major
                               eleventh annual             ity moved the Society to financial stability.              leadership positions.
                               Robert J. Glaser                Steve has exercised remarkable leader-                     Dr. Schroeder graduated with honors
                               Award for his               ship skills. He has been one of a handful of               from Stanford University and Harvard
                               except i o n a l            individuals who have brought general medi-                 Medical School. He trained in internal
                               contributions               cine and primary care to the center of at-                 medicine at Boston City Hospital. He con-
to medicine. Dr. Anthony Komaroff stated                   tention of the leadership of American aca-                 tinues to practice General Internal Medicine
that he deserves this recognition “both on                 demic medicine. His prominence has been                    on a part-time basis at The Robert Wood
the basis of his research, as well as his con-             recognized by his past Presidency of SGIM,                 Johnson Medical School, where he is Clini-
tributions to education. Not only has he                   membership on the editorial boards of                      cal Professor of Medicine.
been a prolific investigator, but the ques-                many major journals, his membership in the                     Throughout most of his career, Dr.
tions he has chosen to address have been of                Institute of Medicine, his Mastership of the               Schroeder has focused attention on the vari-
enormous importance.”                                      American College of Physicians, and his                                           (continued on page 6)


Funding for AHCPR and Title VII Programs Caught in
Budget Impasse
Lynn Morrison
Since October 1, the beginning of the fiscal                         programs are funded at the lower of the FY       tinuing programs to receive 100% of ap-
year, both the Agency for Health Care Policy                         95 or the House-approved level (with a           proved funding levels. New programs are
and Research (AHCPR)and Title VII pro-                               maximum cut to 75% of FY 95).                    being funded at 45% of the approved levels.
grams of the Health Resources and Services                                Under this arrangement, the AHCPR           This formula will continue until a final bud-
Administration have been funded under                                fares far better than it would under the $63     get is agreed upon by the Congress and the
Continuing Resolutions. The most recent                              million cut it was slated for in the House ap-   Administration.
Continuing Resolution states that most De-                           propriations bill. Currently, the AHCPR is           Why has the final HHS appropriation
partment of Health and Human Services                                working with funding of approximately            not been completed for FY 96? In fact, the
                                                                                           $120 million. This         House bill was passed last summer, but the
                                                                                           amount has allowed the     bill was bottled up in the Senate because of
  Contents
                                                                                           AHCPR to fund con-         threatened controversial amendments.
  11th Annual Robert J. Glaser Award ........................... Cover
  Funding for AHCPR and Title VII Programs Caught in Budget                                tinuing grants, but few        Looking Ahead: Absent a Senate bill, a
    Impasse .................................................................... Cover     new grants are being       conference with the House, and the
  Fresh Quotes from the Career Choice Task Force .............. 2                          funded at this time.       President’s approval, the programs have op-
  Residents’ and Fellows’ Corner ........................................... 2                 Title VII programs     erated for most of this year under a “stop-
  President’s Column ............................................................. 3       are also working at 75%    gap” Continuing Resolution. As has been re-
  The Great Takeaway ........................................................... 4         of FY 95 funding—or a      ported daily in the media, most government
  News from the Regions ....................................................... 5          total of $209 million.     agencies were completely closed down for
  Classified Ads ..................................................................... 7   This has allowed con-                             (continued on page 6)
2    April 1996
                                        Fresh Quotes from the Career Choice Task Force

Co Editors: Mark Linzer, MD                       dents graduate looking forward to fellow-          relative size of a Division of General Inter-
            Julia E. McMurray, MD                 ship training.”                                    nal Medicine within a Department of Medi-
            Mark Schwartz, MD                         Commentary by Dr. Ruth-Marie Fincher,          cine may contribute more to its influence
                                                  Vice Dean and Professor of Medicine, Medi-         than the absolute number of general inter-
    With this column, we are initiating a new     cal College of Georgia, Augusta, GA:               nists.
era in the “Occasional Quotes” column (per-           The presence of a preponderance of                 Although the literature does not consis-
haps to be called “Fresh Quotes”?). Heidi         subspecialists attending on general medi-          tently cite role models as important influ-
Nelson and her colleagues at Oregon Health        cine wards sends the unspoken message that         ences on students’ career choices, I agree
Sciences University recently completed a na-      to practice general internal medicine, first       with the resident who wrote that,
tional survey of third year medical residents     one must be a subspecialist. During the past       “Attendings during residency training prob-
seeking to determine the factors that encour-     20 years, when most of the current attend-         ably have the greatest effect on influencing
age residents to specialize or remain gener-      ing physicians completed residency train-          career choices….” One reason I chose inter-
alists. Heidi and her colleagues have gra-        ing, faculty, most of whom were sub-               nal medicine is because I wanted to “be like”
ciously provided us with a dozen comments         specialists, tended to encourage the best          the housestaff and faculty with whom I
from the open-ended question in her survey,       residents to become academic or practicing         worked as a third-year student on the medi-
“In your own words, what factors have influ-      subspecialists and the less talented residents     cine rotation. However, the mere presence
enced you the most (in your career choice)?”      to enter practice as general internists. In ad-    of generalist role models on the wards, in
We have submitted several of these to our         dition, subspecialists often suggested that        the clinics, and in the classroom, does not
panel of national experts in Primary Care.        being a general internist connoted that one        ensure they w ill exert a positive influence.
Thus, for the next several columns, the ini-      concluded the formal part of education pre-        Deliberately or unwittingly, all attending
tiator of the quotation will be an Internal       maturely, further implying that general            physicians and housestaff teach constantly
Medicine resident.                                medicine residency training was actually a         by the attitudes and actions they model. We
                                                  conduit to a fellowship. While we cannot           have all heard ourselves echoed in the com-
   Once again, readers are encouraged to
                                                  practice high quality medicine without our         ments of housestaff and students. Unfortu-
write in and offer their own perspective on
                                                  subspecialty colleagues, their overwhelming        nately, the actions and comments they adopt
the issues raised by the quote or the commen-
                                                  presence and influence in most academic            most readily may not be those attributes we
taries.
                                                  Departments of Medicine may have con-              want them to emulate! If general internists
   “Attendings during residency training          tributed to the unprecedented rise in              are the most prevalent and respected phy-
probably have the greatest effect on influ-       subspecialists in relation to general inter-       sicians with whom students and housestaff
encing career choices. Because many of our        nists. The proportion of generalist role mod-      work, then residents are likely to emulate
attendings on the General Medicine ser-           els with whom residents work, actually may         generalists in their career choice.
vice are subspecialists, many of our resi-        be of critical importance.1 Therefore, the                                 (continued on page 7)


                                                   Residents’ and Fellows’ Corner

Risk Is Money                                     doctors cannot be far behind.                      concerned with the primacy of the trusting
Matthew K. Wynia, MD                                  When a critical mass of the public comes       relationship, which forms the foundation of
                                                  to understand the financial incentives be-         the therapeutic bond between patients and
    “Medicine is, at its center, a moral enter-   hind capitation, I fear that a groundswell of      physicians, have also been sending out a
prise grounded in a covenant of trust.” [Pa-      public distrust of physicians practicing in        warning: While giving physicians an incen-
tient-Physician Covenant, JAMA, May 17,           capitated systems will occur. Since in a           tive to do “too much” is bad, giving physi-
1995] Recent articles in Newsweek, Time,          growing number of areas this is virtually          cians an incentive to do “too little” is poten-
Glamour magazine, and various newspa-             every primary care physician, one can only         tially far worse.
pers, have told a remarkably frightening          hope the profession is prepared to defend              It may be obvious that delivering both
story portending the erosion of this trust.       itself against the inevitable charge that it has   “too many” and “too few” services is not
The Glamour headline perhaps makes the            accepted the role of withholding care from         good, but why is “too few” potentially the
best case for fear on the part of our profes-     patients and, therefore, broken the covenant       greater of these two evils? It comes down to
sion: “Death by HMO,” it read. Contrary to        of trust.                                          risk, money, and trust. How much financial
the headline’s intent, however, I was not             Forward-thinking physicians and ethi-          risk should physicians assume, and to what
frightened that HMO’s were killing pa-            cists have seen this “public relations” prob-      extent will physicians’ financial risk trans-
tients. I was frightened by what the exist-       lem coming. Health policy analysts and             late into risky decision-making when con-
ence of the headline meant for medicine.          economists have bemoaned the lack of con-          sidering patient care? Under capitated pay-
Hardly an opinion leader, Glamour maga-           trols in the health care system that have led,     ment to physicians in its simplest form, ev-
zine generally picks up on the already ex-        at least in part, to dramatically escalating       ery expenditure on patient care is a deduc-
isting fodder of young women’s conver-            costs. They have taught us that the absence        tion from the physician’s paycheck. It is not
sations. If Glamour says that HMO’s are           of a true price for medical care services leads    hard to imagine why this might instill mis-
not to be trusted, then it is probably be-        to overutilization of those services, and to       trust of physician decision-making in pa-
cause enough readers already believe this         overemphasize on technological, rather             tients. The greater the financial risk to pro-
to be true. Mistrust of HMO-employed              than process-oriented, advances. But those                                (continued on page 4)
                                                                                                                                 SGIM Forum                 3
                                                          President’s Column

SGIM Members — A Special Group of People
Wendy Levinson, MD
                                  I can hard-        SGIM is willing to struggle with difficult         gram started as just an idea, and has now
                              ly believe that    issues. For example, this year the Ethics              blossomed into so many exciting projects,
                              this is the last   Committee developed a policy on how                    including the regional and national awards,
                              newsletter of      SGIM should deal with funds from outside               a supplement to JGIM and the new Task
                              my year as Pres-   sources, including pharmaceutical compa-               Force for Clinician-Educators.
                              ident of SGIM.     nies. It is a controversial issue for any pro-             The diversity of interests of SGIM mem-
                              It has been a      fessional organization, but I believe that the         bers is also a great strength of the organiza-
                              wonderful year     Committee developed thoughtful guide-                  tion. The breadth of interests can sometimes
                              for me, and I      lines that can be used by SGIM in the fu-              feel challenging, as we want the organiza-
                              deeply appre-      ture, and could serve as a model to other              tion to be relevant to all the members, and
                              ciate the op-      organizations. Similarly, when challenging             to speak with one voice on policy issues. On
                              portunity to       public policy issues arise, I am impressed             the other hand, we can draw on knowledge
                              serve in this      by the willingness of SGIM members to                  and skills in so many domains to meet our
                              role. I want to    tackle the problem and figure out how                  mission. For example, the Society is devel-
tell you all how much I respect SGIM mem-        SGIM can best play a role in the policy dis-           oping a new Task Force on Managed Care.
bers and why.                                    cussion.                                               This group is developing a plan for an
    The commitment of SGIM members to                The creative ideas of our members are              agenda for SGIM in the domain of managed
the organization is incredible. I have been      bountiful. The incredible array of work-               care. The diversity of interests of the mem-
able to call on many of you to help with spe-    shops and research presentations at the                bers will deepen and strengthen their work.
cific tasks, and you always come through         Annual Meeting is a testimony to the cre-                  SGIM is highly respected by other medi-
with high quality work. We all have busy         ativity of the individual members and                  cal organizations and leaders in internal
schedules, and yet I don’t think anybody         groups. This year we have 651 abstract sub-            medicine and other disciplines. I believe
turned me down when I asked if he or she         missions (a 20% increase over the prior                that the Society has greater opportunities
could help. The office of SGIM is outstand-      year). In addition, SGIM members help the              than many groups of our size because we
ing, but the staff could never do so much        organization develop exciting new initia-              are respected for both our opinions and our
without the enormous volunteer effort of         tives to address needs or problems. For ex-            thoughtful approach to issues. At this time
members.                                         ample, this year the Clinician-Educator pro-                                     (continued on page 5)


          SGIM FORUM                                    SOCIETY OF GENERAL INTERNAL MEDICINE
       Editor                                           Officers                                                Council
       Harry P. Selker, MD, MSPH                        Wendy Levinson, MD                                      William T. Branch, MD
           Boston, 617-636-5009                              President                                               Atlanta, 404-778-5472
                                                             Portland, 203-229-7103                             Lynne M. Kirk, MD
       Editorial Coordinator                            William M. Tierney, MD                                       Dallas, 214-648-3433
       Julie S. Sullivan                                     President-elect                                    Kurt Kroenke, MD
                                                             Indianapolis, 317-630-7660                              Bethesda, 202-782-4039
            617-636-5009                                Eric B. Larson, MD, MPH                                 Ann B. Nattinger, MD, MPH
            617-636-8023 (fax)                               Immediate Past President                                Milwaukee, 414-257-6323
                                                             Seattle, 206-548-6600                              Rebecca Silliman, MD, PhD
       Associate Editors                                Cynthia D. Mulrow, MD, MSc                                   Boston, 617-638-8940
       Victor A. Bressler, MD                                Treasurer                                          Barbara J. Turner, MD
            Atlantic City, 609-441-2199                      San Anonio, 210-617-5300 x 5984                         Philadelphia, 215-955-8907
       David R. Calkins, MD                             C. Seth Landefeld, MD                                   Ex Officio
                                                             Treasurer-elect                                    James C. Byrd, MD
            Boston, 617-735-0722
                                                             Cleveland, 216-884-7320                                 North Carolina, 919-816-4633
       Kathleen Jennison Goonan, MD                                                                             Harry P. Selker, MD, MSPH
            Boston 617-832-7521                         Administrative Office
                                                        Elnora M. Rhodes                                             Boston, 617-636-5009
       David S. Hickam, MD                              700 Thirteenth Street, NW, Suite 205
            Portland, 503-220-8262                      Washington, DC 20005
       Wishwa Kapoor, MD                                202-393-1662, 800-822-3060
            Pittsburgh, 412-648-3233                    erhodes@gwuvm.gwu.edu
       John M. Mazzullo, MD
            Boston, 617-636-6222
       Diana Santini, MD                               Published monthly by the Society of General Internal Medicine as a supplement to the Journal
                                                   of General Internal Medicine.
            New York, 212-746-2900
                                                       SGIM Forum seeks to provide a forum for information and opinions of interest to SGIM mem-
       Jane D. Scott, ScD, MSN                     bers and to general internists and those engaged in the study, teaching, or operation for the practice
            Baltimore, 410-328-7781                of general internal medicine. Unless so indicated, articles do not represent official positions or en-
       Cheryl A. Walters, MD                       dorsement by SGIM. Rather, articles are chosen for their potential to inform, expand, and challenge
            New York, 212-305-3688                 readers’ opinions.
       Matthew K. Wynia, MD                            SGIM Forum welcomes submissions from its readers and others. Communication with the Edi-
            Boston, 617-636-5009                   torial Coordinator will assist the author in directing a piece to the editor to whom its content is
                                                   most appropriate.
4    April 1996



The Great Takeaway
Victor A. Bressler, MD
                                                   over the dismemberment of a once honor-           its preferred denominator, modified by an
     With the closing of my third and final        able and traditional relationship. For the        array of numerators, physicians, and pa-
year as an SGIM Forum Associate Editor, I          physician and the patient, respite or rescue      tients amongst the many.
am rewarded by recalling the luxury of dis-        seem to call for a link-up with the best “sys-        If patients are conceded at least as many
posing brief commentary written at the             tem,” or if that is denied or unclear, then any   positive attributes as physicians, why not re-
beck of whim and a leisurely two month             or all will do. Can it be that this disorient-    duce these for both through the application
deadline. There is also my quickening sense        ing vortex is the retribution that society has    of a relative value scale that will facilitate
that thoughts and ideas queued behind the          wrought, or is a “classic period” in medical      matching each physician to a compatible
pen mainly dwell upon the tensions be-             practice spiraling into disillusioned decline?    patient? Such adroit reductionism, the ulti-
tween what is transitory and what is immu-         Either way, it seems we are embarked upon         mate in subspecialization and certainly
table in the domains of the doctor and the         a very tough tumble.                              within the realm of contemporary com-
patient. Striving to hold focus upon the im-           The drama of the passing health care          puter capability, may over time select out a
mutable is taxed by the perverseness of            crusade has, over time, cast physicians into      standard physician for each category of pa-
changing times and the human condition             myriad roles as healer, clinician, servant, sa-   tient. Eventually, preselected premedical
as it testily tenses to hold the status quo        vant, savior, guardian, mentor, teacher, ad-      candidates might be harvested from a eu-
against the pull of opposing expectations.         vocate, artist, scientist, technician, col-       genically purified, defined and labeled pool,
It is unclear to what degree the consequen-        league, manager, provider, employee, em-          a monument to managerial high achieve-
tial ebbs and flows are affected by the influ-     ployer, humanist, pioneer, scholar, entrepre-     ment that will perpetuate the cast for this
ences of the art, science, and economics of        neur, philanthropist, philosopher, pragma-        futuristic blending.
medicine upon practitioner behavior. His-          tist, dreamer, mystic, statesman, and so on.          There will be ethical obstacles, of course,
torically, physician image and reputation          Such a pantheon does not translate into un-       notably calls for accountability; professional
erode when physician vigilance wavers,             qualified acceptance across the spectrum of       accountability, economic accountability,
dimmed by naive complacency, selfishness,          our pluralistic society, nor has it ever          political accountability, and, we hope, ac-
vanity, indifference, dereliction, habit, or       throughout history, where individuals have        countability to humanity. These calls will
trust. Retribution, if not retaliation, may fol-   been so often inclined to revile all other        defend the inclinations of people to explore,
low at the hands of an alienated society as it     physicians but their own. Managed care will       to ponder, to gamble, and ultimately to
draws its own conclusions. Patient-centered        take none, or very few, of these attributes       choose. Even if these are synchronized
medicine is depicted as our recourse.1,2           into account if they cannot be proven to as-      through some facile stratification of ac-
     Meanwhile, back on the farm, the mael-        sure access, enhance quality, and contain         countability, their permanence is uncertain
strom of managed-care is caricatured as            costs. There is a disconcerting implication       in a contentious, changing health care en-
swallowing both doctor and patient, flail-         here that the new health care paradigm has        vironment. Can we predict in such an envi-
ing and gasping in common consternation            anointed the “integrated delivery system” as                              (continued on page 5)


Risk Is Money
(continued from page 2)
viders, the more willing the provider will be      incentive structures. When this situation is      maximize profits). It is standard corporate
to transfer this risk to patients in the form      changed so that they would make different         strategy and, by their actions, many IPA-
of withheld services that may provide ben-         decisions, the relationship between them is       managed care plans clearly believe that the
efit. This is an unprecedented form of cost-       fundamentally altered. The trusting rela-         degree of individual financial risk should be
shifting, involving the exchange of financial      tionship is stressed.                             maximized to attain maximum profitabil-
cost to physicians into the cost of less-than-         None of this is inevitable. Managing care     ity for the firm. I believe there should be a
optimal care for patients.                         to improve efficiency and deliver care to         limit.
    Of course physicians have financial in-        more people need not mar the trusting                 Working in a capitated system (or within
centives that differ from those of patients        bond of the patient-physician relationship.       a global budget), though related qualita-
in the fee-for-service setting also. But when      The originators of the HMO concept did            tively, is not the same as having capitated
dealing with insured patients under fee-for-       not intend to impair the patient-physician        limits for the care of each patient one sees.
service payment, the incentives of patients        relationship with staff-model HMO’s, they         For example, though a salaried physician
and physicians are aligned generally in the        hoped to improve care for their members—          clearly has a financial incentive to prevent
same direction—to provide any possible             and to a great degree they did just that.         the organization’s failure, the cost of caring
beneficial service. While financial incentives     These original-style staff-model HMO’s,           for any one patient is unlikely to materially
provide additional impetus to the physician        unfortunately, are not the current big win-       affect this outcome. And if the degree of fi-
to perform services, as often as not the pa-       ners in the medical marketplace. With their       nancial risk matters, as I believe it does, then
tient is inclined towards receiving the ser-       unwieldy capital structure, they are losing       regulation of the market could at least at-
vice also. Neither the physician nor the pa-       out to the fast-moving, ultra-sleek and effi-     tenuate these “perverse incentives.”
tient may be concerned enough with the             cient IPA-model managed care groups. It is            As a first step, regulation through local
effects of their decisions on the community,       the latter that are operating under the most      committees charged with approving both
but in general they are both motivated to          stringent capitation arrangements in their        cost-cutting measures and physician pay-
make the same decision based on their own          continuous efforts to minimize costs (and                                 (continued on page 6)
                                                                                                                        SGIM Forum            5
                                                       News from the Regions


California Chapter Discusses Collaboration Between
General Internists and Family Physicians
    The California Chapter held its annual       was particularly well attended, and was es-      gram Director/President-Elect and
meeting in Santa Monica on February 8,           pecially popular with residents. The policy      Arthur Gomez, MD, will be Membership
1996. The theme of the meeting was “Build-       workshop featured Eric B. Larson, MD,            Chair/Secretary-Elect. s
ing a Better Primary Care Doctor: Collabo-       MPH, talking about policy at the national
ration Between General Internists and Fam-       level, Dr. Werdegar talking about state          Scott E. Sherman, MD, MPH
ily Physicians.” The keynote speech, “Arabs      policy, and Bruce Chernof, MD, talking           Program Director, 1996 meeting
and Jews or Just Plain Semites,” was given       about local policy; it also generated much       President, California Chapter, 1996-97
by Mack Lipkin, Jr., MD, Director of the Di-     lively discussion.
vision of Primary Care at NYU Medical                The meeting was attended by 85-90            Bruce A. Chernof, MD
Center and a recent SGIM President. A            people, including about 35-40 residents and      President, California Chapter, 1995-96
panel discussion on the meeting theme fol-       medical students. There were a number of
lowed, moderated by Dr. Lipkin and includ-       abstract presentations at the meeting, in-
ing: Stephen Brunton, MD, President-Elect        cluding oral presentations by Donna Wash-
of the California Academy of Family Physi-       ington, MD and Steve Asch, MD. A $100            SGIM Members — A
cians; David Werdegar, MD, MPH, Direc-           prize for the best abstract by a resident went   Special Group of People
tor, California Office of Statewide Health       to Soma Wali, MD, for her poster presenta-       (continued from page 3)
Planning and Development; and John Beck,         tion on utilization review. The award for        of change in medicine, SGIM can provide
MD, Professor Emeritus of Medicine in the        outstanding Clinician-Educator went to           important leadership to shape the future de-
UCLA Division of Geriatrics. We also had         LuAnn Wilkerson, EdD. While not a clini-         livery of high quality care for our patients.
four concurrent workshops on the theme of        cian, LuAnn is an internationally known              I thank you again for allowing me to
collaboration—one on teaching, one on re-        educator who has done more for medical           serve as President. I encourage any of you
search, one on managed care, and one on          education and medical teaching than al-          to become involved in SGIM activities. I
health policy. The managed care workshop,        most anyone else around. At the Business         think you will find it creative, collaborative,
led by Medical Directors from Kaiser,            Meeting, the next set of officers were           and energizing. I hope to see you at the An-
CIGNA, and Beverly Hills Medical Group,          named: Carole Warde, MD, will be Pro-            nual Meeting! s



The Great Takeaway
(continued from page 4)

ronment that the patient-doctor relation-
ship will reassert its preeminence, at least
                                                     AHSR 13TH ANNUAL MEETING
until such time as our lease on the planet            JUNE 9 -11, 1996           HYATT REGENCY               ATLANTA, GEORGIA
expires?
   To answer, we might just as well apply              Join the nation’s health care leaders and hear the latest
ourselves each day to assure that managed              in health care delivery, network design and evaluation,
care will not deliver damaged care by our              disease management, outcomes monitoring — and
hands and reaffirm our accountability to all
patients, the financially secure and the poor:         much more — at the 13th Annual Meeting of the
worthy tasks for the next millennium. 3,4 s            Association for Health Services Research.




                                                             55
References:
                                                       To receive a conference brochure and registration form,
1. Glass RM. The patient-physician relation-
   ship. JAMA. 1996;275:147-8.                         contact AHSR at:




                                                            5
2. Laine C, Davidoff F. Patient-centered medi-          Phone: (202) 223-2477 or Fax: (202) 835-8972
   cine. JAMA. 1996;275:152-6.



                                                                                                                               55
3. Emanuel EJ, Emanuel LL. What is account-
   ability in health care? Ann Intern Med.
   1996;124:229-39.
4. Emanuel LL. A professional response to de-



                                                                                            55 5
   mands for accountability: practical recom-
   mendations regarding ethical aspects of pa-
   tient care. Ann Intern Med. 1996;124:240-9.
6    April 1996


Steven A. Schroeder, MD, To Receive the 11th Annual Robert J. Glaser Award at SGIM
Annual Meeting
(continued from page 1)
                                                  training program in primary care is often          financing, manpower, quality of care, and
ability in styles of medical practice and the     cited as a model. A remarkably high num-           preventive medicine. From 1987 to 1993 he
influence of extrinsic factors on those styles.   ber of the program’s graduates have gone           served as senior editor of the annually up-
Along with Jack Wennberg, he was one of           into careers as community primary care             dated clinical textbook, Current Medical
the earliest and most effective investigators     physicians.                                        Diagnosis and Treatment. He is currently a
of this phenomenon.                                   Dr. Schroeder has been an astute com-          member of the editorial board of The New
    As an educator, Steve built one of the        mentator on medical manpower and cost              England Journal of Medicine.
great general medicine and primary care           containment issues over the past decade.              Dr. Schroeder continues to be one of the
academic divisions in the country at the          His work has been published in the most            strongest supports of SGIM. As one of
University of California, San Francisco. Not      prestigious general medical journals and           SGIM’s most accomplished and admired
only have its faculty and trainees been           health services research journals. He has          members, we extend our highest honor to
highly successful investigators, they have        over 160 publications in the fields of clini-      one of our stars. s
also been great educators. Their residency        cal medicine, health care organization and

Funding for AHCPR and Title VII Programs Caught in Budget Impasse
(continued from page 1)
several weeks in late December. It is pre-        particularly important.                            runs out this year, and the Senate will be
dicted that Senator Mark Hatfield (R-OR)                                                             working on this bill under the leadership of
and Representative Bob Livingston (R-LA),           Reauthorization Plans for the AHCPR              Senator Nancy Kassebaum (R-KS), chair of
chairmen of the appropriations committees                     Begin to Take Shape                    the Senate Labor and Human Resources
in the Senate and House, will propose that           The Agency for Health Care Policy and           Committee. Senator Kassebaum has already
the Congress pass a year-long Continuing          Research has been operating for the past           expressed some interest in consolidating
Resolution in March so as to allow stability      two years without being reauthorized. Re-          NIH and AHCPR programs.
within the Department of Health and Hu-           authorization allows the current Congress             The SGIM polled its membership in the
man Services and other departments.               to update the policies and direction of the        November issue of the SGIM Forum. Most
    Outlook for FY 97: The Administration         Agency as they see fit. The legislation creat-     respondents indicated they could accept
has released a preliminary budget docu-           ing the AHCPR authorized the program               this alternative if health services activities
ment for FY 97. No details were released          through FY 94. Since then the program has          have protection in a separate institute or
about specific funding levels for programs        been operating without an authorization.           center where a discreet budget could be pro-
in the Department of Health and Human             Until recently this has not created a prob-        tected from basic research in the existing
Services. A complete budget is scheduled for      lem, but under Republican leadership, the          NIH structure. The Washington office be-
release on March 16. The Washington office        Congress could take a more conservative            gan discussions of this with committee staff
is working with the Friends of AHCPR and          approach and eliminate funding for unau-           and they are considering this option. This
the Health Professions and Nursing Educa-         thorized programs.                                 option is a great uncertainty on the House
tion Coalition to monitor the progress of            In light of this possibility, the SGIM has      side, where the oversight committee for
the President’s specific recommendations.         been working with several other organiza-          NIH and AHCPR has indicated that it may
Rumors of a disappointing Administration          tions, including the AFCR, to explore how          not even take up NIH reauthorization lan-
budget request for AHCPR have prompted            AHCPR extramural peer-reviewed pro-                guage this year, and has no plans to consider
the SGIM to write to the President and urge       grams could be protected.                          AHCPR’s authority. As the process contin-
a more generous AHCPR request. With the              One possibility is the transfer of such         ues, the Washington office will keep the
problems confronting the Agency in Con-           AHCPR programs to the National Institutes          SGIM membership informed. s
gress, a strong Administration request is         of Health(NIH). The NIH authorization

Risk Is Money
(continued from page 4)
ment schemes could help to achieve a sta-         Very strong incentives should be at least          organizations, like the SGIM, to help set
bilization of trust, especially if physicians     openly acknowledged to potential plan en-          ethical, and eventually legal, standards.
were to take the lead in pushing for their es-    rollees, and at best be prohibited.                    Ironically, some physicians argue that
tablishment. These committees might be                What is a very strong financial incentive      regulations such as I am proposing are too
patterned after current hospital-based Hu-        will need to be defined. This is best done         intrusive to the profession and encroach on
man Investigation Review Committees, and          locally, though some general guidelines on         the sovereignty of the patient-physician
be composed of both lay people and health         a national level would be useful. For ex-          bond. This is far from the case, however, if
care providers. They should carefully review      ample, I believe physicians should be at risk      one considers trust to be at the heart of the
managed care organizations’ proposals de-         for no more than 10-20% of their potential         profession. While it is true that one cannot
signed to reduce costs for the degree of pa-      take-home pay (varying with the initial level      “legislate morality,” legal requirements that
tient risk involved (sometimes increased          of take-home pay, so that those earning less       help physicians to avoid conflicts of inter-
risk will be inevitable), and for the strength    to start with are penalized less for withhold-     est will strengthen this bond. Regulations
of financial incentives to withhold services.     ing services). Here there is a role for national                          (continued on page 7)
                                                                                                                              SGIM Forum              7


Risk Is Money                                       Fresh Quotes from the Career Choice Task Force
(continued from page 6)                             (continued from page 2)

that enforce our fiduciary responsibility to            With the rapidly occurring changes in           as potential role models for residents. Are
patients, and that are invited by the profes-       health care delivery, I anticipate there will       we committed to quality patient care? Are
sion, will strengthen trust.                        be a surge in the numbers of students choos-        we rigorous in our pursuit of information
    As residents and fellows, it is incumbent       ing residency training in internal medicine,        that will let us better manage our patients
upon us to carefully think about these is-          family practice, and pediatrics, and an in-         or add depth to our teaching? Of course we
sues before we start looking for “real” jobs.       crease in the numbers of Internal Medicine          are (most of the time)! However, do we
Idealism is important, but realism must be          residents who enter medical practice. The           make sure that residents and students have
considered. In real terms, what level of fi-        importance of role models should not be             a chance to observe us performing these
nancial risk do you think it is safe for you to     underestimated. More general internists             crucial functions? Role models must be vis-
assume when caring for patients? How                will encourage more students and residents          ible. It inevitably becomes an individual de-
much of your salary should you be willing,          to become general internists.                       cision to take the time and energy neces-
and legally allowed, to put at risk, and how                                                            sary to show residents the gratifications and
much will this change your practice? There          Reference:                                          tribulations of our professional and our per-
is currently no limit. We should be asking          1. Campos-Outcalt D, Senf J. Medical school         sonal lives, to show them what we do and
our mentors about capitated payments: To               financial support, faculty composition, and      how we think. It is this sharing that most
what extent do they feel comfortable with              selection of family practice by medical stu-     powerfully instructs residents in the deeper
these arrangements? Do they feel they have             dents. Fam Med. 1992; 24:569-601.                meaning of being a generalist. s
any choice in the matter? If not, what are
they doing about it? If our mentors feel pow-           Editorial comment for the Task Force by
erless over changing the system as it evolves,      Dr. Mark Rosenberg, Program Director, In-
then we must inspire in them the necessary          ternal Medicine Residency, Providence Medi-
energy to take this issue to the public. The        cal Center, OHSU, Portland, OR:
“covenant of trust” that forms the center of            As my grandmother would have said,
the patient-physician relationship is at risk.      “Such a responsibility!” Dr. Fincher empha-
We cannot wait for someone else to take the         sizes the importance of the choices we make
lead. s


                                                                 Classified Ads

                                                    available. Colleagues with expertise in medical     pointment at the Assistant Professor level or
  Positions Available and Annoucements              decision making, behavioral medicine, and the       above at the University of Connecticut. If in-
  are $50 for SGIM members and $100 for             doctor-patient interaction, are available and ea-   terested, please send CV to Thomas Lane, MD,
  nonmembers. Checks must accompany                 ger to collaborate. Research opportunities are      Director, Section of General Medicine, New
                                                    available through our Primary Care Institute        Britain General Hospital, New Britain, CT
  all ads. Send your ad, along with the name
                                                    collaboratively developed with the Department       06050; or fax CV to (203) 224-5785.
  of the SGIM member sponsoring it, to
                                                    of Family Medicine. The department is commit-
  SGIM Forum, Administrative Office, 700                                                                PRIMARY CARE INTERNISTS—Washington
                                                    ted to conducting its work in an environment
  Thirteenth Street, NW, Suite 250, Wash-           based in honesty, respect, and compassion. If       DC, Suburban Maryland, and Virginia. Excit-
  ington, DC 20005. Ads of more than 50             interested, please send a recent CV and a letter    ing opportunities for full-time and part-time
  words will be edited. Unless otherwise            describing career interests to: Howard              Primary Care Internists interested in joining an
  indicated, it is assumed that all ads are         Beckman, MD, Program Director and Chief,            innovative and growing academic Adult Medi-
                                                    Department of Medicine, Highland Hospital,          cine Division in a department that links pri-
  placed by equal opportunity employers,
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  and that Board-certified internists are                                                               search activities, with public health, community
                                                    fax # is (716) 256-3243; e-mail address is
  being recruited.                                  dolan@dbl.cc.rochester.edu.                         medicine, health services, preventive medicine,
                                                                                                        and ethics. All positions carry faculty appoint-
ASSOCIATE PROGRAM DIRECTOR, PRI-                    WOMEN’S HEALTH FELLOWSHIP. The Bos-                 ments with variable mix of clinical practice,
MARY CARE PROGRAM, HIGHLAND HOS-                    ton University (BU) General Internal Medicine       teaching, and research opportunities. Practice
PITAL, ROCHESTER, NY. General internists            Fellowship Program offers a special track to        in downtown or suburban small group settings
with at least two years of primary care program     prepare internists for academic careers in          which serve as group model practice sites for
faculty experience, a love of teaching, and an      Women’s Health. Fellows matriculate at BU           The George Washington University Health Plan.
interest in leading and nurturing a creative pri-   School of Public Health earn MPH degree.            High potential for growth in academic, clini-
mary care program, are invited to apply for the     Contact Mrs. Barbara Pekenia, Administrator,        cal, and administrative skills including oppor-
associate program position at Highland Hos-         720 Harrison Ave. #1108, Boston, MA 02118;          tunity for advanced degrees w ith tuition ben-
pital. The position is 70–90% funded with hard      (617) 638-8030.                                     efits. Applications accepted and reviewed on an
money to insure the integrity of our commit-                                                            ongoing basis until each vacancy in this aca-
ment to teaching. The successful applicant will     CONNECTICUT-HARFTORD AREA BC/BE                     demic year is filled. Send CV and cover letter
be appointed to the faculty at the University of    General Internist for full-time clinical/teaching   indicating interest in one or more locations
Rochester School of Medicine. Resources to          faculty position in community teaching hospi-       (Washington DC, Suburban Maryland, and Vir-
support our educational mission are amply           tal. Applicant must qualify for academic ap-        ginia) and full-time or part-time position to:
                                                                                                                                  (continued on page 8)
     SGIM
     Society of General Internal Medicine
     700 Thirteenth Street, NW
     Suite 250
     Washington, DC 20005




                                                     Classified Ads         (continued from page 7)


Debbie Eiland, Faculty Recruitment Assistant,        Washington, DC 20007. Georgetown is an equal         The Eileen E. Anderson Section of Geriatric
Department of Health Care Sciences, George           opportunity employer.                                Medicine is seeking two BC/BE Geriatricians to
Washington University Medical Center, Room                                                                function as Clinician/Educators and to develop
2B-408, 2150 Pennsylvania Avenue, NW, Wash-          MEDICAL DIRECTOR OF CHASE CLINIC,                    interdisciplinary clinical and educational pro-
ington, DC 20037. The George Washington              WATERBURY HOSPITAL. Located in the cen-              grams in: A Teaching Nursing Home; Inpatient
University is an Equal Opportunity/Affirmative       tral Connecticut region, just 20 minutes from        Consultation (especially Geropsychiatry and
Action Employer.                                     New Haven and approximately a two-hour               Orthopedics). In this supportive environment
                                                     commute to either Boston or New York City, is        for both patient care and career development,
DECISION ANALYST — FULL TIME                         an innovative health care center and a major         the successful candidates will join an active and
Georgetown University is conducting a national       teaching site of the Yale Primary Care Internal      stimulating division with established acute in-
search for a researcher to work in a newly es-       Medicine Residency Program. Currently we are         patient/community programs; teaching pro-
tablished “Cancer Clinical and Economic Out-         conducting an active search for a Medical Di-        grams for medical, nursing, and social work stu-
comes Core” at Lombardi Cancer Center. The           rector of Chase Clinic, a hospital sponsored         dents; accredited Geriatric Medicine and Geri-
Core w ill be responsible for conducting state-      clinic supporting a residency and faculty prac-      atric Psychiatry Fellowships; funded research
of-the-art outcomes analyses of a wide range of      tice. Along with strong clinical skills in primary   programs; and a faculty practice. For consider-
cancer services, including cost-effectiveness        care internal medicine, leadership experience in     ation please send or fax CV to: Roxanne M.
analyses assessing the costs and health out-         directing a ma naged care practice and experi-       Leipzig, MD, PhD, Chief, Eileen E. Anderson
comes associated with genetic testing for breast     ence in ambulatory graduate medical education        Section of Geriatric Medicine, Saint Vincents,
and ovarian cancer susceptibility, alternative       are required. Primary responsibilities will in-      153 West 11th Street, NR 1211, New York, NY
breast cancer diagnostic strategies, and pallia-     volve overseeing clinical and support staff in-      10011. Phone (212) 604-2127, Fax (212) 604-
tive treatments for metastatic cancer. The can-      cluding mid-level providers in an ambulatory         2128. Equal Opportunity Employer.
didate will participate in existing research, and    clinic and urgent care center, interfacing with
will develop his/her own independent research        managed care organizations as well as hospital       HEALTH SERVICES FACULTY. Michigan State
in decision sciences for interventions focused       administration, precepting residents/students,       University invites clinician scientists with
on cancer prevention, early detection and/or         developing a faculty practice, and attending on      record of accomplishment in decision sciences,
treatment. Interest in geriatrics a plus. The suc-   the inpatient general medicine wards. Oppor-         health services, or outcomes research for ten-
cessful candidate will have specialized training     tunities exist to develop educational programs       ure position. Teaching and patient care commit-
and experience in economics, mathematical            in ambulatory medicine. The Director will be         ment, MD degree, Internal Medicine Boards re-
modeling, epidemiology, computer program-            appointed to the clinical faculty at Yale Univer-    quired. CV, cover letter, before 7/1/96: Marga-
ming, together with an understanding of the          sity School of Medicine. Please forward your         ret Holmes-Rovner, PhD, Department of Medi-
clinical pathways associated with interventions      curriculum vitae to: David N. Podell, MD, PhD,       cine, B220 Life Sciences, East Lansing, MI
of interest. Fellowship training in the decision     Director of Medicine, Waterbury Hospital             48824-1317. HM967
sciences is desirable. MD or pre-(ABD) or post-      Health Center, 64 Robbins Street, Waterbury, CT
doctoral candidates in economics, health ser-        06721. We are an Equal Opportunity M/F/D/V
vices research, or related disciplines are encour-   Facility.
aged to apply. Faculty appointment, excellent
opportunities for career development. Com-           ACADEMIC GERIATRICIANS. No one knows
petitive salary and benefits. Please send letter     the science of healing the body, or the art of
of interest, curriculum vitae, and short writing     healing the spirit, better than Saint Vincents, a
sample to: Dr. Jeanne Mandelblatt, Director,         major 813-bed academic medical center located
Cancer and Aging Research, Lombardi Cancer           in the heart of Greenwich Village. Challenging
Center, 2233 Wisconsin Avenue, Suite 535,            opportunities exist for Academic Geriatricians.


8    April 1996                                                                                                                       SGIM Forum

								
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