Inspire SGIM Inform To Promote Improved Vol. 31 Connect Patient Care, Research, and Education in Primary Care and Num. 6 FORUM General Internal Medicine June 08 The Society of General Internal Medicine

FROM THE REGIONS The Safety-Net at Risk Elizabeth A. Jacobs, MD, MPP

Dr. Jacobs is Associate Professor of Medicine, Stroger Hospital of Cook County and Rush University Medical Center. She is also a Deputy Editor of JGIM, a member of the SGIM Health Disparities Task Force and Health Policy committees, and a former council member of the Midwest region of SGIM.

CONTENTS he past two years have not been good for public hospitals in the TUnited States. The traditional safety-net institutions that provide care 1. From the Regions for the most disadvantaged in our major urban centers are coming 2. This Month in JGIM under increasing pressure—and some are cracking. Martin Luther King, 3. President’s Column Jr.-Harbor General Hospital in Los Angeles closed after losing certifica- 4. Abstractions tion with the Centers for Medicare and Medicaid Services (CMS), its 5. Innovations major source of revenue. Two-storied public hospitals, Grady Memorial Hospital in Atlanta and Stroger Hospital in Chicago (formerly known as 6. In Training Cook County Hospital), have both faced dramatic financial crises. While 1 7. Morning Report the cause of these crises is multi-factorial, a common thread is inade- 8. Funding Corner quate oversight by the elected officials responsible for these hospitals’ 9. Funding Opportunities financial health. 10. Endgame In the case of Martin Luther King, Jr.-Harbor General Hospital, County Supervisors had known for at least four years that the hospital Heading to the Finish Line was at risk of losing its certification with CMS, yet they failed to com- Remember summer camp? Most of the mit the resources needed to bring the quality of care up to a level that week was highly organized, but several both assured patient safety and satisfied CMS. The story of Grady is hours were set aside for "free choice." more complex, but fiscal mismanagement on the part of the politically For many of us, this was our favorite appointed governance board is an important part of the story. The gov- time. This issue of Forum represents ernance board did not enforce recommended cost-cutting or provide ad- the second-to-last issue for the current editorial team. To commemorate the equate oversight of revenue generation, contributing to its mounting impending transition, we gave our 25 deficit. In a frequently cited example, one in five Medicaid bills over the associate editors license to break from past three years was kicked back to Grady because they were improp- the usual structure of their columns. In erly filed. Similarly, the Cook County Bureau of Health lost a large por- other words, free choice. Some of them tion of its revenue after a planned phase-out of federal funding took took us up on it. We hope that you like effect. Despite the fact that the Cook County Board knew about this the results and that you will join us in pending loss of $50 million in annual revenue for four years prior, billing thanking our wonderful associate editors for Medicare and Medicaid services was not put in place until after the for sustaining the Forum for three phase-out. As a consequence of the resulting gap in funding, services exciting years. and jobs were dramatically cut and the budget reduced 11% over a —Rich Kravitz, span of a few months. Malathi Srinivasan, Tina Slee continued on page 11 THIS MONTH IN JGIM I’ll Write a Non-peer-reviewed Article Any Day Adam J. Gordon, MD, MPH, FACP, FASAM SOCIETY OF GENERAL INTERNAL MEDICINE s I close out my term as the As- Two surprises happened over OFFICERS Asociate Editor of the SGIM the years: not one potential intervie- President Forum, I am happy to reflect. My wee turned down being interviewed Lisa V. Rubenstein, MD, MSPH North Hills, CA [email protected] (818) 891-7711 role as editor of the “This Month in for a featured TMIJGIM piece, and President Elect JGIM” (TMIJGIM) column has been not one potential interviewee asked Nancy A. Rigotti, MD Boston, MA productive, invigorating, and re- to be “co-author” on the TMIJGIM [email protected] (617) 724-4709 warding. Too bad my academic in- SGIM Forum article. The latter sur- Immediate Past-President stitution is less excited about my prise, co-authorship, involved a Eugene Rich, MD Omaha, NE [email protected] (202) 887-5150 work in this role: I should have debate among the SGIM Forum edi- Treasurer been working on my research and torial staff when TMIJGIM origi- Jeffrey Jackson, MD, MPH Bethesda, MD publishing my own peer-reviewed nated: Should we “offer” a [email protected] (202) 782-5603 work. co-authorship to every interviewee? Secretary Through 18 TMIJGIM articles In the end, we decided to offer this Valerie Stone, MD, MPH Boston, MA [email protected] (617) 726-7708 over three years, I have explored if the interviewee requested it. No Secretary Elect with corresponding authors who interviewee did. Monica L. Lypson, MD Ann Arbor, MI have published their work in the Perhaps interviewees recognized [email protected] (734) 764-3186 Journal of General Internal Medicine that the SGIM Forum was not a COUNCIL (JGIM) the origins of their research, peer-reviewed publication and co- Marshall Chin, MD, MPH their research career, and the trials authorship would not be “valued” Chicago, IL and tribulations of original clinically by their academic institutions—even [email protected] related investigations. I found it though the publication was about (773) 702-4769 easy to communicate with the cor- their work and their experiences. Karen DeSalvo, MD, MPH, MSc New Orleans, LA responding authors. They seemed As an academic clinical investi- [email protected] to be excited about having their gator, like many of the interviewees (504) 988-5473 work featured in another format for the TMIJGIM column, I recog- Arthur G. Gomez, MD outside of JGIM. nize that peer-reviewed published Los Angeles, CA [email protected] The TMIJGIM piece was much literature is the “currency” of an (818) 891--7711 more about the interviewee and academic career. In the tenure and Said A. Ibrahim, MD, MPH their work than my “review” or in- non-tenure streams, promotions are 2 Pittsburgh, PA terpretation of the work. Often the judged primarily with the number [email protected] (412) 688-6477 TMIJGIM articles had more expres- and quality of peer-reviewed publi- Laura Sessums, MD, JD sions from the author-interviewee as cations and peer-reviewed grants. Washington, DC quotes than my original thoughts. Reflecting on my recent promotion [email protected] experience, I dutifully catalogued all (202) 782-5560 EX OFFICIO COUNCIL MEMBERS my peer-reviewed articles regarding Donna L. Washington, MD, MPH Los Angeles, CA Regional Coordinator “quantity” (primarily the number) [email protected] Donald Brady, MD Atlanta, GA and the “quality” (the nebulous (310) 478-3711 ext. 49479 [email protected] (404) 616-31171 journals’ impact factors). In the clini- ACGIM President cal-educator’s world, peer-reviewed Health Policy Consultant Frederick Brancati, MD, MHS Baltimore, MD Lyle Dennis [email protected] (410) 955-9843 case reports and original research Washington, DC are also valued extremely highly by [email protected] Editors, Journal of General Internal Medicine Martha S. Gerrity, MD, PhD Portland, OR promotion committees. Many pro- Executive Director [email protected] (503) 220-8262 motion committees are not similarly David Karlson, PhD Ext. 55592 asking for quantification or quality 2501 M Street, NW, Suite 575 William M. Tierney, MD Indianapolis, IN Washington, DC 20037 [email protected] (317) 630-6911 factors of their faculty’s non-peer- [email protected] reviewed publications. (800) 822-3060; Editors, SGIM Forum (202) 887-5150, 887-5405 Fax Rich Kravitz, MD, MSPH Sacramento, CA Why not? [email protected] (916)734-2818 Director of Communications Non-peer-reviewed publications Malathi Srinivasan, MD Sacramento, CA and Publications [email protected] (916)734-7005 include commentaries and opinions, Francine Jetton letters to the editors, print or Washington, DC Associate Member Representative [email protected] Hannah E. Shacter St. Paul, MN web-based reviews, book chapters, (202) 887-5150 [email protected] (612) 963-6813 editorials, and even SGIM Forum continued on page 13 PRESIDENT’S COLUMN What Does it Take to Make a Difference: SGIM at the Crossroads Lisa Rubenstein, MD SGIM Despite national results showing internal medicine training at the top EDITORS IN CHIEF Rich Kravitz, MD, MSPH [email protected] of student quality ratings, more than Malathi Srinivasan, MD [email protected] 80% of our students are choosing MANAGING EDITOR Christina Slee, MPH [email protected] specialist careers. ASSOCIATE EDITORS hen the call came telling me and Rich) and their Councils had de- Abstractions Jeff Jackson, MD, MPH [email protected] W I’d been elected President, I veloped the basis for linking SGIM’s ACGIM didn’t know whether to be thrilled numerous activities into a more co- Anna Maio, MD [email protected] or terrified. Having not been on herent, agile whole by creating Ask Expert Council for several years, I won- three core mission committees (for Nina Bickell, MD, MPH [email protected] dered what I would find when I research, education, and clinical Carol Horowitz, MD, MPH [email protected] joined the SGIM leadership team. practice). SGIM’s Big Tent (de- Ethan Halm, MD, MPH [email protected] Would I find low spirits and red- scribed by Gene Rich in previous Disparities in Health lined budgets, reflecting the dimin- presidential columns in Forum) had Said Ibrahim, MD, MPH [email protected] ishing workforce and unrealized been fortified to continue sheltering From the Regions Keith vom Eigen, MD, PhD, MPH [email protected] dreams GIM currently confronts in hospitalists, geriatricians, end of life From the Society the United States? Or would I, on care experts, women’s health ex- Francine Jetton [email protected] the other hand, find false cheer be- perts, public health leaders, and Funding Corner cause academic GIM survives, de- others whose special work was not Preston Reynolds, MD, PhD [email protected] spite the burdens on our students specifically called out in SGIM’s Joseph Conigliaro, MD, MPH [email protected] and workforce? founding documents but who ac- Human Medicine I’m happy to report that I found knowledge the critical role of our Linda Pinsky, MD [email protected] neither. Instead, I found the same generalist organization in fostering Innovations vibrant, creative spirit that has char- their work and careers. The Health Paul Haidet, MD, MPH [email protected] Haya R. Rubin, MD, MPH [email protected] acterized our field since its incep- Policy Committee had reorganized Rachel Murkofsky, MD, MPH [email protected] tion in the mid 1970s, leavened and engaged an expert consultant In Training with the sophistication gained over organization capable of supporting Karran Phillips, MD, MSc [email protected] the years as increasing numbers of expanded member policy involve- Hannah Shacter [email protected] 3 our members have led major re- ment and advocacy. The Communi- Kristofer Smith, MD, MPP [email protected] search, educational and clinical pro- cations Committee had sponsored Heather Whelan, MD [email protected] grams, and organizations. I found a a revised, accessible SGIM web Morning Report Mark Henderson, MD [email protected] vigorous, engaged organization that page ready to house expanded Craig Keenan, MD [email protected] had found financial stability through content and interaction with mem- Catherine Lucey, MD [email protected] the efforts of its members, rather bers. We had promoted electronic Policy Corner than pharmaceutical funding. I decision support for generalists in Mark Liebow, MD, MPH [email protected] found a dedicated, flexible, and their clinical offices. Regional and President’s Column highly competent SGIM central of- international SGIM leaders had ex- Eugene Rich, MD [email protected] fice team that sought to interpret panded their research into their This Month in JGIM and implement Council and mem- communities. Adam Gordon, MD, MPH [email protected] ber priorities. I found the same So here we are, at the cross- VA Research Briefs Geraldine McGlynn Med [email protected] commitment to diversity, equity, roads. What does it take to make a and quality of care that had drawn difference? We have a wonderful, The SGIM Forum is a monthly publication of the Society of General Internal Medicine. The mission of The SGIM Forum is me to SGIM as a trainee so many sound organization, comprised of in- to inspire, inform and connect—both SGIM members and those years ago. I found that the unreal- credibly dedicated and creative indi- interested in general internal medicine (clincal care, medical education, research and health policy). Unless specifically noted, ized dreams of the ’90s had simply viduals ready to provide the the views expressed in the Forum do not represent the official become instruction for the new generalist clinical care, education, position of SGIM. Articles are selected or solicited based on topical interest, clarity of writing, and potential to engage the dreams of today. and research our world so desper- readership. The Editorial staff welcomes suggestions from the readership. Readers may contact the Managing Editor, Co-Editors I observed that SGIM’s organiza- ately needs. But can we rest on our or Associate Editors with comments, ideas, controversies or tional structure had been adjusted laurels? We know that GIM and re- potential articles. This news magazine is published by Springer. The SGIM Forum template was created by Phuong Nguyen in subtle but powerful ways. The lated generalist fields potentially ([email protected]). two previous presidents (Centor continued on page 13 ABSTRACTIONS One Physician’s View on War Jeff Jackson, MD

The views expressed in this editorial are those of the author and do not reflect those of the Department of Defense or the US Army.

ll perspectives on war are dis- old; my daughter is 15. I know what than 20 minutes. They used all the Atorted. Only those who survive it’s like to be on the receiving end of modern technology available. He was tell their stories; the voices of the surliness. Forty percent of amputees immediately placed in hypothermia dead are silenced forever. The hero hope to remain on active duty, and and had a craniotomy and lobectomy. returns to acclaim. But who speaks 20% will be allowed to do so. More He survived his immediate injury and for those who return in a pine box? than 20 have returned to combat in was evacuated to Germany and then Only the dead can tell whether the Iraq. Last year, 36 amputees ran in to my institution, where he was on cause was sufficiently noble to be the Marine Marathon. Particularly for my team waiting placement in a VA worthy of the sacrifice. None among lower extremity amputees, the pros- TBI center. His wife was constantly the living can be so presumptuous as theses are amazing. In jeans, you at his bedside, sleeping in the room. to speak for them. Who tells the tale can’t tell. My wife has stopped lifting She looked for any sign of improve- of the children whose only memory weights with me in the gym. It dis- ment, no matter how small. During of their father or mother is a picture tresses her to see young men and his entire stay with us, he never over the mantelpiece? The daughter, women, many still struggling with demonstrated more than minimal re- who sits at home when her Brownie teenage acne and wearing the ubiq- sponsiveness to painful stimuli. Each troop has a father-daughter dance. uitous iPod, working out with their morning I’d look in her hopeful eyes The son, whose father will not coach one remaining arm or on one or two and hear her tell about her hopes and his little league team. Who tells the prosthetic legs. She finds it hard not aspirations. I’d hear that he’d terror of the young Iraqi mother hud- to burst into tears or run over and “looked at her” last night when she dled with her children in her home in hug them. She wants to hold them tenderly spoke his name. He’d Basra? She knows that bullets and close and tell them they’re going to “smiled” when she told him about bombs are dispassionate dispensers be okay. She wants to comfort them. their children. He’d “squeezed her of injustice. The good and the virtu- She wants to talk to them, hear their hand” when she told him that she ous die just as easily and inevitably stories, help them heal. Usually she loved him. Some days I’d go to my as the evil and perverse. Her priori- settles on not staring and giving office, close my door, and weep. I ties are not those of global terrorism; them brave smiles. She knows the knew in my heart that he was never she’s just hoping to raise a family, limits of human dignity, and it’s not going to improve. If it had been me, see her children grow, live to a happy her place to intervene. But she feels I’d rather have died in Iraq than re- 4 old age. hollow and sad and somehow guilty turn in such a state. Some days it’s hard to go to for having two healthy teenagers and In the last Great War, the aver- work. Today’s soldiers wear body just avoids the gym. age combat soldier was in his thir- armor and carry tourniquets into bat- My institution has its finger on ties. Today’s soldier is typically in his tle. These tourniquets are technolog- the pulse of the war. When Muqtada twenties. Old men make the deci- ical marvels; they’re simple to use al-Sadr declared a truce, the number sion to go to war, but the young do and can be applied with one hand. of amputees waiting at the elevator the fighting and the dying. The re- Consequently, we’re seeing a lot of plummeted. Some days lately, every- turning youth are not just losing amputees. So far, my institution has one waiting at the elevator has all their limbs and their innocence; treated more than 800 amputees. their limbs. My son is 17 years old; we’re seeing marked increased Some days it’s hard to get on the el- my daughter is 15. It’s hard to not rates of PTSD and other psychologi- evator because of all the 18- or 19- imagine them waiting by the eleva- cal sequella. The scars of this con- year-olds in wheelchairs being tor in a wheelchair. flict are deep. It’s not just the pushed around by their 17-year-old Recently I was attending on the soldiers but their families who are girlfriends or their moms. My son is wards and we had a “TBI.” He was paying the price. It’s a price our na- 17 years old; my daughter is 15. my age, slightly graying, slightly tion will be paying for decades to These young men and women paunchy. He had a lovely wife and come. I hope history will judge the are not morose. They’re patiently two teenage children. He was hit by cause to have been worthy. waiting for the elevator, chatting with an AK-47 round in the right temple. SGIM their friends, like teenagers any- Through the miracle of battlefield where. Sometimes I smile when medicine and the marvel of forward To provide comments or feedback about they say something particularly surly deployed neurosurgical teams, the Abstractions, please contact Jeff Jackson at to their mom. My son is 17 years total time from injury to OR was less [email protected]. INNOVATIONS What the Cats Listen To Paul Haidet, MD

hen we SGIM Forum editors Things. Coltrane was one of the a conductor. Teaming up with Wdiscussed our ideas for the greatest saxophonists of all time drummer Shelly Manne on this last issue this particular team would and was on a spiritual journey disc, Previn is at his bluesy, produce, we were looking to do during the 10 years between sophisticated, and charming best. something different, something 1957 and his death in 1967. • Charlie Parker with Strings. original, something that shared a bit This 1961 disc is one of his best Saxophonist Parker and of our passions and ourselves. As selling. trumpeter Dizzy Gillespie pretty the Innovations in Medical Educa- • Quincy Jones: The Birth of A much invented the way jazz is tion columnist, I have had the plea- Band. Before Quincy became the played to this day. This disc sure of finding some really cool famous producer of Michael gives a good introduction to the stuff in residencies and medical Jackson, the Brothers Johnson, beautiful tone and harmonically schools over the past three years Patti Austin, and others, he was a advanced, sophisticated solos and sharing this with my SGIM col- fabulous arranger and big band that Parker seemed to so leagues. In my own work during leader. This is one of my all-time- effortlessly produce. this time, I have been engaging my favorite swing albums by a really • Sarah Vaughn (with Clifford lifelong passion for jazz music by tight big band. Brown). “Sassie,” as Vaughn was writing about and developing educa- • Bill Evans Trio: Waltz for Debby. known, had a five-octave range, tional sessions about improvisa- This trio, along with the mid- perfect pitch, and was one of the tional skills in medicine. I use jazz sixties Miles Davis Quintet, is first jazz singers to use phrasing music as a metaphor for medical generally regarded as one of the like an instrumentalist. Check out communication during these ses- most empathic groups in jazz her interplay with trumpeter sions, and we usually manage to lis- history. The way that Bill Evans Brown on these tracks. ten to some Miles Davis, John (the pianist) and Scott LaFaro • George Benson: Good King Bad. Coltrane, and others along the way (the bassist) improvised, it was This was the album that started (more about the notion of improvi- hard to tell who was leading and it all for me. When I was 10, my sation in medicine is available in who was following; they older brother used to play this Ann Fam Med 2007;5:164-169). musically communicated and while getting ready to go out Usually, at the end of one of my listened so well. with his high school friends, and sessions, at least two or three peo- • Spyro Gyra: Catching the Sun. I used to sit outside his bedroom ple come to talk to me. They don’t ‘Smooth jazz’ seems to be all listening through the door; I 5 want to talk about anything in par- the rage these days; however, if was mesmerized by the funky ticular with respect to communica- you want to hear some classics grooves. tion, but they do want me to share with really tasty melodies, check with them information about music out any of the late ’70s/early And a bonus for the adventurous: played during the session and what ’80s Spyro, David Sanborn, or CDs they should go out and buy to Grover Washington discs. This • John Coltrane: A Love Supreme. get an introduction to jazz. So, for album (yes, I still have it on vinyl) This is Coltrane’s 1965 devotional this article, I will list my top 10 jazz is one of my faves. suite and one of the most CDs to get if you want to check out • Ella Fitzgerald and Louis sublime musical statements of all jazz, in no particular order. Enjoy! Armstrong. They made three time. If you ever find yourself on albums together, and all are one of the East Coast beaches, • Miles Davis: Kind of Blue. This is classics. There’s also a try going out early in the morning one of the largest selling jazz compilation disc. These discs and listening to this while albums of all time, recorded in give a good, well-recorded watching the sunrise. 1959. The legend about this disc example of Louis’s playing and is that Miles walked in with the singing, which in one way or It has been an honor for me to parts written on little slips of another pretty much influenced serve my SGIM colleagues over the paper and handed them out to all of American popular music in past three years. the band. The band had never the 20th century. SGIM played the songs before but just • Shelly Manne: My Fair Lady. sat down and produced this What most people don’t know To provide comments or feedback about masterpiece in one take. about Andre Previn is that he Innovations, please contact Paul Haidet at • John Coltrane: My Favorite was a jazz pianist before he was [email protected]. IN TRAINING “Pearls” Are Not Just for Special Occasions Heather Whelan, MD

Heather Whelan, MD, is a fellow in General Internal Medicine/Medical Education, NYU School of Medicine, Division of General Internal Medicine, VA.

few years ago, the book Men tions between transferring and ac- Aare from Mars, Women are from cepting physicians. The style of this Venus attracted a lot of popular at- communication is often the direct Why is it that we strive to tention. It seemed to hit a chord in opposite of the collaborative, re- treat our patients with the collective American soul about spectful “PEARLS” approach. The the difficulties encountered by men absence of a mindful and respectful respect but shower distain and women in every day communi- approach to communication in on our colleagues, on cation. A similar discussion about these exchanges reflects the lack of the need to improve physician-pa- importance that has been placed on whom we depend so tient communication is now occur- interprofessional dialogue, but it heavily to help us provide ring in both the medical and lay also reflects underlying attitudes communities. Multiple studies have and forces including resentment, high-quality care? shown a plethora of benefits result disdain, frustration, and exhaustion. from improved communication— I can quote a litany of examples better medication adherence, more from my own and my colleagues’ satisfied patients, more efficient inpatient attending experiences. In time management for physicians. more instances than I would like to The list goes on. recall, my time and energy has colleagues, on whom we depend so The value of good communica- been spent trying to manage the heavily to help us provide high-qual- tion has become so apparent that dysfunction of my team’s dynamics. ity care? Is it because we are all many medical schools now make Team members demonstrate overt overwhelmed and lack the energy this a fundamental part of the cur- disrespect and complete lack of em- and emotional reserve to make the riculum for first-year medical stu- pathy for one another. Instead of effort? Is it because we assume dents. They learn communication partnership or support, they are that other physicians should know gems such as “P-E-A-R-L-S: Part- more likely to show the opposite the same medical facts that seem nership, Empathy, Apology, Re- with the elegant Ask-Tell-Ask sand- “basic” to us, when in fact they are spect, Legitimization, and Support” wich chopped up into the Tell-Tell- not basic to all of us? Or is it be- 6 to build and sustain trusting rela- Tell-then-Tell-Some-more leftover cause it simply has not occurred to tionships with patients and “Ask- casserole. In our impatience to say many of us that applying the same Tell-Ask” strategies to accurately what we feel is important—when it principles of respect might actually assess patient understanding, effec- is convenient for us, without con- improve the collegial milieu of our tively educate, and collaboratively sidering the other participants in the daily interactions, resulting in im- determine treatment plans. The conversation—we run the risk of proved education, better patient hope is that students will learn and damaging ourselves, our learners, care, and, dare we hope it, apply these skills, see them mod- our colleagues, and potentially more fun? eled by mentors and supervising our patients. It may be that men are from physicians throughout their early Consider the following all-too- Mars and women are from Venus. learning, and make them a funda- common scenario—an intern is ver- I’m not sure how to assign plane- mental part of their future practice. bally abused by a consultant for tary communication roles in the Unfortunately, they are less likely to some perceived mismanagement. medical universe. I do know, how- see these behaviors modeled in The result is disrespect and dislike ever, that sometimes it seems like physician-to-physician interaction. for the consultant, reluctance to call “War of the Worlds” in our medical This seems to be a blind spot in our that consultant in the future, and a environment. I, for one, am going to outlook on improving medical com- missed teaching opportunity on the wear my “PEARLS” to work every munication. Unfortunately, this consultant’s part that might save day in the hope of changing that. means we keep stumbling. him or her an inappropriate consult SGIM Physician-to-physician communi- in the future. cation takes place within academic So why is this? Why is it that To provide comments or feedback about In inpatient teams, during discussions we strive to treat our patients with Training, please contact Heather Whelan at with consultants, or in conversa- respect but shower distain on our [email protected]. MORNING REPORT The Seeds of Discontent Michael Langan, MD, and Catherine Lucey, MD

n 18-year-old male was brought Jamestown, Virginia, in 1676.1,2 For- Ato the emergency department mally known as Datura stramonium, by EMS for mental status changes. it is currently found throughout the The anticholinergic toxidrome On the day of presentation, his par- eastern and midwestern United ents found him confused, combat- States from Florida into Canada. Its is classically represented as ive, and hallucinating. It was also toxicity is related to the plant’s po- being “Mad as a Hatter, Hot noted that he had been vomiting tent anticholinergic properties sec- and felt “warm.” The patient was ondary to the presence of as Hades, Dry as a Bone, Red intubated for airway protection and belladonna alkaloids such as as a Beet, and Blind as a Bat.” admitted to the MICU for further hyoscyamine, hyoscine, atropine, evaluation and management. and scopolamine.3 These toxins pro- According to history provided by duce their effects by competitive in- family, the patient was previously hibition of acetylcholine at healthy. He was taking no medica- muscarinic receptors both centrally tions and had no known drug aller- and peripherally.4 Toxic effects are because of anticholinergic proper- gies. He had a history of marijuana thought to be dose-related to at- ties that can intensify the crisis.2 use. Review of systems confirmed ropine, with ten seeds containing The use of physostigmine as an that the patient was in his baseline approximately 1 mg of atropine.1,3 antidotal acetylcholinesterase in- state of health earlier that morning. The anticholinergic toxidrome is hibitor remains controversial. Multi- There was no exposure to sick con- classically represented as being ple relative contraindications in the tacts. However, further history re- “Mad as a Hatter, Hot as Hades, setting of reactive airway disease, vealed that he had recently been Dry as a Bone, Red as a Beet, and intestinal obstruction, epilepsy, or working in the garden with his par- Blind as a Bat.” This is further char- cardiac conduction pathologies have ents and that his mother reportedly acterized by agitation, confusion, limited the drug’s utility.2,4 Case re- saw “seeds” in his emesis. hallucinations, anhydrotic hyperther- ports have also documented in- Vital signs revealed a tempera- mia, dry mouth, nonreactive mydria- duced asystole in the setting of TCA ture of 99.4, tachycardia of 110, and sis, blurred vision, urinary retention, overdose.4 Physostigmine should be a blood pressure of 142/77. He and potential coma. Jimson Weed reserved for extreme cases of anti- moved extremities spontaneously toxicity may be manifest by any or cholinergic toxicity in conjunction but was unable to follow com- all of these findings. Decerebrate with consultation with a toxicologist 7 mands. Skin was warm and dry. posturing, electroencephalogram or regional poison center. Pupils were significantly dilated and changes, and PT prolongation with The patient in this case pre- sluggishly reactive to light. The rest elevated liver enzymes have also sented with symptoms consistent of his neurological exam was no- been reported in the literature.1,3 No with the anticholinergic toxidrome in table for symmetrical bilateral hyper- guidelines exist for monitoring these relation to recent ingestion of Jim- reflexia in upper and lower parameters. son Weed seeds. Supportive mea- extremities. The remainder of the Once the airway, breathing, and sures were provided, and the physical exam was normal. circulation are stabilized, therapeutic patient was extubated with excel- Metabolic profile and CBC were interventions center on cardiopul- lent clinical improvement within 24 normal. A drug screen was positive monary supportive measures. Pa- hours. The toxic ingestion of a for scopolamine. Emesis provided tients may require cooling blankets “handful” of seeds was confirmed from the scene did reveal the pres- for hyperthermia and placement of post-extubation. ence of numerous seeds consistent a urinary catheter if urinary reten- with Jimson Weed. tion occurs.1-3 Gastrointestinal de- Summary contamination with activated • Jimson Weed is a naturally Discussion and Treatment charcoal is still widely accepted occurring plant that can cause The name”Jimson Weed” is with consideration given to airway serious anticholinergic toxicity actually a product of dialect from its precautions.2,4 Benzodiazepines because of the presence of original name “Jamestown Weed,” have been utilized for agitation and belladonna alkaloids. which was one of the first recorded seizures; high doses are often re- • Anticholinergic toxicity is cases of the plant’s toxicity in a quired.4 Phenothiazines and buty- classically represented as being group of British troops at rophenones should be avoided continued on page 11 FUNDING CORNER The VA Genomics Research Initiative: An Emerging Opportunity for General Internists P. Preston Reynolds, MD, PhD, FACP

n 2006, the Department of Veter- Ethics, Public Health, and Environ- health. The commitment to collabo- Ians Affairs (VA) launched the VA mental Hazards. Early initiatives in- ration among VA scientists and in- Genomic Medicine Program to ex- clude establishment of a VA vestigators and their affiliated amine the potential of emerging ge- Genomics Banking program that academic medical systems opens nomic technologies to optimize and has collected already DNA samples the door for large-scale research improve the safety and efficacy of from 25,000 veterans and a Phar- programs in regions and throughout medical care for veterans. The VA macogenomics Analysis Laboratory the nation. has begun building infrastructure in Little Rock, Arkansas. The first While perhaps surprising to and now seeks to understand more clinical studies will be in the areas some, that door has begun to about veterans’ knowledge, atti- of post-traumatic stress disorder, swing open in the area of HSR&D tudes, and beliefs about genetics serious mental illnesses (e.g., bipo- with seven pilot projects funded in and genomics and their willingness lar diseases), and amyotrophic lat- FY08, and more to come in subse- to participate in research. The VA eral sclerosis. quent years. also is in the process of assessing Some of the HSR&D research These small initiatives funded the need for educational activities questions in the area of genomics with $150,000 in end-of-year related to genetics and genomics include: 1) Should screening guide- monies will: for patients and providers. All this lines for a disease be changed represents a sizable opportunity for based on genetic risk for disease? 1. Develop pharmacogenomic general internists to apply their If so, at what level of risk, and does decision support tools (Palo training and expertise in clinical and this change in screening recom- Alto), health services research, patient ed- mendations improve health out- 2 Pilot instruments to measure ucation, and faculty development. comes?; 2) Does increased risk for veteran and family knowledge The VA offers an excellent plat- disease based on genetic informa- and attitudes about genetics form for genomic research because tion enhance behavior and lifestyle issues (Minneapolis), it provides medical care for a large change of an individual patient 3 Develop genomic medicine population of patients (5.5 million) and/or family member?; 3) Is ge- delivery models that incorporate who are followed longitudinally netic testing cost effective and, if family history and genetic tests within one health system. This so, for what diseases?; 4) Is there (Greater LA), 8 health system is comprised of 153 evidence that genetic testing is in- 4 Understand barriers to applying hospitals and 718 outpatient clinics dicated before starting a patient on genomic information in VH as well as nursing homes, rehabilita- a certain medication and, if so, clinical care (San Antonio), tion treatment programs, and coun- should genetic testing be per- 5 Evaluate health services seling centers. More importantly, formed on every patient starting genomics to primary care though, it boasts a system-wide the medication? The VA HSR&D interventions (Durham), electronic health record (EHR) that program in genomics is interested 6 Establish models to translate includes virtually all clinical informa- also in understanding patient, clinical genomics to health care tion—an essential ingredient in ge- provider, and organizational needs delivery systems (Ann Arbor), nomic health services research. for information as well as the barri- and The VA Genomic Medicine Pro- ers and challenges confronting 7 Qualitatively and quantitatively gram’s research arm has emerged those who seek to deliver evi- document VA genomic services from the Office of Research and dence-based genomic care. and develop an evidence-based Development (ORD) and thus will Ultimately, the VA Genomic conceptual framework to inform include biomedical lab services, Medicine Program provides the op- VA policy. clinical science research, rehabilita- portunity to link genetic information tion R&D, and health services re- from DNA analyses with clinical in- The future has arrived and is search. The Genomic Medicine formation in the VA EHR to under- here to stay. SGIM Advisory Committee meets three stand the clinical expression of times a year and engages the lead- genetic predispositions in the gen- To provide comments or feedback about ership of Patient Care Services, eral population and to better define Funding Corner, please contact Preston ORD, and the National Center for treatments to optimize veterans’ Reynolds at [email protected]. Funding Opportunities Showcase Compiled in April 2008 by Sunil Kripalani, MD, MSc, and Raquel Charles, MD Agency Proposal Name Content Max. Due URL or Contact Amount Federal Grants

NIDA Epidemiology of Drug Epidemiologic research to Varies R01: 6/05/08, http://grants.nih.gov/grants/guide/ Abuse (R01, R03, R21) understand the nature, extent, 10/05/08, 2/05/09 pa-files/PA-08-124.html consequences, and etiology R03/R21: (also PA-08-125 and PA-08-126) of drug abuse across 6/16/08, 10/16/08, individuals, families, age 2/16/09 groups, gender, communities, and population groups

NIH Symptom Interactions Observational or Varies R01: 6/05/08, http://grants.nih.gov/grants/guide/ (various) in Cancer and Immune intervention research 10/05/08, 2/05/09 pa-files/PA-08-121.html Disorders (R01, R21) targeting interacting R21: 6/16/08, (also PA-08-122) symptoms associated with 10/16/08, 2/16/09 cancer or an immune disorder

NIH Methods for Prevention Research to advance the Varies 9/07/08, 1/07/08, http://grants.nih.gov/grants/guide/ (various) Packages Program (R01, scientific understanding of 5/08/09 pa-files/PA-08-107.html R03, R21, R34) secondary HIV prevention (also PA-08-108, PA-08-109, and PA-06-248) Foundation Grants

EDS Foundation Educational technology Varies 6/30/08, 10/13/08 http://www.eds.com/about/ solutions, health & human community/foundation/ services

National Patient Safety Foundation Patient safety $100,000 7/23/08 (letter of http://www.npsf.org/r/pd/ (NPSF) intent)

Henry J. Kaiser Family Foundation Health policy, media, and $50,000 9/1/08 http://www.abmrf.org/grants.htm public education

9 ENDGAME Look Both Ways Geraldine McGlynn, MEd, and Evangeline McGlynn, BS

Ms. McGlynn is associate editor for Forum’s VA Research Briefs. Evangeline McGlynn is her daughter.

ur 21-year-old daughter Eve was speak briefly to her. She seemed ex- seven days. While personally mad- Oliving and working in Atlanta for hausted and confused. She did not dening, wasn’t this a very expensive, just about four months when we re- recall if she had been seen by a doc- if not risky, approach? The doctor ceived a phone message that she tor since she got to the room or if said that there was no medical evi- had been in an accident. We imme- anyone had spoken to her about dence that indicated it was a prob- diately phoned and were connected surgery. She said a nurse had asked lem to leave Eve’s arm splinted as it to a hospital Emergency Room. The her to sign something but said it was for a week to ten days. I quietly ER nurse told us that Eve had been seemed complicated so she had told wondered about medical evidence brought in by ambulance after hav- the nurse that she would wait for her related to hospital infections, bed ing been struck by a car while cross- parents to arrive and review it with sores, or possible drug complica- ing the street on her way home her. The nurse left with the form. I tions. When asked what he would do from work. Eve was stable and con- explained that the form may have if his daughter were in this same sit- scious, and they were still running a been a consent form for the surgery uation, he replied that he would not battery of tests. Thus far they had and that if she could, she should try be in this situation because he was a confirmed that she had a concus- to get someone to read it to her and surgeon and so could do it himself. sion, a broken radius and humerus answer her questions, and then she Again we were stunned. in her left arm, badly bruised legs, should sign it. After the call, I left for We asked about transferring Eve and multiple cuts and bruises. Test my flight. to another hospital that might be able results for internal bleeding and My husband arrived and found to perform the surgery sooner. We head injury were pending. It was a Eve in a bed with a splinted arm, were informed that according to hos- parent’s worst nightmare. morphine drip, and a urinary catheter. pital policy, the only way to have her In between our calls to gather She was pleased to see him. The transferred was for us to find a doc- test results, we were desperately doctor was paged, and an orthopedic tor from another hospital that would trying to make travel plans to get to resident soon arrived. He told my call and ask for her by name and re- Atlanta from our home in Boston dur- husband that since Eve had been ad- quest the transfer. Transfer paper- ing the busiest travel time of the mitted she was no longer a trauma work would be involved, and it was, year—the Tuesday before Thanksgiv- patient. This seemed like good news. after all, a holiday weekend. Since we ing. As evening turned into night, Wrong. He went on to say that there were not familiar with the area, we Eve’s prognosis began to look better. were no more scheduled vs. trauma asked for suggestions of hospitals or 10 The CAT scan was clear, and there surgical slots for that day. The next practices we might contact. The resi- were no signs of internal bleeding. day was Thanksgiving Day, and there dent said he was unable to provide Our travel prognosis was not as was no scheduled surgery on a holi- us with any recommendations (hospi- good. We were unable to fly to At- day. Furthermore, Friday was also tal policy) and that our best bet would lanta until morning—each at different considered a holiday at this particular be to look in the phone book, which times and on different airlines due to hospital, so no surgery could be he asked a nurse to give us. Of the holiday rush. The ER nurse and scheduled for Friday, and they never course Eve could sign herself out he orthopedic doctor were thorough and scheduled surgery on a weekend. In added; however, she would be leav- very patient with two distraught par- addition, since it was a long holiday ing against medical advice and thus ents who were trying to grasp the weekend, they would likely be would forfeit her medical insurance situation from so far away. The ER backed up with emergency surgeries coverage. We were trapped! doctor told us that he would stabilize on Monday and maybe Tuesday, so Through our phonebook research Eve’s arm and that she would require Eve’s best chance for her surgery we actually identified two under- surgery and would be admitted when would be Tuesday at the earliest but standing and empathetic doctors a bed became available. He brought probably not until next Wednesday. from different practices, but they too the phone to Eve’s bedside so we My husband was stunned as was I had constraints because of the holi- could briefly speak to her. She when I arrived shortly thereafter. We day weekend. One said he would sounded frightened but relieved to could not understand how it would shoot for a Saturday surgery, and the hear that we would be at her side in be acceptable medical practice to let other could do it on Sunday, but both the morning. a 21-year-old woman lie immobilized of course needed to coordinate the Early the next morning as my in a hospital bed, with two broken transfer paperwork, which they husband rushed to the airport I called bones, open wounds, and a urinary hoped could be accomplished on the hospital. Eve had just been as- catheter—requiring significant pain Friday but no guarantees. signed a bed, and I was able to medication—for five, six, or maybe continued on page 12 MORNING REPORT FROM THE REGIONS continued from page 7 continued from page 1

“Mad as a Hatter, Hot as Hades, Both Grady and Cook County United States. According to the Na- Dry as a Bone, Red as a Beet, hospitals have weathered these tional Association of Public Hospitals, and Blind as a Bat.” storms for now. Both are expecting their member organizations consti- • Treatment centers on supportive infusions of new funds—Grady from tute 2% of the nation’s hospitals, yet measures and benzodiazepines; private sources and Cook County they provide 25% of the nation’s un- phenothiazines and from a recent tax hike. In an ac- compensated care. Local communi- butyrophenones should be knowledgement of the problems ties are struggling under the burden avoided. with the current governance struc- of caring for the un- and under-in- • Physostigmine remains tures at these two institutions, nego- sured. Public safety-net systems are controversial in the setting of tiations for resources at both were going to continue to fail or will need anticholinergic toxicity. tied to agreements for substantial to dramatically cut back on services governance reform. In the case of in the coming years, leaving the References Grady, philanthropic organizations most vulnerable in our society with- 1. Shervette RE, Schyldlower M, et pledged to give $200 million to help out any place to obtain affordable al. Jimson “loco” weed abuse in keep Grady alive if the current gov- health care. We need a revolution in adolescents. Pediatrics 1979; erning board voted to transfer con- health care in the United States that 63;520-3. trol to a new not-for-profit includes a plan for how to care for 2. Clark JD. The history, governance board. In Cook County, everyone in our society regardless of complications, and treatments of the one vote needed to pass a tax local politics and revenue or a pa- jimson weed toxicity. Top Emerg hike was given in exchange for an tient’s ability to pay. In the mean- Med 2005; 27:295-301. agreement by the Cook County time, we need to recognize the 3. Mikolich JR, Paulson GW, Cross Board president to allow an indepen- importance of these safety-net insti- CJ. Acute anticholinergic dent governing board to take control tutions to our local communities and syndrome due to jimson seed of the ailing health system. In each health care systems. Without them, ingestion. Ann Intern Med 1975; case the goal was to reduce the role the health of the most vulnerable will 83:321-5. that political vagaries and corruption be jeopardized, and private health 4. Beno S, Osterhoudt KC, et al. An play in the health of these safety-net networks and hospitals will be put at exceedingly agitated patient. Ped systems and to increase the health risk as they struggle under the added Emerg Care 2004; 20:845-8. care management expertise repre- burden of caring for these patients. SGIM sented on the governing entities. SGIM While Grady and Cook County To provide comments or feedback about hospitals appear to be safe for now, To provide comments or feedback about From Morning Report, please contact Catherine these crises demonstrate how fragile the Regions, please contact Keith vom Eigen at Lucey at [email protected]. the health care safety-net is in the [email protected]. 11 ENDGAME continued from page 10

I called a few of my VA contacts clean, understaffed, and not se- the excellent trauma care. I am of for advice and help. Within a few cure—we had been approached sev- course very grateful to the surgeon hours I was given the cell phone eral times in the halls by and his team for conducting the number of the orthopedic surgeon of panhandlers, including in the surgical surgery on Thanksgiving that allowed the medical school affiliated with the waiting room. We began advocating us to get Eve up and out of the hos- Atlanta hospital. I felt terrible calling for discharge so we could bring Eve pital. I am very grateful to my VA on the night before Thanksgiving, but back to Boston for post-surgical contacts that provided me with key I was a desperate mother. He an- care. We found out what was re- information and support at our diffi- swered the phone, and I pled my quired and then went about tracking cult time. But I also feel uneasy. case. Like the resident earlier, he too down the various people who had to What if we did not have any contacts explained about trauma cases taking sign off, including PT, OT, and the and Eve had to stay in that bed for priority and the policy of the hospital doctor on call. We managed to get six or seven days before receiving regarding transfers, but since he was everything but a copy of the medical the care she needed? What is one to coming in later that night anyway, he records because they were paper do if one becomes sick over a holi- said would try to stop in and check records, and we could not obtain day or weekend? How do injured and on Eve. Early the next morning an copies over the holiday weekend. In- vulnerable people who are alone ne- OR nurse came to the nursing sta- stead we were given the phone gotiate through the health care sys- tion requesting to take Eve to the OR number of medical records depart- tem? What can be done to improve for surgery. We could not believe it! ment and told to call the following informed consent? What if one does The surgeon I had spoken to the week to request an application form. not know what questions to ask? night before had assembled a team (It would be four months before Eve As an epilogue, the following to conduct the surgery on Thanksgiv- received her records.) month, the Atlanta hospital was on ing morning! We flew home to Boston at the page one of the New York Times in The surgery went well, but we end of the weekend, and on Monday an article that touted the exceptional were still on edge. We did not want morning Eve was seen by our local ER trauma care but provided a fright- to experience post-surgical care with doctors for her orthopedic, neurologi- ening account of the hospital’s fiscal a skeleton staff over the long holiday cal, and primary care needs. She was and safety crises. SGIM weekend. In our short experience it given a prescription for antibiotics for was evident to us that the hospital’s hospital acquired infections. To provide comments or feedback about resources were dangerously Looking back on the experience, I Endgame, please contact Geraldine McGlynn at stretched. The large facility was un- have mixed feelings. I am grateful for [email protected].

12 THIS MONTH IN JGIM continued from page 2 articles. Many SGIM members are cians have been trained to be ex- emic physicians, need to interact often invited to author non-peer- perts in medicine, and SGIM mem- with society on its own terms. Non- reviewed work on these products. bers are more than likely to be peer-reviewed publications are a They must delicately balance the physician-leaders. Providing expert currency of this interaction. This time to produce these products opinion on the topics of the day type of currency can accomplish with peer-reviewed papers and (e.g., smoking bans in public places, change. grants. Other SGIM members tort reform, universal health insur- Finally, non-peer-reviewed work contribute original thoughts or ance) are what leaders of academic is valuable to academic physicians. commentaries but don’t seek to medicine should do. It is my opinion that faculty who publish—peer-reviewed journals Peers value non-peer-reviewed enjoy working on non-peer-re- contribute little space for this type articles. Take the TMIJGIM column. viewed projects are more likely to of thought. Interestingly, senior Over the years, I have received become physician-advocates. They members of the faculty are often many positive and engaging com- are advocates for their profession excited about writing an editorial or ments regarding this column. One and their patients. They speak out. writing a book—they already have article prompted a national grant or- They are willing to express opinions the necessary currency of peer-re- ganization to contact me to assist in that may be unpopular. Non-peer- viewed work and more protection contacting the interviewee for a po- reviewed work promotes debate within the institution (e.g., seniority, tential funding opportunity. In addi- and discourse. tenure), making pontificating in non- tion, over the years, I’ve published Peer-reviewed work is (and peer-reviewed work less risky. quite a few opinion pieces in the should be) the currency of acade- Despite the relative non-impor- Bulletin of the Allegheny County mic medicine. But non-peer-re- tance of non-peer-reviewed work Medical Society (Google it—you viewed work is an important in an academic clinician’s dossier, won’t find it in Medline!), which has conduit for opinion and expressions non-peer-reviewed work is valuable influenced local opinion leaders and of leadership. In monetary terms, if to the public, to peers, and the non-academic physicians. Now as peer-reviewed work is valued as academic faculty. president of that organization, I see highly as a dollar, then non-peer-re- Non-peer-reviewed work by aca- that the Bulletin provides an excel- viewed work should be considered demic physicians is valued by the lent conduit to inform the members, at least a quarter. SGIM values the public. When an academic physician non-members, and the public about SGIM Forum, a non-peer-reviewed steps out from behind the ivory what the Society is doing. Re- publication. However, the SGIM tower of academic medicine, the porters, politicians, and other key Forum’s value in academic medicine public receives expert knowledge. stakeholders ask me more about is less apparent. Letters to the editor or commen- my articles in this journal than my Why? taries in metropolitan newspapers latest peer-reviewed article in JGIM. SGIM 13 from academic clinicians are valued. Participating in non-peer-re- Interestingly, more people read this viewed work is akin to community- To provide comments or feedback about This work than a publication in a lower- based participatory research. If we Month in JGIM, please contact Adam Gordon tiered peer-reviewed journal. Physi- are to change society, we, as acad- at [email protected].

PRESIDENT’S COLUMN continued from page 3 offer the most rewarding careers in in different ways with, for example, needs and wishes? What unmet medicine and that these fields are how to maintain morale among needs of our field should SGIM aim the only solid foundation for a pressured, underpaid generalists or to meet? Surely, together, with feet healthy medical care system. Yet in with expanding the academic and placed firmly on our values of fair- the United States, we are watching research components of general in- ness and truth (including equity our health care system overspecial- ternal medicine. In the face of these for generalists!), we can take advan- ize, fragment, and become increas- exigencies, not using our organiza- tage of the tremendous opportuni- ingly inequitable. Despite national tion as effectively and energetically ties SGIM provides to make a results showing internal medicine as possible to promote generalist difference. SGIM training at the top of student quality goals may be unacceptable. ratings, more than 80% of our What ideas do you, our mem- To provide comments or feedback about students are choosing specialist ca- bers, have about how SGIM could President’s Column, please contact Lisa reers. Other countries are struggling best support you? What are your [email protected]. Johns Hopkins is an Affirmative Action, populations in Washington. It is a Positions Available and Announce- Equal Opportunity Employer and primary site for teaching UW residents ments are $50 per 50 words for encourages woman and minorities to and students. Seeking a BC/BE MD SGIM members and $100 per 50 apply. interested in our patient population. words for nonmembers. These fees Successful applicants must have cover one month’s appearance in the Forum and appearance on the Academic general internal medicine demonstrated excellence in clinical care SGIM Web-site at http://www.sgim position available for board eligible and teaching. This position will spend a .org. Send your ad, along with the or certified physician. majority of time committed to patient name of the SGIM member spon- care and teaching, and some time may sor, to [email protected]. It is Position includes inpatient and be allotted for scholarly activities. as-sumed that all ads are placed by outpatient responsibilities; outcomes Appointment title/rank will be at the equal opportunity employers. research and clinical trial experience are acting or clinical level and available. Excellent benefit package commensurate with experience. This with generous incentive plan. Salary and position is not tenure eligible, and is a starting date negotiable. one-year appointment eligible for annual reappointment. Instructor or Assistant Professor, Contact Susan S. Beland, M.D., Department of Ambulatory Care and Director, Division of General Internal Please email CV to: Prevention, Harvard Medical School Medicine, University of Arkansas and Harvard Pilgrim Health Care for Medical Sciences, Rachel Thompson, MD 4301 W. Markham #641, C/O Natalie Merriweather Academic teaching and research Little Rock AR 72205, fax 501-686-5609 [email protected] department seeks clinician educator to e-mail [email protected]. (206)-744-2053 join Center for Population Health UW faculty engage in teaching, Education. The Center trains medical ACADEMIC NOCTURNISTS students and health professionals to research and service. The University of include population and health systems The Division of General Internal Washington is an affirmative action, perspectives in clinical, research, and Medicine at the University of equal opportunity employer. policy roles. Faculty member will Washington (UW), Harborview Medical develop curricula and materials and Center (HMC) is seeking three full-time DIVISION CHIEF, GENERAL nocturnists. HMC is a 400-bed level-one assist with and teach in HMS course in INTERNAL MEDICINE, EMORY Clinical Epidemiology and Population regional trauma center and serves at- UNIVERSITY Health. S/he will also participate in other risk populations in Washington, and a activities such as clinical practice, primary site for teaching UW residents The Department of Medicine at Emory research, or public health practice. and students. We are seeking three University School of Medicine is Candidates should have an MD or DO BC/BE MDs to open our Nocturnist seeking an outstanding academic and Masters in Public Health or Program. Successful applicants must internist to lead and further develop the equivalent degree; background in have demonstrated excellence in clinical research, clinical and educational epidemiology, public health, or related care and teaching. This position will programs of the Division of General activities; and strong record in teaching spend a majority of time committed to Medicine across the healthcare system. and curriculum development. We patient care and teaching. Appointment Emory University School of Medicine, 14 actively encourage applications from title/rank will be at the clinical level and located in Atlanta, is ranked among the women and minorities. Candidates commensurate with experience. This nation’s finest institutions for education, should send a CV and statement of position is not tenure eligible, and is a biomedical research, and patient care. interest to: Jonathan Finkelstein, MD, one-year appointment eligible for annual The Department of Medicine is MPH, Director, Center for Population reappointment. nationally recognized for the provision of Health Medical Education, Department Please email CV to: superior clinical care, outstanding of Ambulatory Care and Prevention, 133 Rachel Thompson, MD teaching and as a leader in discovery. Brookline Ave, 6th Floor, Boston, MA C/O Natalie Merriweather The Division of General Medicine has an 02215, Jonathan_finkelstein@harvard [email protected] annual operating budget of over $57 pilgrim.org (206)-744-2053 million and is comprised of over 160 faculty that span the spectrum from Academic Hospitalists UW faculty engage in teaching, primary care to hospital medicine and (Multiple Positions) research and service. The University of include some of the Department and Washington is an affirmative action, Medical School’s most outstanding Johns Hopkins University, School of equal opportunity employer. educators. Medicine seeks experienced BC/BE Internists interested in an academic Interested individuals should have ACADEMIC HOSPITALIST career combining inpatient care with outstanding reputation for clinical teaching and research. Must be eligible The Division of General Internal innovation, nationally recognized for Maryland medical license. Please Medicine at the University of academic excellence with an see the following website for full job Washington (UW), Harborview Medical established research program as well as description and information on how to Center (HMC) is seeking a full-time leadership qualities, and the apply: http://www.hopkinsmedicine.org hospitalist. HMC is a 400-bed level-one organizational and managerial skills to /gim/training/hospitalist.html regional trauma center serving at-risk lead a major division at an academic medical center in the context of the ACADEMIC CLINICIAN-EDUCATOR changing health care environment. CLINICAL VIGNETTE REVIEW- Stanford University Department of Candidates must have academic ERS NEEDED FOR JGIM: Medicine seeks a full-time BE/BC qualifications commensurate with general internist clinician-educator for Are you a Clinician Educator? Have appointment at or above the level of congenial, 11-person, faculty-based you reviewed submissions for a re- Associate Professor with tenure. group, including ambulatory primary care gional or national meeting? Would Applications from women and practice, resident and student teaching, you be interested in reviewing vi- underrepresented minorities are and potentially ward attending. Practice gnette submissions to the JGIM? This strongly encouraged. Interested uses open-access scheduling and carries a time commitment of approx- candidates should submit their electronic medical record (EPIC). curriculum vitae to: imately 1– 3 hours each time you re- Successful candidates have passion and view; most reviewers do this 1-4 times Melissa Boshart, Manager outstanding skills in patient-centered per year. Go to http://jgim.iusm.iu.edu Emory Search Group, Emory University clinical care and small group teaching. and sign up to be a reviewer. Online E-mail: [email protected] We offer academic appointment (rank registration is simple: once you fill in based on qualifications), competitive or: Carlos del Rio, MD your name and contact information, compensation, excellent benefits, and Chair, General Medicine Division you will be asked to identify 8-10 key- Director Search Committee working in a thriving academic medical center. California license/eligibility words. Select "CLINICAL VIGNETTE" Professor and Vice-chair, Department as your first keyword, and as many of Medicine required. No H1-B visa or J-1 opportunity. others as you would like. This is a Emory University School of Medicine great way to share your wisdom, add 69 Jesse Hill Jr. Drive, Atlanta, GA Send CV, letter of professional goals, to your educational portfolio, and 30303 and three professional references to learn at the same time. E-mail: [email protected] Peter Rudd, MD; [email protected].

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