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Society of General Internal Medicine SGIM

TO PROMOTE IMPROVED PATIENT CARE, RESEARCH, AND EDUCATION IN FORUM PRIMARY CARE AND GENERAL INTERNAL MEDICINE Volume 30 • Number 9 • September 2007

ROM THE IELD On June 6, 2007, the program “Marketplace” aired a brief commentary by F F SGIM Member Stefan Kertesz, MD, of the University of Alabama at Birmingham, asking whether increasingly aggressive standards for glucose control in the care Why So Much of diabetic patients may help to explain the enormous popularity of Avandia. At SGIM Forum’s request, Dr. Kertesz has gently expanded that radio commentary Avandia in the for the SGIM Forum audience.

First Place? he downfall of The Ethics of GlaxoSmithKline’s “The challenge for primary care Tblockbuster diabetes drug Avandia (rosiglita- internists, and for our patients, is Quality zone) took its toll on Improvement morning rounds this past a rise in absolutist, binary, May. A widely publicized outcome-based quality Stefan Kertesz, MD, MSc meta-analysis, first pub- lished online by the New standards for the treatment of England Journal of Medicine, reported an each chronic medical condition.” increased risk of myocar- Contents dial infarction among per- sons receiving Avandia in comparison to minutes of notoriety. Where was the 1 From the Field other treatments [Odds Ratio (OR) 1.43, FDA? What about that marketing? These 95% Confidence Interval (CI) 1.03- questions matter, but they were not my 2 This Month in JGIM 1.98]. The same paper also suggested a question. To frame Avandia’s downfall as possible association between Avandia merely Vioxx “Part Deux” is to miss the 3 President's Column and all-cause mortality (OR 1.64, 95% point of greatest relevance to those who CI 0.98-2.74). Amid fierce media reac- are passionate about quality in the pri- 4 From the Society tion and public outrage, Avandia joined mary care of people with chronic illness. our morning rounds. Diabetes is a lethal chronic disease 5 Abstractions During visits to patients’ rooms over increasingly central to primary care, and the next few weeks, we heard televisions it has been the formidable target of 6 Ask the Expert blare: “If you think you’ve been harmed national quality initiatives for at least a by Avandia, call our attorneys.” One decade. My question, first broadcast on morning, a resident was drawn away from Public Radio International’s Marketplace, 7 Between Us the bedside of a man admitted for unsta- is “why were we prescribing so much ble angina to handle a call from a clinic Avandia in the first place?” 8 Funding Corner patient worried about Avandia. We grum- In recent years, we’ve put patients on bled about the intrusion on our time, but two or even three medications just to 9 In Training that mild inconvenience paled in com- meet the elusively low glycosylated parison to the possibility that some hemoglobin target of 7%, as endorsed by 10 From the Regions patients might have been hurt or killed by the American Diabetes Association and medicines offered with every intention of recently enshrined in the measures speci- helping them. fied by the National Committee for Editorialists quickly resurrected the Quality Assurance, although other expert same questions that had been on our lips bodies (e.g. the Veterans Health two years ago, when Vioxx enjoyed its 15 continued on page 11 SGIM_September 2007-Web.qxd 8/10/07 4:18 PM Page 2

SGIM FORUM

HIS ONTH IN SOCIETY OF GENERAL INTERNAL MEDICINE T M JGIM OFFICERS Life Chaos: Impacts on Health PRESIDENT Eugene Rich, MD • Omaha, NE [email protected] • (202) 887-5150 and Health Care Utilization PRESIDENT ELECT Lisa V. Rubenstein, MD, MSPH • North Hills, CA Adam Gordon, MD, MPH [email protected] • (818) 891-7711 This month in JGIM, Mitchell D. Wong, MD, PhD, of the UCLA Division of IMMEDIATE PAST PRESIDENT Robert M. Centor, MD • Birmingham, AL General Internal Medicine and Health Services Research discusses his article, [email protected] • (205) 975-4889 “The Association Between Life Chaos, Health Care Use and Health Status TREASURER Among HIV-infected Persons.” Redonda Miller, MD, MBA • Baltimore, MD [email protected] • (410) 955-3010 ew approaches to SECRETARY health care delivery Valerie Stone, MD, MPH • Boston, MA often require astute “They found that higher chaos [email protected] • (617) 726-7708 N observations that develop TREASURER ELECT scores were associated with Jeffrey Jackson, MD, MPH • Bethesda, MD into research foci. These [email protected] • (202) 782-5603 foci can inform and direct those in the sample who were COUNCIL health care delivery. From observation to inquiry to without a significant other, Jasjit Ahluwalia, MD, MPH • Minneapolis, MN [email protected] • (612) 626-6033 practice change, clinical had one or more unmet social Marshall Chin, MD, MPH • Chicago, IL investigators are important [email protected] • (773) 702-4769 conduits for advancing service needs, or had lower Donna L. Washington, MD, MPH • Los Angeles, CA generalist care. The obser- [email protected] • (310) 478-3711 ext. 49479 vation of the problem is mental health status.” Karen DeSalvo • New Orleans, LA [email protected] • (504) 988-5473 often the most important Said A. Ibrahim, MD, MPH • Pittsburgh, PA step. the similarity with some of my own [email protected] • (412) 688-6477 This month in JGIM, Mitchell D. patients in my continuity clinic in East Alicia Fernandez, MD • San Francisco, CA [email protected] • (415) 206-5394 Wong, MD, PhD, describes the genesis Harlem. We only started thinking about of his line of inquiry into “chaos.” He chaos as a research topic after we left EX OFFICIO notes, “The original idea of the research New York the following year.” Regional Coordinator was that of Catherine Sarkisian, my wife Their research involves an investiga- Donald Brady, MD • Atlanta, GA [email protected] • (404) 616-3117 and co-investigator, when we were living tion regarding the development and test- Editors, Journal of General Internal Medicine in New York City over 10 years ago. I ing of a global measure of life chaos for Martha S. Gerrity, MD, PhD • Portland, OR was finishing my primary care Internal adults regarding social and environmen- [email protected] • (503) 220-8262 Ext. 55592 Medicine residency at Cornell/New York tal aspects of life. They further sought to William M. Tierney, MD • Indianapolis, IN Hospital, and had just finished her examine whether this chaos measure dif- [email protected] • (317) 630-6911 residency and was practicing at Jacobi fers among HIV-infected persons by Editors, SGIM Forum Rich Kravitz, MD, MSPH • Sacramento, CA Hospital in the Bronx. She had this rev- socioeconomic status, social supports, and [email protected] • (916) 734-2818 elation after she saw a particular patient, stressors. They also examined whether Malathi Srinivasan, MD • Sacramento, CA a single mother living in poverty whose life chaos was associated with lower use [email protected] • (916) 734-7005 brother had just been released from jail, of HIV care and worse health status. Associates’ Representative had nowhere to go, and so was coming To achieve their objectives, they Neda Ratanawongsa, MD • Baltimore, MD [email protected] • (410) 550-1862 to New York to stay with her. Of course, examined survey data including measures HEALTH POLICY CONSULTANT the patient had few resources and really of life chaos, health status, and health Lyle Dennis • Washington, DC no room for her brother, but he was care use collected from a sample of HIV- [email protected] coming to stay with her and her children infected persons. They found that higher EXECUTIVE DIRECTOR anyway.” chaos scores were associated with those in David Karlson, PhD He continues, “It suddenly seemed so the sample who were without a significant 2501 M Street, NW, Suite 575 • Washington, DC 20037 [email protected] clear to Catherine why this woman was other, had one or more unmet social serv- (800) 822-3060; (202) 887-5150, 887-5405 FAX having such difficulty trying to check her ice needs, or had lower mental health sta- DIRECTOR OF COMMUNICATION AND PUBLICATIONS finger stick blood glucose levels and tak- tus. They concluded that their measure of Francine Jetton • Washington, DC ing her medications—given what she was chaos was associated with mental health [email protected] • (202) 887-5150 dealing with in her life. She told me status and health care service utilization. about this patient, and I immediately saw continued on page 13

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SGIM Forum PRESIDENT’S COLUMN EDITORS IN CHIEF EMAIL “The Vision Thing”: Rich Kravitz, MD, MSPH [email protected] Malathi Srinivasan, MD [email protected] Leadership and MANAGING EDITOR EMAIL Christina Slee, MPH [email protected] SGIM FORUM COLUMN ASSOCIATE EDITOR EMAIL Eugene Rich, MD Abstractions Jeff Jackson, MD, MPH [email protected] ACGIM Anna Maio, MD [email protected] Ask the Expert n this issue, Francine Nina Bickell, MD, MPH [email protected] Jetton has done an Carol Horowitz, MD, MPH [email protected] outstanding job sum- “Of course organizations need Ethan Halm, MD, MPH [email protected] I marizing the outcome of Disparities in Health a vision; that’s Strategic Said Ibrahim, MD, MPH [email protected] the SGIM Council’s June From the Regions planning retreat. This Planning 101. But a shared Keith vom Eigen, MD, PhD, MPH [email protected] leaves me free to reflect vision is a bigger challenge. From the Society more broadly on the lead- Francine Jetton [email protected] ership process and SGIM. How do we articulate that Funding Corner Given my 20 years Preston Reynolds, MD, PhD [email protected] holding titles in teaching vision and make sure its one Joseph Conigliaro, MD, MPH [email protected] hospitals and medical Human Medicine schools, I’ve participated in shared by all our members?” Linda Pinsky, MD [email protected] many discussions on “lead- Innovations ership” that have added to my collection of shared vision is a bigger challenge. How Paul Haidet, MD, MPH [email protected] Haya R. Rubin, MD, PhD [email protected] aphorisms, if not my store of wisdom. do we articulate that vision and make Rachel Murkofsky, MD, MPH [email protected] Winston Churchill observed the secret of sure it’s one shared by all our members? In Training leadership was “going from failure to fail- As I reflected in my column last month, Karran Phillips, MD, MSc [email protected] ure with no loss of enthusiasm.” Ngo we academic general internists have high- Morning Report Ding Diem famously charged, “Follow me ly varied perspectives across research Mark Henderson, MD [email protected] if I advance, kill me if I retreat, revenge (qualitative methods to econometrics), Craig Keenan, MD [email protected] me if I die.” After the 1949 World Series education (pre-clinical education to Catherine Lucey, MD [email protected] win, Casey Stengel admitted, “I couldn’t CME), patient care ( visits to ICU), Policy Corner have done it without the .” Harry and health policy (national health system Mark Liebow, MD, MPH [email protected] Truman noted, “You can accomplish any- to health savings accounts). President’s Column Eugene Rich, MD [email protected] thing in life, provided you do not mind At last year’s summer retreat, Bob This Month in JGIM who gets the credit.” Various pundits have Centor led the Council to develop the Adam Gordon, MD, MPH [email protected] observed that “managing is doing things following vision for SGIM: “Academic VA Research Briefs right; leading is doing the right things.” General Internal Medicine will be the Geraldine McGlynn, MEd [email protected] While I have found each of these insights driving force in advancing comprehensive

Published monthly by the Society of General Internal useful from time to time, they don’t nec- health care for adults.” I believe it’s a Medicine as a supplement to the Journal of General essarily apply to leadership for an academ- statement compatible with the hopes and Internal Medicine. SGIM Forum seeks to provide a forum for information and opinions of interest to SGIM mem- ic professional association like SGIM. aspirations of all our disparate members. bers and to general internists and those engaged in the Some years ago I was “resting my eyes” In our deliberations this year, we on study, teaching, or operation for the practice of general internal medicine. Unless so indicated, articles do not during a conference for hospital medical Council have repeatedly reminded our- represent official positions or endorsement by SGIM. Rather articles are chosen for their potential to inform, directors when a phrase drifted from the selves of this vision. Doubtless we need to expand and challenge reader’s opinions. podium and roused me to alertness. The make the same effort to ensure this vision SGIM Forum welcomes submissions from its readers and speaker said “the leader is the custodian of is shared with and by our members. others. Please send your ideas and pieces to one of the editors-in-chief, who will direct you to the appropriate the shared vision.” This is a simple phrase, What does it mean to be the custodian Associate Editor for consideration. trite at first blush, but I’ve found it invokes of the shared vision? As elected leaders of The SGIM World-Wide Website is located at http://www.sgim.org important concepts relevant to SGIM. SGIM, we must look after shared hopes, Cartoons are provided courtesy of Stitches—The Journal Of course organizations need a vision; engaging our members and deploying our of Medical Humor. that’s Strategic Planning 101. But a continued on page 12

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FROM THE SOCIETY Council Retreat Report, Summer 2007 Francine Jetton, MA

ne year ago, the SGIM Council variety of other necessary initiatives, the newly designed SGIM web site, which formally voted to focus on a new three core committees each proposed ini- will be full of new content and valuable Oset of priorities and redirect lead- tiatives geared toward providing the fol- member services. Additionally, this year ership to avoid micromanagement and lowing “value-added services” to all the Communications Committee will be support the Society’s mission and goals. SGIM members. conducting a search for a new editor of Three core committees—Education, The Research Committee will be SGIM Forum. The Development Research, and Clinical Practice—were expanding the K23 and K24 registries by Committee has been slightly restructured set up under this new “mission-based inviting prior recipients to share samples to focus on fundraising activities. The governance structure.” A variety of sup- of their grant proposals and other advice new SGIM Development Professional porting committees and task forces were with potential grantees. This same com- addresses grant writing for specific oppor- added to promote SGIM’s mission and mittee hopes also to enhance the career tunities also identified by committees and vision—that academic general internal development awards section of the SGIM Council during the retreat. medicine be the driving force in advanc- web site. Both activities seek to actively This year marks the highest level of ing comprehensive health care of adults. increase the number of SGIM members funding available for committee and task The SGIM Council met again June receiving funding and awards through force initiatives in many years. The addi- 13 to 15, 2007, in Washington, DC, to these mechanisms. tion of a membership coordinator at SGIM provide strategic leadership, ensure ade- The Education Committee will be will enable the national office to provide quate resources, and provide oversight working to completely overhaul both the more support for these and other projects, and accountability to the Society. One fellowship and residency directories on which will benefit all SGIM members. SGIM of the first goals that Council set for the SGIM web site. These valuable itself was the establishment of two key resources have been in need of a To provide comments or feedback about From the mega-issues fundamentally important to redesign for a few years and will be get- Society, please contact Francine Jetton at jet- the Society, where Council is looking to ting the attention they deserve. The [email protected]. be more active in the coming year. Clinical Practice Committee will be Through a variety of brainstorming ses- working with the Institute for sions and a survey instrument adminis- Healthcare Improvement (IHI) New tered by SGIM President-elect Lisa Health Partnerships Collaborative on Rubenstein, the two mega-issues that identifying SGIM members interested in emerged were: 1) a gradual decrease in self-management and providing this the size of SGIM membership despite resource on the SGIM web site. recruitment activities (internal focus) Three mission-support committees— and 2) threats to the future of clinical Membership, Communications, and general internal medicine (external Development—will be working on enor- focus). mous tasks that will enable the SGIM With these two mega-issues at the national office to function more effec- forefront, Council was better able to focus tively and thereby provide better services on the initiatives suggested by committees to members. and task forces for the coming year and As the decline in SGIM membership identify where Council leadership and was identified as a mega-issue, Council SGIM financial resources could be best voted to increase the size of SGIM staff placed in order to work toward partial res- to 13 with the inclusion of a full-time olution of these mega-issues. membership coordinator who will work All major committees/task forces were to increase the membership of both asked to develop annual plan proposals SGIM and ACGIM. This new staff per- this spring to inform Council of their son will help the membership committee 2007-2008 initiatives and ask for financial develop a full-scale marketing/member- and staff resources to support these proj- ship plan for recruitment and retention ects, where available. A number of com- of new members. mittees and four task forces brought for- The Communications Committee will ward proposals to the Council. Among a be working all year to finally launch the

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ABSTRACTIONS From Somalia to SGIM:A Path Less Traveled! Said Ibrahim, MD, with Jeff Jackson, MD This month Jeff Jackson interviews Said Ibrahim, SGIM Council’s newest member. Most of us are unaware of the journey Said took on his path to GIM. Jeff had a chance during this past annual meeting in Toronto to catch up with him.

ell me about yourself. What happened when you landed in gry, I had a nice lunch that cost me $15, Well, I was born in Somalia to a Cleveland? half my money. Now I had $15 and Tfamily of 10 kids supported by a I arrived in the early evening of October 1, nowhere to go, and I knew absolutely no policeman father who earned less than 1984, after about 38 hours on a plane. one in Cleveland. So I walked to the $30 a month. This sounds poor, but it was There, waiting for me was the Cleveland immigration office in downtown considered middle class by Somali stan- State University basketball coach and his Cleveland to find out what my options dards. I went to elementary and interme- assistant. As soon as they saw me, I sensed were. They told me to go to the Legal diate schools in Belet Weyne, a small disappointment. It turned out that the Aid Society, an organization that provides town located about 150 miles west of Somali coach told them how tall I was in representation for people who can’t afford Mogadishu on the Somalia-Ethiopia bor- meters, and when they did the conversion one. Unfortunately, there I learned one der. For high school, I attended a UN- they had me at over 7 feet tall. Their faces has to be a US citizen or permanent resi- sponsored agricultural boarding school dropped with surprise when they realized dent to qualify for their services. As I was near Mogadishu. Although I was raised that I was only 6’8”. walking out of the office, one of the staff speaking Somali, English was the primary members ran after me and asked me to language at high school. Most of the You should have told them you shrank tell him my story. After hearing it, he sug- teachers were from Asia and Eastern on the flight.... gested I come stay with him until I could Europe and spoke English as a second lan- So there I am, very tired. They drove me figure out what to do next. guage. My high school didn’t have formal straight to the University basketball arena. sports teams until my senior year, so I “Here are some clothes, change, and let’s What did you do next? started playing some pick-up basketball. I play basketball,” they said. Then came a Well, as you can imagine, my options were was recruited to play basketball for minor pick-up game with bunch of huge guys— limited. I reasoned that my best choice, league teams in Mogadishu. In 1982, I was one was over 7 feet tall—or so it appeared other than just taking the plane ticket drafted to play center for the Somalia to my excessively skinny frame. I was so home, was to find a way to pressure national basketball team that competed in tall and so thin! They crushed me and Cleveland State University to offer some the Pan-African Games in Egypt. quickly reached the decision that I wasn’t kind of scholarship even if I couldn’t play competitive for NCAA Division I basket- basketball. I left Somalia having been told What brought you to the US? ball. that I’d get a scholarship even if I didn’t One of the Somali national basketball They put me up overnight in an athlet- make the team. So I wrote and called the coaches came to Cleveland State ic dorm, and the coach asked me to come University President’s Office, the NCAA, University for a coaching seminar and to his office first thing in the morning. and the Cleveland Plain Dealer, the leading worked with Cleveland State’s head There he tried to hand me a plane ticket city newspaper. The newspaper sent a coach, who had a reputation for recruit- back to Somalia. I told him I didn’t want reporter, and the story made the national ing basketball players from Africa. For the ticket. I said, “I’m here to play basket- press. A young woman in San Diego read example, one of his recruits was Manute ball. If I’m not good enough, fine. I’m here my story and called her father, an econom- Bol from Sudan. The Somali coach told for an education.” I refused to take the ics professor at a college near Cleveland. the Cleveland State University coach plane ticket. He threatened to call the She knew he’d be interested in my story about me, so the Cleveland Coach called police, but when I wouldn’t give in, he because he’d spent time in Somalia as a and invited me to come play for him. said, “Fine. If you don’t want to take the Mennonite volunteer teacher. I left my home and entire family plane ticket, then you have to walk out of behind to come to the United States. I here, and I don’t want to see or hear from So weeks pass and your three-month had to sneak out of the country because you again.” student visa is about to expire. What did at the time it was not legal for a national you do next? figure to leave the country unauthorized. What happened then? I had a college degree from Somali Furthermore, each Somali citizen was Well, I walked out with my bag and $30 National University, but I wanted to go to allowed to take no more than $30 out of in my pocket onto the streets of medical school and needed more college the country. Cleveland. It was lunchtime. Being hun- continued on page 12

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ASK THE EXPERT Ethics at the NIH: An Interview with Marion Danis Marion Danis, MD, with Nina Bickell, MD, MPH Marion Danis, MD, is Head of the Section on Ethics and Health Policy in the Department of Clinical Bioethics in the Clinical Center of the National Institutes of Health. She also serves as Chief of the Bioethics Consultation Service at the NIH Clinical Center.

hat does a physician who exorbitantly expensive proposition. write grants. serves as an ethicist do? These results provided the focus for the The department is a great place to do W Physician ethicists most fre- question I have studied for most of my a fellowship in bioethics after medical quently find opportunities to work either career—how can we balance respect for residency. Fellows get to spend 70% of in clinical or research ethics. If they patient preferences with the need to dis- their time doing research, learning to engage in clinical ethics, they might tribute health care fairly? This question serve on IRBs, and acting as clinical chair or be members of ethics commit- is really an ethical question. That is, ethics consultants. There are likely to be tees in hospitals or other health care how can we balance respect for patient an increasing number of job opportuni- organizations. If they engage in research autonomy with concern for justice? ties for physicians trained in ethics par- ethics, they are likely to serve on institu- Based on my interest in empirical ticularly as the NIH funds a number of tional review boards (IRBs) in a medical research in medical ethics, I was invited new clinical research centers around the school or other medical research setting. to chair the ethics committee for the United States that will require personnel Some physician ethicists also do Society of Critical Medicine. I began to with knowledge and skills in ethics. research—either conceptual analysis chair the ethics committee for my hospi- regarding how an ethical problem ought tal at the University of North Carolina What are some of the new, hot topics to be addressed or empirical research where I was teaching and was eventually in bioethics? such as surveys regarding people’s atti- invited to run the ethics consultation There are lots of questions in environ- tudes about an ethical issue. service at the National Institutes of mental, new technology, and enhance- Health Clinical Center. Now I head the ment ethics that are getting attention. Why did you get interested in ethics? section on Ethics and Health Policy in People want to know if we should hold I have always been interested in what is the Department of Bioethics at the NIH. patients morally responsible for their now called “patient-centered care”— behaviorally induced medical problems making medical care attentive to the What are you working on now? or provide ancillary medical care or needs and preferences of the patient. At Since coming to the NIH, I have been access to an intervention to human sub- the end of my medical residency, I had a working on getting the public involved jects who have participated in a clinical patient who had told me that he had in making some of the hard decisions we trial. I asked my internal medicine col- had a terrible experience in the ICU and face in prioritizing and rationing health leagues and they offered these questions: did not want to ever have that experi- care so it can be both affordable and tai- ence again. So as a young general medi- lored to meet the public’s needs. A lot of 1. What are the ethics of using evi- cine faculty member, I decided that I my work aims at reducing health dispari- dence-based medicine and cost-effec- would do a systematic survey of all ties by incorporating the priorities of tiveness to determine the “value” of patients coming out of our ICU (and low-income and uninsured populations. new treatments? family members of patients who did not 2. Should off-label use of drugs be cov- survive) to learn about their preferences Why go to the NIH to do ethics? ered by insurance? Should it require for intensive care if they had to do it The Department of Bioethics at the NIH informed consent? over again. offers a remarkable opportunity to work 3. Is it ethical to require patients to par- To our surprise, we found that people with physicians, philosophers, and others ticipate in clinical trials as a condi- were extremely interested in receiving who are interested in both empirical and tion of insurance coverage for some intensive care even if they were likely to conceptual work regarding the ethics of new treatments? SGIM survive for as short a time as one month. research, patient care, and health policy. Not only was this finding surprising, it The department has an extremely stimu- To provide comments or feedback about Ask the was also very problematic because lating and collegial atmosphere. We can Expert, please contact Nina Bickell at nina.bick- accommodating this preference is an do scholarly work without having to [email protected].

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BETWEEN US That Lurking Shadow in the Distance: Is It...the IRB? Richard Kravitz, MD, MSPH

s it just me, or are Institutional an intervention, just a series of questions after the program was implemented. Review Boards (IRBs) getting scary? I administered to cognitively intact adults? The QI program was going ahead with or Idon’t mean scary like monsters in the Contemporary IRBs do more than without my academic colleague’s night; some of my best friends serve on ensure informed consent and protect involvement. However, because the con- IRBs, and I know them to be reasonable human subjects from abuse or mistreat- sulting team hoped eventually to report people. (Disclosure: I served on the ment. They venture, sometimes quite on the success or failure of the program in RAND IRB in the late 1980s.) casually, onto ground previously left to an academic journal, it dutifully submit- I mean scary in the sense that scientific peers, managers, and investiga- ted an application to the local IRB. Big unchecked power, even when exercised tors themselves. mistake! After learning that the team had benignly, is always worrisome. IRBs are The question is whether such mission already made site visits and had started to doing things they weren’t intended to do. creep is good for researchers, patients, or implement the program (part of the con- And there is no one to call them on it. the public. The question is particularly sultant’s role), the IRB issued a “cease and This is mission creep with muscle. poignant for generalist researchers who desist” order that may shut down all of What was the original intent? IRBs rarely test new drugs or devices; who the team’s activities (even those that gained legal status in 1974 with the pas- almost always collect data using methods could not remotely be associated with sage of the National Research Act. The that pose little direct risk to patients; and research). My guess is that the dispute in atmosphere at the time was charged with who are frequently engaged in work relat- this particular case will get worked out as cumulative knowledge of a series of sor- ed to quality improvement or public the line between program implementa- did events. Among the accounts heard in health, where the distinction between tion and research is adjudicated. In the testimony by the Senate Subcommittee “practice” and “research” is less clear. meantime, however, accounts are frozen, on Labor and Public Welfare were the Two years ago I became aware of the staff members dependent on those unapproved use of DES for post-coital following case. An investigator was asked accounts are in financial jeopardy, and contraception, psychosurgery on patients by the IRB to translate questionnaires anxiety runs high. in mental hospitals, and sterilization of into Spanish so that non-English speakers The irony here is that major changes in minor welfare recipients without their would not be excluded from a study of a organizational structure and process occur parents’ consent. behavioral treatment for chronic pain. all the time; they are off the IRB’s radar. Clearly researchers could not be left to The investigative team had already con- My own institution, like many others, has police themselves. IRBs were created to sidered doing so but had rejected the idea recently invested millions of dollars to cre- ensure that the rights of human research based on the low prevalence (5%) of ate an electronic medical record (EMR). subjects were respected. That means Spanish speakers in the particular clinical Implementation of the EMR has disrupted ensuring that the risks of human subjects population to be studied. Additionally, lives and radically changed clinical work- research are minimized, that the potential they were disuaged by the high cost of flow. No large scale evaluation (certainly benefits of the knowledge gained out- translating, back-translating, and validat- not one resulting in “generalizable knowl- weigh the risks, and that subjects are fully ing such materials, which would have far edge”) is ongoing. The IRB doesn’t know informed and consenting. exceeded the study budget. The research and may not care. Only when some junior There’s no doubt such oversight is nec- plan (including restriction to English faculty member requests permission to cre- essary. Nuremberg and Tuskegee are, we speakers during the initial trial) had ate a survey pop-up asking EMR users to hope, behind us. However, as ever more already been exhaustively peer reviewed rate the utility of a warfarin dosing guide- potent but potentially dangerous therapies by a committee arguably much better pre- line will the IRB step in. It’s hard to say emerge from the laboratory and line up at pared to assess the science than the IRB. whether this is right or wrong, but it’s defi- the bedside, waiting to be tested in More recently, a colleague was asked nitely inconsistent. humans, vigorous and independent review to participate in developing a quality What is the solution? I don’t claim to is essential. improvement (QI) program for a state have the whole answer. The proposal by But what happens when the “interven- health agency. The program involved pro- Joanne Lynn and colleagues (published in tion” is a reorganization of care in the viding educational materials to agency the May 2007 issue of the Annals of interests of quality improvement, coupled clinicians; developing evidence-based Internal Medicine) to create special QI with a systemtatic evaluation? Or the clinical guidelines, flowsheets, and algo- subcommittees within IRBs is a reason- effects of an educational intervention? Or rithms; and soliciting feedback from clini- able approach to dealing with projects at when the research doesn’t even involve cians and patients both prospectively and continued on page 11 7 SGIM_September 2007-Web.qxd 8/10/07 4:18 PM Page 8

SGIM FORUM

FUNDING CORNER Robert Wood Johnson Foundation’s Program for Substance Abuse Policy Research P. Preston Reynolds, MD, PhD, Professor of Medicine, University of Virginia

he Robert Wood Johnson Among the RWJF’s programs in sub- ing and drinking attitudes and behaviors. Foundation (RWJF) has supported stance abuse is the Substance Abuse The next call for proposals will be Tresearch in the area of substance Policy Research Program that will issue a issued soon, with a due date for brief appli- abuse for more than 20 years. In those 20 call for new proposals soon. To date, 12 cations in November 2007. There is a years, scientific views on substance abuse rounds of grant awards have been made. three year maximum of grant funding for have changed significantly. For instance, Many of these funded projects would each application; small grants are available substance abuse is now considered a interest SGIM members. (See up to $100,000, large grants at $100,000- chronic medical illness, based on under- http://www.rwjf.org for program areas and $400,000. Tobacco research-related pro- standing the biological and neurological national programs.) posals are limited to small grant awards; causes of addiction. The grantees in this RWJF program are large grants are open to proposals focusing Despite this investment by RJWF (in tackling important policies in substance on alcohol and drugs, such as barriers or partnership with other foundations, state abuse and ones that are making headlines dissemination strategies for buprenorphine and federal agencies, and local communi- around the country. For instance, some or naltrexone use. The Foundation has ties), substance abuse continues to be a investigators have been funded to investi- allocated $4 million for this upcoming major health problem that largely gate all of the tribal laws on alcohol use grant cycle to be distributed based on the remains untreated. On its website, the and their impact on reducing Native quality of applications. For more informa- Foundation highlights three studies that American substance abuse; barriers to tion, contact Susan Frye, grants adminis- capture this lack of adequate treatment: buprenorphine use among physicians in trator, at [email protected]. SGIM private practice for treatment of opioid • Only 8% of the approximately 22 dependence; and implementation of To provide comments or feedback Funding million Americans age 12 and older screening tools for substance abuse in a Corner, please contact P. Preston Reynolds at who need addiction care receive managed care population. [email protected]. treatment for their disease; A number of RWJF-funded investiga- • One study found that of 171 tors are focusing on the impact of smoke- community-based treatment centers, free ordinances. Dianne Barker is examin- only 48% used proven psychosocial ing the combined effect of the 100 clean interventions, and only 17% routinely indoor air ordinances or smoking bans on prescribed medications known to older adolescents and young adult smokers’ alleviate alcohol or opiate dependents; demand for and use of smoking cessation and interventions as they age, cycle through • Among all primary care centers, 89% do quit attempts, and transition from school not offer addiction treatment services. to the workforce. Amy Williamson from the University of Wisconsin is studying the To maximize the impact of its invest- impact of Madison’s ban on the smoking ment, the Foundation will move the pro- and drinking behaviors of both students gram to its vulnerable populations area and non-student residents of this large col- and focus on three major issues, including: lege town. Data will include a survey of UW students on smoking and drinking- 1. Discouraging underage alcohol use and related attitudes before and after the ordi- increasing the understanding of its nance, as well as a cross-sectional survey of harmful effects; adult residents. Semi-structured interviews 2. Mobilizing communities and increas- will be conducted with community leaders, ing public understanding about the bar owners and managers, alcohol and harmful effects of drug use; and tobacco coalitions, neighborhood and 3. Improving the quality and availability community organizations, and public safety of treatment for those with substance- officers to determine the perceived abuse disorders and addictions. changes in social disruption and in smok-

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IN TRAINING An Investment That’s Worth the Risk Hannah Shacter, BA Hannah Shacter is the new medical student Associate Editor for the Forum’s In Training column. She is a first-year medical student at the University of Minnesota.

any of you may not remember influenced by the exposure the precise series of events that “This [mentoring] allowed and guidance, whether direct Mled you to a career in internal or indirect, that I’ve received. medicine. I, however, am just starting my me both to explore my own I urge you to look at the medical education and career, so the rea- students around you in your son for my choice is still very clear. It is potential as a researcher day-to-day activities, includ- the direct result of the mentoring I have ing the research assistants or received. and also gave me a glimpse students looking to shadow There is no question that mentoring is into the vast world of you in clinic, and consider valuable. It provides fellows and junior investing in these students as faculty with guidance and support in internal medicine.” a mentor. It may be a risky refining career goals, securing research investment, but I sincerely funding, and finding collaborators. Many believe that the return will be residency programs also include organized cialties, and it is crucial that these stu- worth the risk. mentoring that helps to shape the paths dents are thoughtfully exposed to the field SGIM of medicine residents into clinical, of internal medicine before their choices academic, or countless other careers. It are made. While many undergraduate and To provide comments or feedback about In gives those of us who are at earlier stages pre-clinical medical students work in Training, please contact Hannah Shacter at of our education the chance to benefit health services research as research assis- [email protected]. from the perspectives of people who have tants, it has been my experience that this been where we are and have gone on to involvement is generally limited to data where we want to be. collection and day-to-day project man- For me, this mentoring came much agement. While this may be an appropri- earlier, in the form of my undergraduate ate way for these less experienced stu- thesis advisor at the University of dents to contribute to a project, it doesn’t Pennsylvania. Not only did she assist me expose them to the aspects of a career in with my own research but she also invited internal medicine that, in my opinion, are me to play a significant role in her work. most exciting. What made this mentoring relation- I acknowledge that faculty members, ship unique was that I was only a sopho- whether clinicians, educators, or more in college when we met. Dr. Judith researchers, are taking a risk with their Long was generous with her time and time when mentoring a younger student. counsel and, most importantly, gave me There is no guarantee that this student the opportunity to experience all aspects will continue on to pursue a career in of her professional life. This allowed me internal medicine or even medicine at all. to explore my own potential as a However, there is still the potential, as researcher while giving me a glimpse into happened with me, that this student will the vast world of internal medicine. I am be drawn into the field. now beginning my first year of medical My role with SGIM Forum is to share school, and although our relationship has with you the medical student perspec- changed, I still value it more than ever as tive. As I’m only just starting out, all I I make choices that will guide my medical can offer to you is my perspective on the education and career. little I’ve seen so far, and much of what I believe that mentoring at the pre- I’ve seen and done results from the doors clinical or undergraduate level is under- that have been opened for me by others. valued. Medical students take countless Of course I’ve made my own decisions, factors into account in choosing their spe- but these decisions have been heavily

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SGIM FORUM

FROM THE REGIONS Opportunity from Tragedy: Patient-centered Medical Homes in Post-Katrina New Orleans Michael Landry MD, MSc, and Karen DeSalvo, MD, MPH, MSc Michael Landry is Assistant Professor of Internal Medicine and Pediatrics at Tulane University School of Medicine in New Orleans and is President-Elect of the Southern Region. He led a workshop on Medical Homes at the national meeting this year. Karen DeSalvo is Chief of the Section of General Internal Medicine and Geriatrics at Tulane. She is a board member of the Louisiana Health Care Quality Forum and participated in the Louisiana Health Care Redesign Collaborative. She is the Immediate Past-President of the Southern Region and serves on the SGIM Council.

wo years ago, Hurricane Katrina dev- “medical home systems of care,” develop- models. Increasing access to coordinated astated New Orleans and nearly ing a statewide quality forum, and leverag- health care and wider use of HIT promot- Twiped out its health care system, ing health information technology (HIT) ed better preventive care and helped including Charity Hospital and the state- to improve and streamline care. patients manage their chronic health care run system that provided a safety-net for The Louisiana paradigm for the “med- conditions more effectively. Such improve- the uninsured, as well as the medical edu- ical home” grows from the concept that ments would be welcome in New Orleans, cation hub. (See January 2006 SGIM originated in the 1960s in reference to where care has been inefficient and unco- Forum, page 1.) While threatening the sur- children with special health care needs ordinated, with costly overuse of ER’s by vival of the health care system, this tragedy and has since evolved into a model of residents with poor access to care. has given Louisiana an unexpected oppor- care that includes adults, especially those Louisiana is moving ahead with imple- tunity to implement and test innovative with multiple and complex illnesses. In mentation of all of the reform ideas health care delivery models, such as “med- March 2007, a consensus statement on described in the Concept Paper, including ical homes,” in its rebuilding process. the “Patient-Centered Medical Home” expansion of coverage through the Reformation of the Louisiana health (PCMH) model was developed and Medicaid program, creation of the care system has long been a desire of endorsed by several professional societies Louisiana Health Care Quality Forum, many health care providers and policy- including the American Academy of and support for better use of HIT in prac- makers. The state has consistently ranked Family Physicians, American Academy of tice settings. at or near the bottom of many national Pediatrics, American College of Two major projects aimed at realizing health quality surveys and health care Physicians, and American Osteopathic the medical home system are currently indicators. Much of this has been attrib- Association. Key elements of the PCMH, underway in New Orleans. Both will uted to a high proportion of uninsured which incorporates SGIM’s “Coordinated undergo extensive evaluation with the residents and a low ratio of primary care Care” model, include: help of national experts to ensure lessons physicians to population. learned are documented and disseminated. Following Hurricane Katrina, health • An individual and ongoing Local providers, particularly those who are care stakeholders have taken advantage of relationship with a personal physician, part of the safety net, are enthusiastically the clean slate left by the storm to re-engi- • A multi-disciplinary medical team embracing the opportunity to serve as a neer the care system into one that is more responsible for patient care, test ground for the nation to refine ideas efficient, accessible, and effective. A • Direct or coordinated care for all stages around the medical home that will be broadly representative group of policy of a patient’s life, applicable to other communities. makers came together to form the • Coordinated care integrated across all The State is developing a demonstra- Governor’s Louisiana Health Care aspects of the health care system and tion project financed by Medicaid and Redesign Collaborative (LHCRC) and the patient’s community, Disproportionate Share Funds to test the look nationally and internationally for best • Quality and safety, medical home system of care concept in practices to adopt locally. These planning • Enhanced access to care, and the Greater New Orleans area, with the efforts culminated in October 2006 with • Payments based on the added value for Charity system serving as the core of the the presentation of their final Concept care of patients with medical homes. infrastructure. This project is slated to Paper with recommendations to reform begin in the fall of 2007 and will focus on health care in the Greater New Orleans In June 2007, the Commonwealth the care of low-income uninsured and the area (www.lhcrc.gov). The Concept Paper Fund released a report showing that racial Medicaid population. recommends expanding coverage (the only and ethnic disparities in health care quali- Complementing this state funded pro- politically controversial portion of the ty and access can be significantly reduced gram is a federally supported grassroots plan), emphasizing primary care through through implementation of medical home continued on page 13

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FROM THE FIELD continued from page 1 Administration) have not drawn the clinically. Analyses show that a 1% gly- for quality serves only the interests of our same conclusions from available data. cosylated hemoglobin (HgbA1c) reduc- patients? Typically, Avandia has been the second tion (the mid-point estimate for what gli- At an absolute minimum, we must or third drug in a cocktail of costly medi- tazones achieve) is associated with a insist that health care standards organiza- cines that have not consistently obviated 0.2% reduction in microvascular compli- tions—the National Committee for the need for insulin. cations for a newly diagnosed 65 year old Quality Assurance being only one of The challenge for primary care whose HgbA1c falls from 8% to 7% many—publicly and fully disclose the internists, and for our patients, is a rise in (Number Needed to Benefit (NNB) = financial interests of their experts. absolutist, binary, outcome-based quality 500) (Vijay et al. Annals of Internal We should require disclosures not just standards for the treatment of each chron- Medicine 1997;127:788-95). The same from Boards of Directors or the commit- ic medical condition. Those standards analyses suggest we will save more eyes tees that give final approval to new include the notion that we should drive and kidneys by helping reduce HgbA1c guidelines and performance measures diabetic blood sugar, cholesterol, and even from 12% to 11% among persons diag- (who rarely are tasked with weighing blood pressure as low as it can go. nosed at age 45 (NNB= 34). However, medical evidence) but from the technical The single-disease quality targets guid- those accomplishments will count (bit- expert panels and other consultants who ing primary care practice reflect advice tersweetly) as failures in the system of help to devise benchmarks that affect the from experts whose perceptions are skewed performance benchmarks soon to be health of millions. in at least two respects. First, data given sharp teeth through Medicare’s Pay Disclosure alone will not immunize our guiding expert panels are based on single for Performance program. quality industry from improper bias, as has diseases, often from “ideal” patient sam- A second potential source of bias was been pointed out by Dr. Jerome Kassirer, ples. An article by Boyd et al. illustrated brought to public attention by the belat- former Chief Editor of the New England how guidelines based on single diseases ed (but commendable) financial disclo- Journal of Medicine (and himself a member rarely take into account just how compli- sures of the National Cholesterol of NCQA’s Board of Directors). But it’s a cated and dangerous it can be to treat a Education Program in 2004, where panel first and necessary step. patient with four diseases and 12 different members reported a median of 10 finan- And, as we begin to grapple with the medications that can mix in unforeseen cial ties to health industry companies challenge of benchmarking quality in ways (JAMA 2005;294:716-24). (only one panel member had none). We ways that are solely to patients’ benefit, Simple binary outcome measures (e.g. are obligated to wrestle with the reality we should ask our government to slow percentage of patients at target) may be that the experts who devise quality stan- down before rushing headlong into a tor- helpful to clinical reflection and research, dards often benefit financially from the rid affair with quality standards that may but they also create perverse incentives. I drug companies who naturally want us to yet betray us all. SGIM can earn superior performance scores by prescribe more drugs in service of ever- diagnosing and medicating as many mild more demanding targets for blood sugar, Dr. Kertesz discloses that he serves on the Board cases of diabetes as possible, even if such cholesterol, or anything else. of Directors for a service learning organization patients are the least likely to benefit So how can we ensure that our quest that received a major grant from Merck.

BETWEEN US continued from page 7 the juncture of service and research. More evaluating studies in clinical epidemiolo- IRBs tremendous power. At most univer- broadly, IRBs need to humbly acknowl- gy and health services research, IRBs sities, the decision of the local IRB to edge that questions of scientific merit, should remember that most of the time, disapprove a study is not subject to including internal and external validity, physical risks (the kind that can maim appeal. In this instance, Hebrew have been largely settled for peer- and kill) are non-existent and psychologi- National is wrong: there is no higher reviewed research funded by the federal cal and privacy risks are minimal. authority. With great power comes great government or a major foundation. IRBs IRBs are supposed to assure that the responsibility. Our colleagues who sit on should be provided with copies of scientif- value of the knowledge to be gained IRBs are some of the most thoughtful and ic peer reviewers’ comments when avail- exceeds the risk of harm to human sub- committed scientists and citizens around. able and should obtain consultation when jects. Under conditions of very low risk, We shouldn’t have to be afraid of them. necessary but should not embark into even incremental knowledge gains are SGIM technical areas where they lack expertise. potentially worthwhile. (“And yes, (Research that has not been externally Virginia, most of the time, research is To provide comments or feedback about Between peer reviewed should continue to receive incremental.”) Us, please contact Richard Kravitz at a higher level of scrutiny.) Finally, when The Federal government has given [email protected].

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PRESIDENT’S COLUMN continued from page 3 resources to forward our members’ vision December retreat, Council will consider GIM leaders including research section that academic GIM become the driving in more detail how best to nurture and heads, hospitalist section chiefs, and force advancing comprehensive health advocate for SGIM’s shared vision while ambulatory directors. care. As we work to accomplish this shared giving voice and support to our varied Academic general internists are also vision, the Council has endeavored to interest groups and caucuses. taking up leadership roles in the dean’s make sure we create leadership opportuni- Leadership is important not just to office of medical schools; in fact, SGIM is ties for many distinct viewpoints in SGIM. Council positions but to all our activities planning its first formal gathering at the The National Council directly accesses in SGIM. To accomplish our shared vision 2007 Association of American Medical many different perspectives through our for academic general internal medicine to Colleges meeting to create a new oppor- “core committees” of Research, be a driving force for advancing health tunity for networking of current and Education, and Clinical Practice; our care, it is important that we develop the future GIM leaders in medical education. Annual Program, Health Policy, leadership capabilities of our members and Leading is what we are called to do in Communications, Development, that we keep SGIM closely engaged with SGIM—not just on Council but on the Membership, Ethics, and CME commit- members who have achieved leadership wards and in clinics, program offices, and tees; our task forces for Hospital roles. To this end, SGIM sponsors mentor- project teams. We are leaders because we Medicine, Geriatrics, Health Disparities, ing programs and facilitates various inter- share the vision of a better world where and Evidence-based Medicine; our initia- est groups relevant to program leadership academic general internal medicine is a tives on Quality in Complex Patients, (eg, Academic Physician Administrators driving force in advancing health care in Global GIM, and now Women’s Health; and Leaders, Primary Care Program the United States. And we know “a our Associate Representative on Council; Directors, and Medical Resident Clinic vision without action is a daydream.” SGIM our Regional Coordinator; and the seven Directors). ACGIM nurtures academic Regional Councils. Nonetheless, these are GIM leaders through its networking and To provide comments or feedback about just a fraction of the diverse constituen- leadership institute; it also is undertaking President’s Column, please contact Eugene Rich cies that make up SGIM. At its membership outreach to a broad range of at [email protected].

ABSTRACTIONS continued from page 5 before I could apply. I contacted Oberlin the story becomes more traditional. I much support from people from all walks College, a small liberal arts school near went to Oberlin and met my wife. We of life. In this age of political, ethnic, and Cleveland. They didn’t know what to do married just after I graduated. Then I religious strife, it is easy to forget the with me; they’d never had someone apply spent a couple of years running DNA gels wonderful ways that humans help each from Somalia before. However, they were at the Wistar Institute in Philadelphia, other. I try very hard to look at the world impressed with my transcript. So they waiting for my green card. My wife and I from that perspective both in my personal said, “Ok, we’ll give you a chance. Why were both accepted to medical school at and professional life. don’t you enroll in a community college Case Western. SGIM and take pre-medical courses and see how you do. If you do well, we will reconsider I just can’t imagine. It would have been To provide comments or feedback about your application.” But I had no money easy just to take the ticket and go back. Abstractions, please contact Jeff Jackson at and no place to stay. Here the generosity There were some bleak days. Occasionally [email protected]. of people who had read my story comes I wondered if I had done the right thing in. The Mennonite family paid my tuition not taking the plane ticket and going at a local community college, a Cleveland home. But I was determined. dentist offered me a place to stay in a house he owned—a huge dilapidated So how has this experience shaped who unheated mansion. This is the winter of you are today? 1984; Cleveland winters aren’t Somalia When I look back, there are a couple of winters. (Editor’s Note: In January 1984, things that jump out at me. First, contrary Cleveland received 26 inches of snow and to popular opinion, it is often not where averaged 20.5 degrees.) To study, I used you come from that is critical to success heated places like libraries and the but your goals and vision. Perseverance Subway/Metro system, which ran until pays off. Secondly, and most importantly, midnight. After two quarters, Oberlin there is greater good in humanity than offered me a scholarship. At this point suggested by the daily news. I received so

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THIS MONTH IN JGIM continued from page 2

Implications partner had such a strong positive associ- care and take better care of themselves. I Dr. Wong indicates that assessing chaos ation with chaos. The association was think it could potentially be a new and has important considerations for general- stronger than we expected.” different approach to helping patients.” ist care: “Looking at chaos and its impact Originating from his wife’s observa- on receiving regular care is a new area of Future Directions tion, a unique and rewarding line of research, and much more work is needed Dr. Wong indicates that examining research has developed for Dr. Wong. in order to be certain of what the impli- chaos in other populations will be “Given our different research interests cations are for patients and physicians. important. He says, “While we did not (hers is prevention of disability among That being said, our study looked at a examine those without HIV infection, I underserved older adults), we almost sample of persons infected with HIV— suspect that the relationship between never collaborate,” he notes, “but in this most of whom were very poor and had chaos and receiving adequate care is not instance, it made sense given the history many life stressors and barriers to care.” specific to HIV but rather a conse- of the idea behind the project. And also Confronting chaos may yield better quence of poverty and having many dif- because of Catherine’s expertise in psy- health and health care services. Dr. ficult and challenging life circum- chometrics and instrument development Wong explains, “While helping patients stances. Thus, I would hypothesize that and my experience with disparities in overcome social and economic barriers is the same findings would likely be pres- HIV care. important as well as difficult, it may not ent among similar populations with “As far as working together, I have had be the only way to help patients get reg- other chronic illnesses.” a long history of following her lead. We ular medical care. Our research suggests Dr. Wong adds that he and colleagues first met in medical school where she was that it might be possible to help patients are planning to test the chaos measure in my TA in anatomy. I then followed her to get regular medical care by helping them a variety of populations, including those New York for residency, and of course, at take control of their life chaos by with other chronic illnesses and those one point we were on ward service becoming more organized, planning bet- representing other demographic samples. together—where she was the resident ter, keeping track of appointments, and He says, “Hopefully, these investigations (R2) and I was her intern. It has been reducing the amount of chaos in their will help us understand whether the great (and fun) to work with her on this lives through coping strategies.” association between chaos and health project, not only because she is terrific to care use is a causal association and work with but also because I got to take Surprising Findings whether chaos leads to worse health care the lead for once.” SGIM Dr. Wong expected more differences in use. My hope is that we can eventually chaos by demographic characteristics of show that helping patients become more To provide comments or feedback about This the sample. He notes, “I was a bit sur- organized and reduce their life chaos will Month in JGIM, please contact Adam Gordon at prised to see that having a spouse or make it easier for them to get regular [email protected].

FROM THE REGIONS continued from page 10 initiative to promote the building of indi- As New Orleans recovers from the Joint Principles of the Patient-Centered vidual neighborhood-based medical devastation of Hurricane Katrina, an Medical Home: http://www.medicalhome homes with linkages to other providers. opportunity has emerged to test new info.org/Joint%20Statement.pdf In May 2007, the US Department of models of health care delivery. The con- History of the Medical Home concept: Health and Human Services announced a sensus of stakeholders in Louisiana has http://pediatrics.aappublications.org/ grant of $100 million from Deficit been to develop medical home systems of cgi/reprint/113/5/S1/1473 Reduction Act (DRA) funds in response care with neighborhood-based clinics for to a community request for support. The the underserved. The learning potential Commonwealth Fund Report on the funds are designated to provide immediate for the nation is immense, and the hopes Medical Home impact on equity in improvements in access to primary care of many are high. SGIM health care: http://www.commonwealth through the loose network of patient-cen- fund.org/publications/publications_show tered, neighborhood clinics that have Visit these links for more information .htm?doc_id=506814 emerged in New Orleans since the storm, about... the Partnership for Access to Health care SGIM’s Coordinated Care Model: http:// Please send any comments, suggestions, or ideas (PATH). This program is scheduled to springerlink.com/content/y473n11037175 for From the Regions to Keith vom Eigen at begin in January 2008. 62g/fulltext.pdf [email protected].

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GENERAL INTERNAL Please send letter stating your area of interest CLASSIFIED ADS MEDICINE POSITION and current CV to: physicianrecruiting@uwmf LEHIGH VALLEY HOSPITAL— .wisc.edu, University of Wisconsin Medical Positions Available and Announcements are PENNSYLVANIA Foundation, 555 Zor Shrine Place, Madison, WI 53719. UW-Madison is an EEO/AA $50 per 50 words for SGIM members and $100 Lehigh Valley Hospital, a high-performing, employer; women and minorities are per 50 words for nonmembers. These fees premier academic community hospital, has a encouraged to apply. Wisconsin caregiver and cover one month’s appearance in the Forum superb opportunity for a general internist to open records laws apply. and appearance on the SGIM Web-site at join a cohesive, academic general internal http://www.sgim.org. Send your ad, along with medicine group. We seek an experienced ASSISTANT OR ASSOCIATE PROFESSOR. the name of the SGIM member sponsor, to clinician/educator who has a passion for the The Center for the Evaluative Clinical Sciences [email protected]. It is as-sumed that all underserved and a commitment to clinical care and the Norris Cotton Cancer Center at ads are placed by equal opportunity employers. and the education of medical students and Dartmouth Medical School seek candidates with residents. Join a group of excellent clinician- experience in health services research related to educators who see patients, teach medical the quality of care provided to patients with students and residents, conduct research, and cancer. The successful candidate will become a provide community service. Our ambulatory Tenure Track member of a multidisciplinary Make Your Voice Heard in SGIM! practices are located four miles apart and our research team exploring the causes and Apply to Become the Next Forum patients are seen in our main Allentown consequences of regional and -specific campus and at our downtown campus where we differences in clinical practice and health Editor! serve a large minority community in a outcomes and will be expected to lead the Council is currently accepting applica- multidisciplinary setting. Responsibilities also development of a research program focused on include managing inpatients on our TSU cancer. Prerequisites include an MD, PhD or tions for the next Forum editor. The new (transitional skilled unit), and participating in other terminal degree, demonstrated research Editor’s three-year term commences July 1, medical student and resident education. Lehigh experience and a successful track-record of peer- 2008 (with responsibility for the August Valley Hospital comprises over 800 beds on 3 reviewed publication. We are particularly issue) and ends June 30, 2011. Interested campuses in the contiguous cities of Allentown interested in candidates with experience with and Bethlehem, and is nationally recognized for large health care databases. Interested applicants persons/teams of people should send to quality and clinical innovation. We are located should send letter and CV to Dr. Elliott Fisher, Francine Jetton ([email protected]), SGIM in a beautiful suburban area 1 hour north of CECS, 35 Centerra Parkway, Room 110, Director of Communications and Philadelphia and 1.5 hours west of New York Lebanon NH, 03766. Dartmouth AA/EOE. Publications, in electronic format: (1) a City that has good schools, numerous colleges letter expressing this interest; (2) a cur- and diverse cultural and recreational offerings. General internist clinician-educator, Interested BC internists should email a CV to UT-San Antonio riculum vitae; and (3) a summary of antic- Debbie Salas-Lopez, MD, Chief, Division of ipated directions for Forum, unique attrib- General Internal Medicine, c/o Seeking a BC/BE general internist for a non- utes qualifying the applicant as Editor, [email protected], or call (610) 969- tenure track appointment in a mature Division what the home institution might bring to 0207 for more information. Visit our website at of General Medicine. Responsibilities include www.LVH.org the management of Forum, and any other teaching medical students and residents in clinic and hospital settings, direct patient care particularly important issues that nomi- at the Audie Murphy Veterans Hospital, and nees believe the Communications assisting in the development of curricula. The Committee should know as we consider GENERAL INTERNAL position is available in September 2007. All them for candidacy. A full RFP is available MEDICINE OPPORTUNITIES faculty appointments are designated as security MADISON, WI on the SGIM web site at www.sgim.org. sensitive positions. Send CV and cover letter to Andrew Diehl MD, Chief, Division of General The deadline for receipt of proposals is The University of Wisconsin School of Medicine, MSC 7879, University of Texas 11:59 PM EDT October 15, 2007. Medicine and Public Health seeks qualified Health Science Center at San Antonio, San candidates BE/BC in Internal Medicine for Antonio TX 78229-3900, or to opportunities in academically oriented clinics [email protected]. The University of Texas and community based practices. Positions Health Science Center at San Antonio is an include clinical teaching (medical students, Equal Employment Oppor-tunity/Affirmative residents and/or fellows), excellent support staff Action Employer. services and electronic medical records at many locations. We are also recruiting for a float or CLINICIAN INVESTIGATORS: Outstanding locum tenens clinical position to provide leave opportunities to join a large, growing and Washington—Seeking a BE/BC hospitalist for coverage, without night or weekend call. nationally renowned group of interdisciplinary an established 10-physician, 100% inpatient researchers in the Section of General Internal service at a 210-bed medical facility. The With over 1,000 faculty physicians, we are one Medicine and the Center for Chronic Disease program is part of a highly supportive multi- of the 10 largest medical groups in the country. Outcomes Research at the Minneapolis VA specialty group that is owned by one of the We are the clinical faculty and group practice Medical Center. We are seeking candidates at largest physician-led health systems in the plan of the University of Wisconsin School of the Assistant and Associate/Full Professor levels Pacific Northwest. One week on/one week off Medicine and Public Health, the medical staff with fellowship training and expertise in health block scheduling, three to four night shifts per of UW .Hospitals and Clinics and the medical services or outcomes research, clinical month with no more than two in a row. staff of over 60 clinical practice locations epidemiology or clinical trials to fill 2 positions. Competitive compensation package, including throughout Wisconsin. These are primarily research positions with signing bonus and loan repayment. This area limited clinical responsibilities. BC/BE in enjoys an arid climate, mountains, lakes, and Madison continually ranks as one of the best Internal Medicine required. Academic 300 annual days of sunshine! Outdoor places to live, work and play in the United appointment at the University of Minnesota. enthusiasts enjoy sports of every kind, making it States, offering incredible natural beauty, Send CV with cover letter by Fax (612-725- an exciting place to raise a family. Contact stimulating cultural opportunities and a plethora 2118) or email ([email protected]) to Timothy Michelle “Mickey” Conner at mconner@ of restaurants, shops and attractions. To learn Wilt, MD, MPH. Additional questions by hortonsmithassociates.com or 866.464.3428 more, check out www.visitmadison.com phone: 612-467-1979.

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Baystate Medical Center seeks an outstanding academic physician to be the Section Chief and the Medical Director of Baystate High Street Health Center (BHSHC), Baystate Medical Center's south campus. BHSHC is the ambulatory teaching site of Baystate's Medicine Residency Program with 50 residents, 10 clinician-educators, 3 nurse practi- tioners, and many subspecialty programs. It has a $4 million annual budget and over 30,000 adult patient visits each year. Applicants must be ABIM certified and qualified for faculty appointment at the Assistant/Associate Professor level. The successful candi- date will have demonstrated excellence in clinical care and medical education, experience in clinical practice management, and the skills to expand academic opportunities within the Department of Medicine.

Baystate is one of New England's largest integrated, multi-institutional healthcare sys- tems and offers a coordinated continuum of hospital, physician, and home healthcare services. The campus is located in the beautiful Connecticut River valley of Western Massachusetts, at the foothills of the Berkshires with convenient access to coastal New England, Vermont, metropolitan Boston, and New York. The area also supports a rich network of academic institutions including the University of Massachusetts, Amherst, Smith, Hampshire, and Mount Holyoke Colleges. The Baystate continuum includes Baystate Medical Center, Franklin Medical Center, and Baystate Mary Lane Hospital. Baystate Medical Center (BMC) is a teaching hospital and the Western Campus of Tufts University School of Medicine. BMC is designated a Magnet™ hospital for excellence in nursing services by the American Nurses Credentialing Center (ANCC). Baystate Health is ranked in the top 50 most highly integrated healthcare networks in the United States.

Baystate Medical Center, recently named one of America’s 100 best hospitals, is the health system’s flagship hospital. It is the only ACS Level I designated trauma center with pediatric designation in Western New England. It has over 650 beds, 34 surgical suites, and performs approximately 2,000 trauma evaluations per year. Residency and fel- lowship programs include medicine, surgery, anesthesiology, radiology, pediatrics, obstet- rics/gynecology, emergency medicine, and pathology. Baystate Medical Center serves as the regional referral center for Western New England.

If you would like more information, or would like to be considered for this and other opportunities, please submit your CV to: John Larson, Senior Manager, Physician Recruitment 759 Chestnut Street, S1571, Springfield, MA 01199 Email: [email protected]; Phone: 413-794-2571; Fax: 413-794-5059 EOE/AA

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