MedChallenge – The Connecticut Chapter’s Medical Knowledge Competition

For the past 17 years, the Connecticut Chapter has been conducting a Jeopardy-style medical knowledge tournament for internal medicine residents in the state. This is a rousing event, one of the best the chapter has to offer. Throughout most of its existence, it has been held at one of the residency program’s institutions. Since 2011, the final round has been held at the Chapter Annual Meeting, after a preliminary round at another site. It has been great to welcome this excitement to the setting of the annual meeting. Every year, talented women and men amaze us with their ability to recall exact details of routine and obscure medical conditions, and the treatments required, under tremendous pressure. It is one thing to come up with the answer while sitting in the audience, and yet another to do so with buzzer in hand – with everything on the line. This year, the initial round was held at the Frank H. Netter M.D. School of Medicine, on the North Haven Campus of Quinnipiac University. Eight teams battled in three preliminary heats to become one of the four teams that will play in the final round on October 31. In the first match, St. Vincent’s Medical Center advanced by edging out Norwalk Hospital and Waterbury Hospital. In the next match, the University of Connecticut Primary Care Program prevailed over Griffin Hospital, whose second place point total still had them in the running for the fourth advancing spot. In a thrilling third match, University of Connecticut outlasted Saint Mary’s and the Yale Traditional Program, who eclipsed Griffin Hospital to earn the fourth spot in the October 31 final by achieving the highest second place score.

Below is a list of winners from past years:
1998-1999: University of Connecticut*
1999-2000: Hospital of Saint Raphael
2000-2001: University of Connecticut
2001-2002: Hospital of Saint Raphael
2002-2003: Hospital of Saint Raphael
2003-2004: University of Connecticut Primary Care
2004-2005: University of Connecticut
2005-2006: University of Connecticut
2006-2007: University of Connecticut
2007-2008: University of Connecticut
2008-2009: University of Connecticut
2009-2010: University of Connecticut
2010-2011: University of Connecticut
2011-2012: University of Connecticut
2012-2013: University of Connecticut
2013-2014: University of Connecticut

*In 1999, as our inaugural entry into the national ACP Doctor’s Dilemma competition, the University of Connecticut won the competition. For more on the ACP Doctor’s Dilemma, including a list of past winners, click here.

Will this be the year that the University of Connecticut stranglehold is finally broken? Please come to the Annual Meeting to support the four programs that will face off in this year’s MedChallenge: St. Vincent’s Medical Center, University of Connecticut Primary Care, University of Connecticut, and the Yale Traditional Program.  The final starts at 3 p.m.  To see the Annual Meeting agenda, click here.

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Chapter Highlight: The Annual Chapter Meeting

On October 31, we will host our annual chapter scientific meeting. We hope to see you there!

As has become customary, we will start the day with our highly successful resident poster session, consisting of both clinical vignettes and research categories. A great way for members to get involved in chapter activities is to serve as a judge for the poster session. It is a lot of fun, and I can honestly say I learn something every time I participate. If you are interested, please notify Chapter Executive Director Nancy Sullivan at By the way, the winners of both categories have their abstracts automatically admitted to the poster competition at Internal Medicine 2015.

We are looking forward to the morning CME sessions. For the past few years we have had positive feedback about the parallel outpatient and inpatient-focused tracks. We have four talented speakers, covering the new lipid guidelines, dermatology for the internist, perioperative management of antithrombotic therapy, and an update on pneumonia (CAP and HCAP).

At lunch, we will give out the chapter awards, update you on what’s going on with ACP, and get a review of interesting resident posters from former governor and Master of the ACP Eric Mazur and former Laureate and Thornton Award recipient Ernie Moritz. Throughout the day, stop by one of the three unknown case stations and test your diagnostic acumen.

Our theme session in the afternoon is High Value Care, with two sessions on Choosing Wisely in the inpatient and outpatient settings; for residents and students, the innovative “Razor Case” where participants listen to a case and then try to reach the diagnosis in the most direct, cost-effective manner possible. We wrap up the day with two standbys: an ABIM SEP module which can be submitted for MOC credit, and the finals of the 17th MedChallenge, the resident medical knowledge tournament.

Then, in a few short weeks after the meeting takes place, we begin the process of planning for our 2015 meeting. If you would like to be a member of the planning committee, let me know!

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The Cost of Medical Care

I’ve had the opportunity to be a patient this summer. Many physicians have written about their experiences “on the other side” (for some interesting recent writings, see these by Rebecca Crow, Eric Manheimer as well as an interview with Robert Klitzman or his book, “When Doctors Become Patients”). I’m not going to tread that same ground except to say that I could corroborate moments of depersonalization, while also recognizing that most of the time I was getting special treatment because I am a physician. This didn’t come as too much of a surprise to me, having had a hospitalization for orthopedic surgery when I was a medical student. But there is one aspect of this experience, despite feeling like it is something that I have been giving attention to as a physician, and about which I take responsibility for teaching our residents, that caught me completely off guard: the cost of care. It sounds crazy to even say this out loud, with all of the attention that has been given to healthcare costs in the wake of healthcare reform. And it is not like I haven’t heard that medical costs are the most common reason for personal bankruptcy in this country, or haven’t seen the choices our patients must sometimes make between medicines/tests or other essential expenses for daily living (also outlined in this Annals of Family Medicine article). It’s just fascinating what the impact of personal experience can be.

So I wonder, am I doing enough? I will continue to teach about High Value Care. I will try to Choose Wisely. I will continue to support the efforts of ACP and other organizations to help our patients get access to affordable healthcare. But what about addressing the actual price of care? While it is not easy to get the data, we clearly pay more in this country for the same service compared to other countries. It will be interesting to see who has the political will to address this.

While it is not exactly in the same vein, I was prompted to write about the topic of healthcare costs by this article that just appeared in Politico by Katie Jennings about the RUC, the AMA committee that advises CMS about how to set physician reimbursement.

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College Priorities for 2014-2015

Last month, the ACP Leadership outlined their top priorities for the year, and while it is noted that they are presented in no particular order, in response to member concerns there has been a lot of effort devoted to the first item, MOC.  Here is an explanation of each of the main priority items:

1) Discuss with the American Board of Internal Medicine (ABIM) reform of the Maintenance of Certification (MOC) process; and develop and implement a MOC Navigator and associated communications that will help members (a) understand the requirements of the ABIM’s MOC process; and (b) identify the best resources to meet MOC requirements in a way that is optimal for their specific FY and needs. (On July 19, EVP/CEO Steven Weinberger sent an email to the membership describing the results of ongoing discussion with the ABIM, and changes that ABIM will initiate in response to concerns raised by ACP and other subspecialty societies.)

 2) Help ACP members experience more joy in their professional lives by (a) advocating reducing the unintended consequences of administrative mandates and other complexities for both physicians and their patients; (b) providing information and developing tools and resources to decrease administrative complexities, increase practice efficiency, and decrease professional isolation; and (c) encouraging initiatives that increase satisfaction and fulfillment derived from clinical practice.

3) Expand ACP’s reach internationally, through local partnerships and using evidence based and financially viable strategies tailored to specific countries and that specify metrics to determine success.

4) Increase knowledge and use of High Value Care (HVC) by effective coordination among physicians and other members of the care team; addressing system-level elements that reduce inappropriate and support appropriate use; refining and  increasing the use of the HVC curriculum and online cases; developing faculty development programs; and building assessment of HVC into certification and MOC.

5) Increase the impact of ACP Smart Medicine through greater use among members and institutions, expanded content, integration with electronic health records, and partnership with other medical societies.

6) Increase ACP’s visibility in academic centers/institutions to demonstrate the value of ACP to the academic departments and their faculty; to increase membership among academic physicians; and to facilitate an early-career commitment to ACP among internal medicine residents and subspecialty fellows.

7) Support implementation of the Affordable Care Act and advocate for refinements that address potential obstacles to optimal care, such as the impact of narrow networks and restrictive drug formularies and related issues on patient choice, access and continuity of care; ensuring fairness and due process for clinicians and patients, including improvements in federal and state regulatory oversight of qualified health plans; and increasing state expansion of Medicaid.

8) Improve the utility, safety, and quality of Electronic Health Records through collaboration and advocacy, focusing on usability and interoperability; refining use and implementation requirements (“Meaningful Use”); and integration with registries and other reporting mechanisms.

9) Facilitate transitions to value based payment and delivery models through advocacy, including working toward elimination of the SGR; and the development of partnerships and ACP resources, such as ACP Practice Advisor and ACP Quality Connect programs.

10) Support effective partnerships among patients, families and care teams through development and provision of culturally and educationally appropriate patient resources, collaborations, and engaging patients in the design of practice and delivery systems.

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Legislative Update

Courtesy of Keith vom Eigen, Health and Public Policy Committee Chair

We have been addressing several health policy issues at both the state and national levels that are of interest to ACP and its members.

State Level Issues
The state legislature has completed its session. The governor signed some significant bills:

1. APRN Independent Practice – This issue came up again after multiple failed attempts by the Nurse Practitioner organization to get approval for practice independent from physician supervision. ACP, CSMS and other physician groups opposed this legislation, as they have in the past. ACP policy favors APRN participation in physician led team based care, rather than independent practice, which could affect patient access to physician expertise. It is unclear whether NP independent practice will increase access to primary care or help keep costs down. One possible outcome is excessive referral to specialists, and further reductions in physician availability for primary care. The impact of this bill remains to be seen, but we should continue to track this.

2. For-Profit Hospital Ownership – Previously state law did not allow for-profit hospitals to employ physicians which has hindered major for-profit hospital purchases in the state so far. The legislature passed and the governor signed legislation that would make these conversions easier. At this point, Sharon Hospital is the only for-profit hospital in the state, however there are several proposed for-profit conversions. Tenet is moving ahead with plans to purchase Waterbury and Bristol Hospitals, as well as Eastern Connecticut Health Network (Manchester and Rockville Hospitals). Tenet and Yale made an agreement for Yale to provide physician services to ECHN. A public meeting has been announced regarding the ECHN purchase.

State SIM Grant – Connecticut has submitted its State Innovation Model (SIM) grant proposal, which could provide approximately $50 million in funding for transformation of the health delivery system in Connecticut. Currently the steering committee is putting together an implementation grant request. Former chapter governor Robert McLean is serving on the steering committee for the proposal development, and several other ACP members are serving on other advisory committees. CSMS is coordinating physician members on these committees. There was a meeting earlier this evening of the steering committee at which they discussed several issues of interest to us. One issue of direct interest is the standard for designation of Medical Homes under state programs, and the conversion of practices to the PCMH model of care.

There have been ongoing services cuts around the state. St. Francis has been cutting various primary care services. Institute of Living is eliminating its schizophrenia program. Hartford Health is cutting 350 positions around the state. These staffing cuts are generally explained as efforts to control costs while maintaining services, however they may have effects on access to care, especially for low income, vulnerable populations. With ongoing consolidation there are threats to access as hospitals and systems focus on high profit services and markets consolidate. We need to keep an eye on this. Members can contact us if they are aware of other potential access issues that arise.

ACA implementation – Several of the Exchange plans have asked for rate increases next year, while one has proposed a decrease (Healthy CT). The OHA has asked for public hearings on the issue. There was a recent data breach from Access Health CT, but it appears accidental and low impact. They are making changes to prevent further breaches.

National Issues
At the national level, there are several health policy issues of ongoing interest, although partisan gridlock and budget constraints continue to dominate the political process in Congress. We had a successful Leadership Day on 5/22/14, with several students accompanying our group in meetings with Congressional staffers. The key issues we discussed include:

1. Medicare Payment/SGR Issue – The SGR was pushed out again to the end of the year (after the election) ACP and other groups advocating for elimination of the SGR are hopeful that it may finally be possible this year. The budget cost is projected to be lower than in previous years, and the involved committees have been able to work towards legislation needed to replace the SGR with an alternative payment plan. However, there has been no agreement on budget offsets that will be needed to eliminate the SGR. So even if there is bipartisan agreement to eliminate the SGR, it may be put off yet again. ACP favors elimination of the SGR and transition to a new payment system that will reward high value care.

2. ACA implementation – The ACA (“Obamacare”) is still drawing opposition from Republican legislators despite ongoing implementation. After initial problems with enrollment websites, especially on the federally run exchange, enrollment has been picking up. Implementation of the Connecticut exchange has been relatively smooth. Lack of Medicaid expansion in some states (mainly Republican controlled) will be one of the significant factors hindering more universal insurance coverage. There are continuing legal challenges, and future political campaigns are likely to raise it as a major issue. A shift to Republican control of Congress or the Presidency may pose a threat to ongoing implementation. Going forward, the cost of policies on the exchanges and in the private market may determine whether this program can provide sustainable near-universal health insurance coverage. ACP favors extension of the Medicaid pay parity for primary care services through at least 2016.

3. GME Funding – Graduate Medical Education funding may become a more contentious issue this year. The President’s recently released budget proposes additional funding for primary care residency slots and other primary care training programs, with some funding being shifted from current hospital based GME funding. Physician groups, such as AAFP and ACP have come out in support of the increased funding for primary care training, and better alignment of GME funding with workforce needs. However ACP and other organizations such as AAMC and hospital associations are opposing cuts to hospital based training programs. Although it is unlikely that the divided Congress will pass the President’s proposal as it is, GME funding may be subject to other legislative action going forward.

4. Medical Liability Reform – The current medical liability system is failing to meet its goal of compensating patients when they are injured due to negligent care, and reducing the need for compensation by incentivizing physicians and systems to provide better care. Although medical liability systems are controlled at the state level, ACP supports national legislation to provide funding to states to implement and test alternative strategies such as Health Courts, and to promote Safe Harbor laws that protect physicians who can document that they are following guidelines in providing care. In Connecticut, ACP is working with CSMS and other organizations to promote patient safety measures and a more effective system for compensating injured patients.

If you want to get more involved in health policy, let us know!

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Remembering the Fallen

Memorial Day is our country’s holiday to remember the men and women who have died defending the United States. Many of us have personal connections to war, either through family members, friends or acquaintances (for me, a childhood friend: Col. John McHugh, who was killed four years ago in Afghanistan). It is important that in the midst of holiday hype – the unofficial start of summer, the barbecues, the sales – we don’t forget the reason for the holiday.

Another thing occurring to me in my moment of reflection this weekend is the appropriation of military language in medicine. Think of how we talk about the efforts to oppose diseases: we are in a global fight against AIDS; trying to combat antimicrobial drug resistance, engaged in a war against cancer. We are allies with our patients as they fight their individual battles against a legion of acute and chronic diseases.

As a U.S. Air Force officer (back in the day), I took an oath to protect the country “against all enemies, foreign and domestic”.* In the context of healthcare as battlefield, we have numerous “domestic enemies”. Internists know many of these foes well: heart disease, cancer, COPD and diabetes, to name a few. While we encounter them every day in our practice, it can be instructive to look at data about burden of disease. The Institute for Health Metrics and Evaluation has created an excellent, interactive data visualization that allows you to look at causes and risks of death or disability, by country or section of the world, and by percentage or absolute numbers (I encourage you to spend some time with it). It leads me to think of the aforementioned diseases more as the agents of death and misfortune, while the enemies launching these weapons are tobacco use, dietary risks, high BMI, high blood pressure, etc. Taken even further: poverty, poor health literacy, sedentary lifestyle are the seeds that foment this rebellion against health and vitality. Maybe I have pushed the metaphor too far. But when you think about the vast numbers of “casualties”, you can understand why this terminology is so frequently used.

As with any military campaign, we need strategy, tactics and logistics. We need the resources and personnel to carry out the strategy. We’ve enjoyed some successes. But what might the landscape look like if it were easier to choose healthy food? If daily life was more conducive to physical activity? If people didn’t have to choose between eating and buying their medicine? If mental health services were more abundant? If we had more resources for chronic disease management? These are big public health items that would make life in the trenches of healthcare easier. There is recognition that these are important issues. But new strategies are needed. In the meantime, we continue to fight; small skirmishes and battles in the overall conflict. And we remember the fallen.

[* technically, it was to “support and defend the Constitution of the United States against all enemies, foreign and domestic”, but defending the Constitution against disease didn’t fit the metaphor well.]

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Reducing Firearm-Related Deaths: A Public Safety Issue

Recently, the ACP released its updated position paper on gun-related violence. In the 19 years since ACP first stated its position on this topic, little progress has been made and the number of high-profile, mass shootings has pushed this into our nation’s consciousness. While these tragedies grab the headlines, the epidemic is much more far reaching, with an average of nearly 88 deaths every day – this included homicides, suicides and accidents. Regardless of politics, our duty to the public’s health mandates that we “speak out on prevention of firearm-related injuries and deaths, just as physicians have spoken out on other public health issues” [Position Paper, item #2]. It is difficult to argue with the evidence that having a firearm in the home is a risk factor for death and injury; this risk is magnified when the household contains adolescents or children, people with mental illness, or those with alcohol or substance abuse. Most internists, in a 2013 survey, reported having a patient injured or killed by a gun. Counseling by physicians has been demonstrated to make a difference in safe gun storage or removal from the home.

The ACP Policy Paper not only states the position and provides the rationale in a comprehensive manner, it also summarizes existing gun laws. As is their practice, they relied on available evidence to guide their position. I encourage you to read the policy paper. For those interested, other physician organizations have taken a strong position on Gun Violence Prevention, in particular the National Physicians Alliance .

The NRA response was predictable, and you will repeatedly hear their reference to a reduction in gun-related homicides since the 1990’s – and that is true. But it does not diminish the importance of firearm safety as a public health issue. I would also refer you to a report by a coalition of US Mayors on gun violence; the visuals showing years of life lost due to firearm-related deaths versus other causes of death (heart disease, cancer, etc) and the funding for research allotted to these causes is striking. Also, the graphic of firearm deaths versus population in economically similar countries is also dramatic.

You can also get more insight into the ACP Position Paper on Reducing Firearm-Related Injuries and Deaths in the United States from Bob Doherty, ACP’s Senior Vice President for Government Affairs and Public Policy, in the ACP Advocate Blog (see his April 22 entry).

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