The Connecticut Choosing Wisely Summit

I just returned from attending the first Connecticut Choosing Wisely Summit – an excellent meeting.  If you are not already aware, Choosing Wisely is an initiative of the ABIM Foundation to promote the selection of care that is supported by evidence and truly necessary.  It should be pointed out that the National Physicians Alliance pioneered this movement by creating lists of things primary care physicians could do in their practices to foster practical use of resources.  Today’s event was hosted by the CT Choosing Wisely Collaborative and held at the Frank H. Netter MD School of Medicine of Quinnipiac University.  We first heard from Dominic Lorusso, Director of Health Partnerships for Consumer Reports (one of the primary groups partnering with the ABIM Foundation in the Choosing Wisely initiative).  He noted that since the initiative began in 2012, the number of partners has grown from 11 to 65.  There are now 67 specialty society lists of “Five Things Physicians and Patients Should Question” as well as 74 “two-pager” monographs aimed at educating patients (check out the lists at http://www.choosingwisely.org/doctor-patient-lists/).  Lorusso described their use of Wikipedia, embedding information and links to the Choosing Wisely monographs (for example, look up “sinusitis” on Wikipedia and scan the references).  He introduced the list of general questions they are promoting: 5 questions to ask your doctor before you get any test, treatment or procedure:

  1. Do I really need this test or procedure?
  2. What are the risks?
  3. Are there simpler, safer options?
  4. What happens if I don’t do anything?
  5. How much does it cost?

As you can see, this basically constitutes elements of shared decision making, which we should be prepared to discuss anyway – although admittedly the fifth question, about the cost, can be challenging to answer.  If you haven’t already seen Healthcare Bluebook, check it out; it can give you a starting point about price (even if that doesn’t represent what your patient will have to pay).

We then heard from Jasmine Dupont, JD, of Maine Quality Counts.  She talked about how her group engages consumers about health care by using Choosing Wisely.  She described how they selected 8 focus areas that they are encouraging providers to limit, drawn from the Choosing Wisely lists:

  1. Cardiac imaging for patients at low risk for heart disease
  2. Imaging tests for low back pain
  3. Antibiotics for upper respiratory infections
  4. Imaging tests for uncomplicated headaches
  5. Bone-density scans for low-risk women
  6. Sleeping pills or sedatives for insomnia, agitation, or delirium in older adults
  7. Opioids or butalbital as pain medications for treating migraine headaches
  8. Imaging tests of the head in emergency department for minor head injuries.

One of the highlights was the presentation by the group from Vanderbilt University.  Donald Brady, Senior Associate Dean for GME, described their institution’s resident-led, leader-supported initiative around Choosing Wisely.  They formed the House Staff Choosing Wisely Steering Committee (about which you can read more here).  Two resident leaders, Wade Iams (Internal Medicine) and Josh Heck (Radiology), described the program.  Residents selected an area of focus they were very familiar with – daily labs for hospitalized patients – and developed a plan to reduce use.  They partnered with others in the institution to create a dashboard reporting use and estimates of what was avoided by limiting use: such as how many unnecessary labs were eliminated, how much blood not drawn, and how many misleading results avoided.  An intensive education campaign, and some friendly competition, helped their initiative to succeed.

Breakout groups gave an opportunity to discuss ideas for implementation here at home.  There were groups for Communities and Consumers, Health Professionals, Health Systems, Point of Care and Workplace.  We discussed how prompts built into EMRs could be helpful and how integrating with the SIM project could give Choosing Wisely a lot of visibility in Connecticut.

I want to remind you that the ACP, as well as contributing its own list to Choosing Wisely, launched the complementary High Value Care initiative.  This includes a toolkit to help facilitate patient-centered communication in the referral process, between primary care and subspecialist doctors; a curriculum for educating residents; and the online cases, which provide free CME and MOC credit.  I would like to encourage you to incorporate High Value Care and Choosing Wisely into your practice.

-Rob Nardino

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Report on Healthcare Disparities Symposium

Resident member Katrin S Sadigh, MD, a PGY2 resident in the Yale Internal Medicine Primary Care Program, attended the recent “Symposium: Racial and Ethnic Disparities in Readmission Rates” and submitted the following report:

The Symposium on Racial and Ethnic Disparities in Readmission Rates took place on 4 February 2015, sponsored by the Connecticut State Medical Society (CSMS) and Connecticut Health Foundation. Hospital administrators, patient advocacy groups, social service administrators and leaders, policy makers, mental health clinicians, physicians, nurses, and students convened from all over the state. Research conducted by CSMS was presented on significant disparities in readmission rates of Black and Latino patients in the areas of uncomplicated delivery, joint replacement surgery, heart failure/chest pain and digestive disorders with the hope of initiating a discussion of ways to address these disparities. The day’s events included a guest appearance by Robert Wah, MD, President of the American Medical Association (AMA), who described ways in which minorities are disproportionately affected by hypertension and diabetes mellitus. He offered the example of Jackie Robinson, the first African American to play in Major League Baseball and who contributed profoundly to the Civil Rights Movement, but ultimately died at the age of 54 from complications of diabetes. Dr. Wah also outlined several key initiatives to combat racial disparity, including joining ranks with YMCAs and implementing Doctors Back to School, which places doctors in classrooms with sixth through eighth graders to expose the young to “real life” doctors, and to fill in the gap in cultural training. Other speakers included M. Natalie Achong, MD, Chair of CSMS Health Equity Committee, who outlined the disparities spectrum from cardiovascular disease to diabetes to HIV/AIDS, and Robert Aseltine, Jr., PhD, who presented data from the analysis of disparities in hospital readmission. Lawrence Sanders, Jr., MD, President of the National Medical Association (NMA), passionately combined personal and historical narrative, from Harry Truman and the desegregation of armed services in 1948 via executive order to President Obama’s second State of the Union address, to advocate for continued combined efforts towards health care equity and fairness. Towards the end of the day, participants broke out into smaller groups for more targeted discussion of ways to address disparities in readmission in the four specific areas of medicine as outlined above. Post symposium, attendees will receive a summary of these brainstorming sessions with the hope that they may add additional comments and contribute to solution development.

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A More Welcome MOC Update!

Hello Everyone!  By now, I am sure you have seen the email from Richard Baron, President and CEO of the ABIM, regarding MOC and the changes being implemented.  Also, you should have received a follow-up communication from Steven Weinberger, EVP/CEO of ACP.   This is a remarkable turn of events and evidence of the effectiveness of our ACP leadership in representing the voice of members.

I want to clarify one important point, after reading some responses from members.  MOC has not gone away.  It is being rebooted, so to speak.  Here are the salient points:

1) The ABIM has temporarily suspended three MOC requirements:  Practice Assessment, Patient Voice and Patient Safety;

2) They will be changing the wording of credentials on the website from “Meeting MOC Requirements” to “Participating in MOC” (so it does not imply a requirement for those with unlimited lifetime certificates to remain certified);

3) They are revising (but not eliminating) the secure exam to be more relevant to what internists do daily – this will go into effect with the Fall 2015 exam.

To be clear – MOC still exists.  If you are in the process of recertifying, you still need to accumulate 100 MOC points and take the secure exam.  As it stands now, it appears you can obtain all points by completing medical knowledge modules (and it appears we can also anticipate a wider array of activities that will be accepted for this purpose).  If not due in the next two years, you still have to complete some activity by the end of 2017 to stay current with MOC.  The individual MOC status pages on the ABIM website have not yet been updated, so check in periodically.

Most of your questions regarding these changes can be answered by going to the ABIM MOC FAQ page.

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Introducing Chapter Members on National Committees: Auguste Fortin

We have several members serving on national committees for the College, and I wanted to introduce you to what they are up to.  Auguste H. Fortin VI, MD, MPH, FACP, who is a member of the Yale-New Haven Medical Center (Primary Care) Program, sits on the ACP Clinical Skills Committee.  Dr. Fortin writes:

“I have had the pleasure of serving on the ACP Clinical Skills Committee from 2001-2008, and again since 2012. I chaired the committee from 2004 to 2008. The Clinical Skills Committee is responsible for the educational content of the Herbert S. Waxman Clinical Skills Center at ACP Internal Medicine meetings. The committee (aided by superb staff), requests proposals for clinical skills sessions and evaluates submissions, selecting the most highly rated ones for inclusion. These workshops range from skin biopsy techniques to ultrasound-guided lumbar puncture to using motivational interviewing for behavior change. Committee members monitor accepted workshops, evaluating their quality and providing the presenters with feedback.  We also review applications from chief residents who are competing to be Waxman Teaching Scholars at the Clinical Skills Center, learning how to teach procedures and getting feedback and mentoring from committee members. Many members of the committee help to teach hands-on skill sessions at ACP Internal Medicine. I will be doing so this spring at ACP Internal Medicine Boston; please stop by to say hello and, better still, sign up for a clinical skills workshop!”

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MOC, One Year Later

Well, it has been one year since the new MOC requirements went into effect, but there has been no reduction in the surrounding controversy.  ACP continues to represent the concerns of membership in frequent discussions with the ABIM.  One of the positions advocated by ACP regards the wording that describes a diplomate’s MOC status.  The College sought a change from “Meeting MOC Requirements” to “Participating in MOC” (with an indication that this is voluntary for those who had previously obtained time-unlimited certificates).  ABIM has conceded on this point, while they continue to stand firm on the necessity of the secure examination.  The American Board of Medical Specialties (ABMS) apparently has the final say on this wording change.  Stay tuned for email updates from ACP EVP/CEO Steven Weingberger.

Former Board of Regents Chair Chuck Cutler participated in a debate with ABIM President Richard Baron at a meeting of the Philadelphia County Medical Society, which you can view here.

In the meantime, we are committed to helping members who choose to participate in MOC achieve recertification. If you haven’t checked out the ACP MOC Navigator, established by the College to help members find MOC activities that are most suited to their practice, take a look.

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World AIDS Day, 2014

Last year, I wrote about World AIDS Day and I reflected briefly on the changes in HIV care over the years.  Once again, I want to remind you that while we have made great progress, there is much still to be done.

Here are some additional facts about HIV in the United States:

  • As of 2011, 1.2 million people in the US were living with HIV infection;
  • Only 4 in 10 people living with HIV were in HIV medical care;
  • Only 3 in 10 people living with HIV achieved viral suppression, which is the key to managing the disease (compared to 76% for those who are receiving HIV medical care).
    Check out CDC Vital Signs for more data.

The 2014 theme for World AIDS Day is “Focus, Partner Achieve: an AIDS-Free Generation.” AIDS.gov has a listing of various activities and events that are planned in association with World AIDS Day. For local activities, see AIDS Connecticut’s website.

What can you do?
Test your patients. 14% of people infected with HIV don’t know it. Patients can learn more at CDC’s GET TESTED site.
Counsel patients who don’t have HIV about how to prevent it.  More discussion of HIV prevention in the clinical setting can be found in this article in the JAMA HIV/AIDS theme issue from July 23/30, 2014.
Make sure patients with HIV get appropriate care, and take medication.  A person aged 20 diagnosed with HIV who receives current HIV medication has an average of 71 years of life; without medicines, that average plummets to 32 years.
Be a champion for organizations that provide supportive services that make it more likely to achieve the therapeutic goal. This includes organizations that provide housing, mental health services, addiction treatment, and so on. Since I practice in New Haven, I will put a shout out to Leeway, AIDS Project New Haven, the APT Foundation, and Columbus House. Get to know the organizations in your community and advocate for them!
Familiarize yourself with available resources. A great place to start is the AIDS.gov Provider Tools site.

An “AIDS-free generation”, the ambitious goal set by the President’s Emergency Plan for AIDS Relief (PEPFAR), will require some new advances, most particularly a vaccine. However, we can continue to make strides in that direction by connecting people infected with HIV to the right care and services and emphasizing detection and prevention in our daily practice.

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Providing Care For Our Veterans

Today’s entry was inspired by Dr. Lucile Burgo, a general internist at the VA Connecticut Healthcare System and National Co-Director of the Post-Deployment Integrated Care Initiative (and recent ACP Fellow!).  It is in honor of Veterans’ Day last week.  Dr. Burgo and colleagues have published a guide to the care of the returning combat veteran in the Journal of General Internal Medicine.

It is important to recognize that of the nearly 1.5 million individuals who served in Iraq and Afghanistan and have since separated from the military, only about half have received care in the VA system.  That means a large group of veterans are receiving care from non-VA providers, indicating a need for familiarity with the particular needs of this population.

Dr. Burgo urged me to call your attention to two additional articles.  First, in this Annals On Being a Doctor piece, The Forever War, Dr. Ross Boyce chronicles the struggle of transitioning from soldier to physician and the unaddressed psychic pain caused by war.  Second, appearing in JAMA’s A Piece of My Mind series  in November 2012, is The Unasked Question by Dr. Jeffrey Brown.  Dr. Brown is a pediatrician and Vietnam War veteran; he reminds us the importance of taking a military service history.  To quote from his article: “Few of the veterans who visit their physician have the stereotyped appearance of young amputees, older men wearing gold-embroidered “I Am a Veteran” caps, or anxious patients taking tranquilizers. They represent one of every six average-looking adult male (and an increasing number of female) patients. And because they served their country, many are at risk for potentially serious problems that are not being addressed by our medical community.”  What better way to honor our country’s defenders than to acknowledge their experience and its important role in their overall health.

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