Since we have 24 hours a day fromnow until we die, time is about priori-ties. What are yours? What if you

controlled how your obituary read, sowhen you turn to reflect upon your life,you feel you have lived your values andserved your genius well; aided and comfort-ed the needy; and helped a new generationlearn to protect the earth, the medical pro-fession, our vulnerable patients, science,and each other? That you made a differ-ence? Determine to do so, and you will.

What differences can you make?Consider three areas.

First, policy and politics. We are in apossibly irreversible battle for our nation’ssoul and our planet’s viability. One sidecomprises those who pursue profit,growth, ideology, or religion as ends inthemselves. They are destroying our com-mons, air and water, freedom and civility,even life itself, and they require a perma-nent underclass.

SGIM

FORUMVolume 30 • Number 8 • August 2007

FROM THE FIELD

Time forPriorities:

Remarks onReceiving the

2007 GlazerAward

Mack Lipkin, MD

Contents1 From the Field

2 From the Society

3 President's Column

4 Policy Corner

5 Morning Report

6 This Month in JGIM

7 Photos from the 2007 Annual Meeting

8 In Training

9 Ask the Expert

10 VA Research Briefs

Society of General Internal MedicineTO PROMOTE IMPROVED PATIENT CARE, RESEARCH, AND EDUCATION IN PRIMARY CARE AND GENERAL INTERNAL MEDICINE

The other side includes people withcaring values who embrace primum nonnocere, predicate their work on the sus-tainable, and correct the disparities thatimpact health, well being, and fairness—especially for our kids. Sleeping throughthis battle risks waking up incarcerated inan uninhabitable world. Elections matter.We cannot pass on engaging with ourmoney, time, and expertise.

Second, our institutions are in red zonestatus, strangled by well-meaning buttimid regulators who force hospitals, resi-dencies, and schools to meet narrow, fad-dish requirements based on weak or noevidence. Our responsibility is to helpfuture doctors give mind, heart, and soulto the core of medicine—helping eachpatient live and die according to his or herpersonal values. Not Risk Management’sor the hospital president’s values. Not yourvalues but the patient’s.

continued on page 11

Dr. Lipkin received the 2007 Glaser Award at the SGIM Annual Meeting inToronto. This slashed condensation of his remarks omits his 177 slides.

From April 25-28,2007, SGIM memberstapped into Toronto,

Ontario, for the 30thAnnual Scientific Meeting,“The Puzzle of Quality:Clinical, Educational, andResearch Solutions.” Themeeting, held at theSheraton Centre TorontoHotel in downtownToronto, focused on howGeneral Internists addressquality issues through spe-cific mechanisms in research, education,and clinical practice. The meeting wasattended by 1,653 participants; 668 scien-tific abstracts were submitted, and 591were presented at the meeting in eitheroral or poster format.

SGIM’s Program Committee was excit-ed to introduce several innovations at the2007 annual meeting, including specialsessions featuring several internationalleaders in education, clinical epidemiolo-gy, and research. One such session, theFirst International Symposium onAcademic General Internal Medicine,promoted the globalization of GIMthrough collaborative international dia-logue on important issues facing interna-tional physicians. A series of presentationsduring the precourse period on Wednesdayafternoon was attended by 112 partici-pants and focused on global collaborationfor patient safety, chronic disease manage-ment in the era of e-Health, and the gen-eral internist and global health challenges.

Another innovation for the 2007conference was the offering of master cli-nician walking tours of the clinicalvignette poster presentations during thetwo-hour lunch sessions. And debatesreturned to the meeting by populardemand. These included a debate on Payfor Performance and Physician Profiling,as well as the Sydenham Society ClinicalDebate on PSA Screening.

Innovations in Medical Educationshowcased novel programs developed bySGIM members, and Innovations inPractice Management showcased newsolutions to pressing issues in inpatientand outpatient arenas, including highmedical costs, critical care, and the needfor quality and safety improvement inmedicine. Also popular this year wereseveral updates. The Update inPerioperative Medicine hosted 165 partic-ipants, and the Update in Women’sHealth saw 120 participants join in for areview of the current literature.

Thursday, Friday, and Saturday morn-ings started off right with distinguishedplenary speakers who shared theirthoughts on a variety of topics. NicoleLurie, MD, MSPH, RAND Center forPopulation Health and HealthDisparities and former SGIM President,spoke on thinking about quality initia-tives in a broad context. Also, duringthis plenary session, the Robert J. GlaserAward was presented to Mack Lipkin, Jr.,MD for outstanding contributions toresearch and education in generalism inmedicine. Molly Cooke, MD, Haile T.Debas Academy of Medical Educators,University of California at SanFrancisco, explored opportunities to“hard wire” a concern with quality intomedical education at both the pre-MD

2

FROM THE SOCIETY

Annual Meeting 2007 inReviewFrancine Jetton, MA

SGIM FORUM

SOCIETY OF GENERAL INTERNAL MEDICINE

OFFICERSPRESIDENTEugene Rich, MD • Omaha, NE richec@creighton.edu • (202) 887-5150

PRESIDENT ELECTLisa V. Rubenstein, MD, MSPH • North Hills, CAlisar@rand.org • (818) 891-7711

IMMEDIATE PAST PRESIDENTRobert M. Centor, MD • Birmingham, ALrcentor@uab.edu • (205) 975-4889

TREASURERRedonda Miller, MD, MBA • Baltimore, MDrgmiller@jhmi.edu • (410) 955-3010

SECRETARYValerie Stone, MD, MPH • Boston, MAvstone@partners.org • (617) 726-7708

TREASURER ELECTJeffrey Jackson, MD, MPH • Bethesda, MDjejackson@usuhs.mil • (202) 782-5603

COUNCIL

Jasjit Ahluwalia, MD, MPH • Minneapolis, MNjahluwal@umn.edu • (612) 626-6033

Marshall Chin, MD, MPH • Chicago, ILmchin@medicine.bsd.uchicago.edu • (773) 702-4769Donna L. Washington, MD, MPH • Los Angeles, CAdonna.washington@va.gov • (310) 478-3711 ext. 49479Karen DeSalvo • New Orleans, LAkdesalv@tulane.edu • (504) 988-5473Said A. Ibrahim, MD, MPH • Pittsburgh, PASaid.ibrahim@va.gov • (412) 688-6477Alicia Fernandez, MD • San Francisco, CAalicaf@itsa.ucsf.edu • (415) 206-5394

EX OFFICIO

Regional CoordinatorDonald Brady, MD • Atlanta, GAdbrady@emory.edu • (404) 616-3117

Editors, Journal of General Internal MedicineMartha S. Gerrity, MD, PhD • Portland, ORgerritym@ohsu.edu • (503) 220-8262 Ext. 55592William M. Tierney, MD • Indianapolis, INwtierney@iupui.edu • (317) 630-6911

Editors, SGIM ForumRich Kravitz, MD, MSPH • Sacramento, CArlkravitz@ucdavis.edu • (916) 734-2818Malathi Srinivasan, MD • Sacramento, CAmalathi@ucdavis.edu • (916) 734-7005

Associates’ RepresentativeNeda Ratanawongsa, MD • Baltimore, MDneda@jhmi.edu • (410) 550-1862

HEALTH POLICY CONSULTANTLyle Dennis • Washington, DCldennis@dc-crd.com

EXECUTIVE DIRECTORDavid Karlson, PhD2501 M Street, NW, Suite 575 • Washington, DC 20037KarlsonD@sgim.org(800) 822-3060; (202) 887-5150, 887-5405 FAX

DIRECTOR OF COMMUNICATION AND PUBLICATIONSFrancine Jetton, MA • Washington, DCjettonf@sgim.org • (202) 887-5150

continued on page 13

“Another innovation for the2007 conference was theoffering of master clinicianwalking tours of the clinicalvignette poster presentationsduring the two-hour lunchsessions.”

In my first two columns, I’ve touchedon some of my experiences in aca-demic general internal medicine and

some of the ways SGIM and SGIM mem-bers have contributed to my professionalgrowth. For more than 30 years, SGIMhas sought to be the professional associa-tion for people “like me”—generalinternists who do research, teach, andserve the patients and communities ofteaching hospitals and academic medicalcenters. But each SGIM member has aunique background and career path, andthe roles and needs of general internistsvary widely across our diverse institu-tions. Therefore, we have diverse repre-sentation on the SGIM Council. As weprepared for our summer retreat, we triedto imagine what “people like us” needand want from SGIM.

The struggle with “who we are” is nota new problem for general internal medi-cine; in fact it may be at the heart ofbeing a generalist! In the 1970s, theAmerican Board of Internal Medicine(ABIM) identified primary care as animportant role for general internal medi-cine, but there were competing voicesand visions even then. In a 1979 Annalsarticle, Barondess described “...the ‘con-sultant-level internist’ [who] can bringunified control to the diagnostic studyand management of the not-uncommonpatient in whom multiple disorders com-plicate the planning and interpretation oftests and treatment....” This was a fore-shadowing of more specialized roles ingeneral medicine like the hospitalist.SGIM’s first name, Society for Researchand Education in Primary Care Internal

Medicine (SREPCIM), seemed to declarea focus on “primary care.” Yet I felt mostwelcome at SPREPCIM despite the hos-pital-oriented focus of some of my earlywork (inpatient attending, inpatientclerkship director, researcher of inpatientpractice variations).

In 1988, SPREPCIM became SGIM,embracing the breadth of our activities as“generalists.” For all the advantages of thenew acronym, our name certainly doesn’tprovide much specific direction toCouncil on how to prioritize our work onbehalf of current and future members!

As I reflect on my own career, I amreminded of the amazing variety of ourexperiences and roles in GIM. The indi-vidual perspectives of my many close col-leagues have encompassed a very widespectrum of ethnic, religious, political, andsexual orientations. Yet these categoriessay little about their individual capacities,aspirations, motivations, and perspectives.

I’ve provided patient care in residentclinics, HMO practices, hospital wards,nursing homes, homeless clinics, urgenttreatment centers, peri-operative careservices, Legion Halls, and patient homes,and I’ve overseen travel clinics, immigranthealth services, AIDS programs, executivehealth programs, and women’s health cen-ters. I have worked with GIM researchcolleagues in schools of public health, incenters for medical education research,decisions science research, informatics,health services and policy research, inhealth plans, and in the research centersof integrated delivery systems. Given thediversity of perspectives, it’s not been rare

3

PRESIDENT’S COLUMN

The “Big Tent” ofSGIMEugene Rich, MD

“We are an organization of general internal medicinephysicians and other professionals who care forpatients; educate students, residents, and fellows; conduct research; and are leaders in health care organizations and government.”

—From the SGIM Governance Principles

continued on page 12

SGIM Forum

Published monthly by the Society of General InternalMedicine as a supplement to the Journal of GeneralInternal Medicine, SGIM Forum seeks to provide a placefor exchange of information, perspectives, and opinionsof interest to SGIM members and others engaged inteaching, research, or clinical care related to generalinternal medicine. Unless otherwise indicated, articlesdo not represent official positions or endorsements bySGIM.

SGIM Forum welcomes submissions from its readers andothers. Please send your ideas and pieces to one of theeditors-in-chief, who will direct you to the appropriateAssociate Editor for consideration.

The SGIM World-Wide Website is located athttp://www.sgim.org

Cartoons are provided courtesy of Stitches—The Journalof Medical Humor.

EDITORS IN CHIEF EMAIL

Rich Kravitz, MD, MSPH rlkravitz@ucdavis.eduMalathi Srinivasan, MD malathi@ucdavis.edu

MANAGING EDITOR EMAIL

Christina Slee, MPH cakuenneth@ucdavis.edu

FORUM COLUMNASSOCIATE EDITOR EMAIL

AbstractionsJeff Jackson, MD, MPH jejackson@usuhs.mil

ACGIMAnna Maio, MD amaio@yahoo.com

Ask the ExpertNina Bickell, MD, MPH nina.bickell@msnyuhealth.org

Carol Horowitz, MD, MPH carol.horowitz@msnyuhealth.org

Ethan Halm, MD, MPH ethan.halm@mountsinai.org

Disparities in Health Said Ibrahim, MD, MPH said.ibrahim2@med.va.gov

From the Regions Keith vom Eigen, MD, PhD, MPH vomeigen@adp.uchc.edu

From the Society Francine Jetton, MA jettonf@sgim.org

Funding CornerPreston Reynolds, MD, PhD pprestonreynolds@comcast.net

Joseph Conigliaro, MD, MPH joseph.conigliaro@med.va.gov

Human MedicineLinda Pinsky, MD lpinsky@u.washington.edu

Innovations Paul Haidet, MD, MPH phaidet@bcm.tmc.edu

Haya R. Rubin, MD, PhD rubinh@pamfri.org

Rachel Murkofsky, MD, MPH rmurk@hawaii.rr.com

In Training Karran Phillips, MD, MSc karran.phillips@jhmi.edu

Morning ReportMark Henderson, MD mark.henderson@ucdmc.ucdavis.edu

Craig Keenan, MD craig.keenan@ucdmc.ucdavis.edu

Catherine Lucey, MD Catherine.Lucey@osumc.edu

Policy Corner Mark Liebow, MD, MPH mliebow@mayo.edu

President’s Column Eugene Rich, MD richec@creighton.edu

This Month in JGIMAdam Gordon, MD, MPH adam.gordon@va.gov

VA Research Briefs Geraldine McGlynn, MEd Geraldine.McGlynn@va.gov

The unusually early coverage givento the 2008 presidential campaignhas fleshed out the candidates’ pro-

posals for improving health insurance farsooner than usual, especially on theDemocratic side. Most Democratic candi-dates want universal coverage, althoughthe plans often differ substantially in howthey would get there. While the details ofthe candidates’ plans are likely to bewhat is argued about in the primaries,there are other factors that may eventual-ly determine whether we will get to uni-versal coverage.

As we learned in 1994, people whoalready have health insurance may bethe biggest barrier to universal coverage.Many fear their coverage will get worseif there are major changes in the system.This may not be as big an issue as it wasin 1994. A lot of people feel their insur-ance coverage is worse and their expens-es higher than in the 1990s, so they maybe more open to change. On the otherhand, many large employers are anxious

system for most privatelyinsured people, often witha play-or-pay rule.

Another area that maybe contentious is how tocover people who are noteligible for employer-basedcoverage. One option is torequire them to buy insur-ance, usually with provi-sions to subsidize the costfor lower-income people(“individual mandate”)while the other is to createa public program or expandexisting ones. The first

option, which would increase the num-ber of people private insurance compa-nies cover, may reduce the oppositionthese powerful groups can organizeagainst a plan. Insurance companies werevery effective in mobilizing opposition tothe Clinton health reform efforts. Whilemany plans include individual mandates,they are likely to be more expensive, socost control will also be an importantaspect of these plans. The more expen-sive the plan, the more opposition it willattract from other groups, such as agri-culture and defense, competing forFederal dollars. These groups fear thattheir programs will be crowded out if theFederal government spends a lot ofmoney providing more people withhealth insurance.

Physician and hospital groups mayalso obstruct plans to move toward uni-versal coverage. I suspect most physi-cians and hospitals believe in the con-cept of universal coverage, but manywould be highly suspicious of any planthat would substantially change the cur-rent system, such as a single-payer plan.Where physicians and hospitals do nothave to deal with many uninsured orseverely underinsured patients, they arelikely to see their benefit from change as

4

SGIM FORUMPOLICY CORNER

The Politics of Universal Health Care:Helps and HindrancesMark Liebow, MD, MPH

for change because of the increasingcosts of providing health insurance.Large employers may be comfortablemaintaining coverage so long as smalleremployers also have to do so (or pay apenalty if they do not—“play or pay”)and if there is a public program intowhich others can buy. Most candidates’plans would continue an employer-based

“I suspect most physicians andhospitals believe in theconcept of universal coverage,but many would be highlysuspicious of any plan thatwould substantially change thecurrent system, such as asingle-payer plan.”

continued on page 13

no obvious etiology could be ascertainedby history, physical, or initial lab tests, thepatient underwent renal biopsy. The his-tology of the kidney showed abundant cal-cium phosphate deposits in the distaltubules and collecting ducts.Immunoflourescence was negative. Thisbiopsy established the diagnosis of acutephosphate nephropathy.

Discussion and TreatmentRenal insufficiency related to tubular calcium phosphate deposits has been traditionally known as nephrocalcinosis and is typically associated with conditionscausing systemic hypercalcemia. Whenthis histology is a result of hyperphos-phatemia in the setting of normocalcemia,it is known as acute phosphate nephropa-thy. This entity has been described inpatients who have undergone colonoscopyfollowing the use of oral sodium phos-phate solution (OSPS) purgative regimens(Fleet phosphosoda®, generic phosphoso-da, or Visicol®). Concerns have beenraised about a potential increase in incidence of this condition because of an increasing frequency of screening colonoscopies and patient preference for the low-volume OSPS purgative regimen over the high-volume polyethylene glycol-based lavage solution (Golytely®).1

Two distinct syndromes are seen. Inacute phosphate poisoning, patients pres-ent with confusion, lethargy, and tetany inthe setting of elevated serum levels of phosphate and decreased serumcalcium levels. This syndrome occurswithin hours to days of oral sodium phos-phate use. Renal function generally recov-ers quickly following rapid therapy withphosphate binding gels and administrationof calcium gluconate.2 Our patient mani-fested incidental, chronic renal failure dueto OSPS. This syndrome presents weeksto months following the exposure. Renal

failure is evident with either a bland urineor mild proteinuria (600 mg/24 hours).Serum calcium and phosphate levels aretypically normal. Renal function generallydoes not return to normal.

Elderly patients handle oral phosphateloads less well than younger patients.Studies have shown that the phosphatelevel in young adults increases by 3.4mg/dl after two 45 ml doses of OSPSadministered 12 hours apart. In contrast,patients over age 65 show an increase of5.5 mg/dl in serum phosphate after thesame dose. The calcium phosphate prod-uct, normally 21 to 45, may increase to 71after an oral sodium phosphate dose.3

Patients at risk of phosphate nephropa-thy include the elderly, patients with loweffective circulating volume due to volumedepletion or co-morbid conditions, andthose with intrinsic renal disease. Patientswith hypertension and those with alteredglomerular hemodynamics, such as patientstreated with angiotensin convertingenzyme inhibitors (ACEI), angiotensinreceptor blocking agents (ARB), orNSAIDs, are also at increased risk.

In the largest single institution series,20 out of 21 patients with biopsy-provenphosphate nephropathy had had a recentcolonoscopy; all but one had used oralsodium phosphate in normal doses as theirbowel purgative. Seventeen of the twentyone patients had normal renal functionprior to their colonoscopy; the remainingfour had mild renal insufficiency. Eightypercent of the patients had underlyinghypertension; 87% of those patients weretaking either an ACEI or an ARB. At six-teen months post biopsy, four of thepatients were on hemodialysis, and theremainder had an average creatinine of2.4 mg/dl.3

SummaryPhosphate nephropathy is a rare but seriousform of acute and chronic renal failure. In

A61-year-old woman presented to herprimary care physician for ongoingmanagement of essential hyperten-

sion. Her blood pressure was well con-trolled with enalapril 10 mg andhydrochlorothiazide 25 mg daily. Her onlyother medication was intermittent ibupro-fen. She had been seen two months priorto this visit for complaints of rectal bleed-ing. Internal hemorrhoids were found at acolonoscopy, which was performed afteradministration of two 45 ml doses of oralsodium phosphate solution (OSPS). Thepatient described feeling well and had nocomplaints. Physical exam revealed ablood pressure of 114/72 and was other-wise normal except for evidence of degen-erative arthritis.

A creatinine of 3.1 mg/dl was found onlab evaluation, increased from a baselineof 0.8 mg/dl one year prior to this visit.Serum calcium was 8.9 mg/dl and phos-phate was 4.2 mg/dl. Complete bloodcount was normal. Urinalysis revealed nocells or casts and no protein. A 24-hoururine for protein showed 100 mg of pro-tein. All other lab tests were normal.

The DiagnosisThis patient presented with acute renalfailure in the setting of well-controlled,chronic essential hypertension. Because

5

MORNING REPORT

A 61-year-old Woman with Renal FailureFollowing ColonoscopyCatherine R. Lucey, MD, and Swapna Kamadana, MD

continued on page 12

Long-term use of benzodiazepines hasbeen shown to be effective in thetreatment of panic disorder and social

phobia. Long-term use for other indica-tions, such as insomnia, may incur signifi-cant morbidity, especially in older popula-tions. Prior research has suggested that formany elderly, short-term use of prescribedbenzodiazepines can progress into chronic,medically inappropriate use with deleteri-ous social and health consequences.

This month in JGIM, Joan Cook, PhD,sought to understand patient factors con-tributing to chronic benzodiazepine use byolder adults. By understanding thesepatient factors, she sought to lay a founda-tion to develop acceptable interventionstrategies for tapering or preventingchronic, medically inappropriate use ofbenzodiazepines.

In her qualitative investigation, Dr.Cook and colleagues from ColombiaUniversity, New York State PsychiatricInstitute, and University of PennsylvaniaSchool of Medicine interviewed 50 elderlypatients, recruited from primary care prac-tice settings in or near Philadelphia,Pennsylvania, with benzodiazepine pre-scriptions for anxiolytic indications.

They found that many of these olderchronic benzodiazepine users had a psy-chological dependence on benzodi-azepines. Many described the medicationsas affording control over daily stress,bringing tranquility, and (surprisingly)prolonging life. Most of the patient sub-jects expressed resistance to taper or dis-continue the medication. The investiga-tors concluded that the reluctance of olderchronic benzodiazepine users to taper ordiscontinue use highlights the importanceof prevention and early interventionstrategies to avoid long-term use.

Dr. Cook noted that this research hadapplication to primary care practitioners.“Most physicians have doubts aboutwhether chronic benzodiazepine use in

older adults is a public health problem, aswell as about their ability to get older per-sons to reduce their use,” she said. “Yet ifphysicians were vigilant at the outsetabout avoiding long-term use, they couldget far in reducing the problem.”

The investigators “came away with anappreciation of just how difficult it is forphysicians to deal with sensitive issues likethese in the closed relationship with apatient, particularly given the physicianscommitment not to cause suffering.” Dr.Cook said the results suggested that physi-cians were not at fault for this phenome-non but were often “stuck” with this diffi-cult clinical problem. “Many older chronicusers see their use of a benzodiazepine askeeping life in balance, and they are reluc-tant to give up this medication,” she said.

Surprising FindingsDr. Cook and colleagues were most sur-prised by patient wariness regarding thequestions that were asked about long-termbenzodiazepine use. She explained, “Somepatients became so leery of our line ofquestioning that they forbade us to telltheir physicians to take them off thismedication.”

Dr. Cook also believed that elderlypatients on chronic benzodiazepinesseemed to avoid discussing their use withtheir physicians. “Physicians and their eld-erly patients who are chronic benzodi-azepine users seem to be working togetherto avoid needed discussions about thepotential risk of this medication becausethey know such discussions could jeopard-ize their working relationship,” she said.

Questions UnansweredDr. Cook and colleagues also interviewed33 physicians of the patient subjects; theresults were published earlier this year inJGIM. Dr. Cook explained that bothpatient and physician interview resultsleft many questions unanswered. “The

question we were left with was ‘What canbe done to persuade older patients andtheir physicians that chronic daily benzo-diazepine use is a problem worthy and inneed of address?’ ” she said.

Dr. Cook explained that larger systemissues can also contribute to this unan-swered question: “The health system isbroken. Physicians keep getting asked todo more for less; many of them do not getreimbursed for treating psychiatric condi-tions; they do not know where to referpatients for mental health problems; andif they do, older patients often do notwant to go.”

Work in ProgressDr. Cook and colleagues are activelyworking to further define and interveneon chronic benzodiazepine use in the eld-erly. Their current work includes inquiryinto “what medication and patient charac-teristics differentiate those patients whoare willing to attempt taper and discontin-uation versus those who are absolutelyadamant they will not stop. This may helpphysicians decide which chronic olderusers to approach first.”

Certainly, this is the first next step tohelp physicians confront this difficultproblem. Dr. Cook summarized, “Primarycare physicians have to pay attention tolots of other health issues in a shortamount of time with elderly patients.With all other demands on physicians, itis no wonder they find it hard to addresslong-term benzodiazepine use.” With allother demands on physicians, it is nowonder they find it hard to address chron-ic benzodiazepine use. However, chronicuse should not be viewed as somethingthat can be ignored.

SGIM

To provide comments or feedback about ThisMonth in JGIM, please contact Adam Gordon atadam.gordon@va.gov.

6

SGIM FORUMTHIS MONTH IN JGIM

Chronic Benzodiazepine Use: Evaluating Impacton the ElderlyAdam Gordon, MD, MPH

This month in JGIM, Joan M. Cook, PhD, of Columbia University and the New York State Psychiatric Institute discusses herarticle, “Older Patient Perspectives on Long-Term Anxiolytic Benzodiazepine Use and Discontinuation: A Qualitative Study.”

7

SGIM 2007 Annual Meeting © Toronto

We spend at least seven yearslearning everything we canabout medicine, but when it

comes to securing our first job we realizethat it was not enough. Our medicalknowledge is sound; our business knowl-edge is not. In choosing a career in med-icine, we thought we had left the worldsof law, finance, and business behind;instead, we find that maybe we shouldhave paid a little more attention in ourrequired microeconomics course.

The Medical Practice Monitor, a2005 survey of a nationally representa-tive sample of 350 physicians by OPEN(the small business arm of AmericanExpress), showed that 51% of surveyedphysicians spend seven or more hoursper week managing their business; fur-thermore, 16% say practice managementtakes as much as three days a week.

Regardless of specialty, survey respon-dents find managing the dual role ofpracticing medicine and running a busi-ness to be challenging (89%) and thatfurther training in financial management

skills would help them to run their prac-tices more efficiently (74%).

If we need business skills to secure agood job and manage our practice, wheredo we learn them? They are not taught inmedical school, and few if any residencyprograms address the issue. But theyshould. Residency training shouldinclude how to find a job, negotiate anemployment contract, bargain with man-aged care organizations, and run a prac-tice among other things. Of paramountimportance in all of these situations isthe ability to negotiate—the art of thedeal. Whether it is a job contract, a man-aged care contract, or a lease on office

8

SGIM FORUMIN TRAINING

The Art of the DealKarran Phillips, MD, MSc

In Training considers issues of interest to SGIM associate members. Here, Forum Associate Editor Karran Phillips offers advice to graduating residents seeking their first job.

space, negotiation is a skillthat can and should belearned. It is one partknowledge, one part confi-dence, and one part diplo-macy; it permeates every-thing we do in medicinefrom convincing a patienther blood pressure medi-cine is important to take

even when she feels well to ensuring thatmanaged care organizations give us thebest reimbursement for the quality carewe provide. By artfully balancing inter-acting influences, we ensure the best forour patients, our practices, and ourselves.

The following is advice I receivedwhen negotiating a job contract. Thefirst four principles can also be applied tonegotiations we physicians confrontdaily:

1. Do your homework. Know about theorganization, the salaries, and benefitsthat those working there experience.

2. Decide what is important to youpersonally to negotiate. This is the timeto ask for more vacation, loanrepayment, family leave, etc.

3. Don’t be afraid to ask. Whether it is fora signing bonus, another week ofvacation, CME reimbursement, or forresearch or administrative support.

4. After an offer is made always counteroffer. Ask for more than you think youneed, and then settle somewhere inbetween.

5. If you have educational loans, ask forloan repayment.

6. Understand the non-competeclause/restrictive covenant (delineation ofa zone and timeframe in which adeparting physician can not practice) andagree on something that makes practicalsense for you and your family.

7. Understand the tail coverage (protectionagainst future claims that may be made

“If we need business skills tosecure a good job and manageour practice, where do welearn them?”

continued on page 13

I believe it is something new. Academicmedical centers have become silos ofresearch—often with little communicationamong different types of investigators.Bench scientists may not talk to clinicalscientists, and many academic centers havenot effectively developed community-basedresearch. I believe CTSAs will foster com-munication and collaboration resulting innew approaches to enhance the applicationof discoveries for improving health care.

How many CTSAs will there be nation-wide? Will this create new tensionsbetween “haves” and “have nots”?The first 12 CTSAs were funded inSeptember 2006. NIH says it plans tofund about 60 CTSAs over the next fiveyears. There is much anxiety among uni-versities about not getting a CTSA sincewithout one it will be much harder tofund training programs, career develop-ment, and clinical research infrastructure.

How might they affect us in generalinternal medicine (GIM)?First, many GIM faculty have (or areplanning) leadership roles in CTSAsincluding directing the overall CTSAand/or key programs regarding: clinicalresearch training (Master’s and PhDs inclinical research), career development(K12 mentored junior faculty careerawards), predoctoral student training inclinical and translational research (T32s),design, biostatistics, clinical researchethics, evaluation and tracking, and com-munity engagement and community-based research, among others. Many GIMfaculty will be tapped for their expertisein these areas, as well as clinical trials,translating research into practice, andcommunity- and practice-based research.

Second, GIM clinical investigators andfellows will be able to take advantage ofthe education programs (courses, degrees)and career development awards (such asK12 awards that provide up to five years ofsalary and research support). In addition,the resources of the CTSA can be usefulfor clinical research including: pilot funds,research design and biostatistics support,access to mentors from multiple disci-plines, access to patient populations, com-munity-based collaborations, GCRC sites,and ethics and IRB assistance.

What do clinician-educators and clinician-clinicians need to know about CTSAs?CTSA resources may be useful to educa-tors for areas such as educational research(especially those with impact on patientcare), biostatistics and design assistance,and collaboration with investigators. Forclinicians, the major area would beenrolling patients in clinical studies, aswell as efforts to implement research inpractice and community-based settings.

Has being involved in this enterprisechanged the way bench scientists thinkabout GIM?At Pitt, prior to the CTSA, there was aconsiderable strength in training, clinicalactivities, and health services research inGIM, and as a result there was a signifi-cant appreciation of GIM. I feel this haseven become stronger with the CTSA.

Are there new research questions ordesigns you think we need to getincreasingly involved in?CTSAs provide opportunities to developprograms in translational research. Bothtypes of translation (from bench to clini-

What are Clinical andTranslational Science Awards(CTSAs)?

NIH is recognizing that new approachesare needed to speed the translation of basicbiomedical research into effective treat-ments and to incorporate those treatmentsinto practice. CTSAs are large institution-al NIH grants to improve research transla-tion. They bring many institutionalresources together under one umbrella andadd new resources to promote collabora-tion among investigators from multiple dis-ciplines, improve training programs inclinical research, provide early careerdevelopment support and pilot funding,enhance capacity to use informatics and ITtools, transform General Clinical ResearchCenters (GCRCs) to broaden their areasof research, and promote community-andpractice-based research.

CTSA grants are the “600-pound goril-la” of NIH institutional funding forresearch training, career development, andinfrastructure. They will likely averagebetween $25 and $80 million dollars overfive years, depending on the institution.

How narrowly or broadly does NIHdefine “translational” research?NIH defines this as follows: “Translationalresearch includes two areas of translation.First is the process of applying discoveriesgenerated in the laboratory and preclini-cal studies to the development of trialsand studies in humans (T1 Translation).The second area of translation concernsresearch aimed at enhancing the adoptionof best practices in the community (T2Translation).”

Is this something new or old wine innew skins?

9

ASK THE EXPERT

The ABCs of CTSAs:Translating TranslationalResearch to a General Internal MedicineAudienceWishwa Kapoor, MD, MPH, with Ethan A. Halm, MD, MPH

Wishwa Kapoor, MD, MPH, is the Chief of the Division of General Internal Medicine and Director of the Center for Researchon Health Care; Director, Institute for Clinical Research Education; and Co-Director, Clinical and Translation Science Institute,at the University of Pittsburgh School of Medicine. He is also a Past President of the Society of General Internal Medicine.

continued on page 12

VA RESEARCH BRIEFS

Self-management with Chronic Diseases withinthe VA: Hypertension as an Example Hayden B. Bosworth, PhD, Eugene Z. Oddone, MD, MHS

Both Drs. Bosworth and Oddone are from the VA HSR&D Center for Health Services Research in Primary Care, DurhamVAMC, Durham NC and the Department of Medicine, Division of General Internal Medicine, Duke University, Durham NC.

Hypertension, like many chronic dis-eases, is increasing in prevalenceand, with the aging of the US pop-

ulation, poses challenges to our nationalhealth care system. Hypertension servesas an excellent model for self-manage-ment treatment because patients must ini-tiate and maintain multiple complexbehaviors to attain long-term control.Furthermore, to ensure adequate treat-ment adherence, effective hypertensiontreatment requires patients to developcollaborative relationships with healthcare providers and the greater health caresystem. When these relationships fail,poor patient adherence and clinicians’failure to initiate or intensify hyperten-sion treatment significantly contribute topoor blood pressure (BP) control.1 Webriefly describe two clinical trials con-ducted within the VA that attempt toaddress many of the problems that plaguethe development and implementation ofpatient self-management interventions.

Two studies examine the administra-tion of patient interventions outside theconfines of the traditional health care set-ting. The first study, Veteran Study toImprove the Control of Hypertension (V-STITCH), involved a tailored behavioral/educational intervention administered bya nurse for patients who were currentlyusing a hypertensive medication, irrespec-tive of whether their BP was adequatelycontrolled. The intervention lasted 24months and involved bimonthly tele-phone calls focusing on nine domainsdeemed relevant for hypertension control.These domains included patient/providercommunication, memory, literacy, sideeffects, hypertension knowledge, pill refill,missed appointments, social support, andlifestyle.2 The intervention improvedpatients’ BP control by 22% over 24months —an absolute difference of 13%

when compared to usual care.3 The inter-vention took approximately three min-utes to implement bimonthly becausematerial was tailored to patients’ needs.There was no increased health care uti-lization, and based on an average nursesalary and considering relevant costs, thedirect intervention cost $70 per personover the 24-month period.

We are now evaluating an interven-tion that involves telemedicine home BPmonitoring to identify patients withinadequate BP control who need moreintensive care. While V-STITCH focusedon all individuals with hypertension, theHypertension Intervention NurseTelemedicine Study (HINTS) focuses onthose individuals with poor BP controlover the last year. To address past find-ings of clinical inertia (a tendency forproviders to not increase medicationwhen clinic visit BPs are above goal),HINTS is implemented by nurses with aphysician overseeing medication deci-sions. Medication recommendations arebased upon a hypertension algorithmdeveloped by Dr. Mary Goldstein andcolleagues.4 Using a factorial design,patients are randomized to control group(usual care); tailored behavioral interven-tion; medication management; and acombination of the tailored behavioraland medication management interven-tions. The interventions are triggeredbased on home BP values transmitted viatelemonitoring devices over standardtelephone lines. The tailored behavioralintervention builds upon earlier workfrom V-STITCH and promotes adher-ence with medication and health behav-iors through the following modules:hypertension knowledge/risk perception,memory, social/medical environment,patient-provider relationship, adverseeffects of antihypertensive medication,

diet, exercise, smoking, alcohol, andstress reduction.

There are three significant differenceswith the current behavioral interventionimplemented in HINTS as compared tothe previous one in V-STITCH. HINTSincludes more goal-setting and exploresambivalence to making changes. This isevident by the fact that an averageHINTS telephone call is taking morethan 10 minutes as compared to threeminutes for V-STITCH. Second, HINTSprovides more reinforcement of what isdiscussed during contacts, and phone con-versations are supported by mailed materi-al. Third, in HINTS, the behavioralintervention was based on inadequatehome BP values, so HINTS patientspotentially received more frequent inter-vention contacts as compared tobimonthly calls independent of individu-als’ actual BP values as in V-STITCH.

One could possibly view the two stud-ies along a continuum of intensity. Thatis, V-STITCH, while tailored to patients’needs, is more didactic and potentiallyrelevant for anyone with hypertension,whereas HINTS is more appropriate forharder-to-treat individuals. Results ofthese studies suggest that tailoring theintensity of interventions based uponpatients’ needs is likely necessary giventhe prevalence of hypertension in theUnited States. In addition, given timeconstraints, treatment for some chronicdiseases like hypertension can potentiallybe treated outside the clinic walls, and atleast in the case of V-STITCH, in cost-effective ways. While the trials rangefrom 18 to 24 months, a majority of thefocus has been on initiating behaviors,thus further examination of maintenanceof these behaviors is warranted. Lastly,methods of reimbursements need to be

10

SGIM FORUM

continued on page 11

11

FROM THE FIELDcontinued from page 1

Several weeks ago a young, 420-poundpoliceman panted into my clinic. Hisshortness of breath, fatigue, and hyperten-sion suggested sleep apnea. We needed asleep study. I spent two hours using gueril-la tactics on a complex system so thepatient could get tested before too late.Primary care doctors must change badregulations, not just cope with them.

Caught in bureaucratic gridlock, wealready suffer dangerous inability to exer-cise sensible judgment. Enough is enough.To learn to be professional, young doctorsmust make autonomous decisions backedup by supportive supervisors who under-stand that mistakes are part of growth andwho watch them work, not just listen tothem talk about their work.

Third, we need to examine, under-stand, and embrace complexity.Reductionism has hit a brick wall. Whilethe decoding of the human genome istremendously exciting, for most commongenetic conditions penetrance rangesfrom 10% to 100%; only 20% to 40% ofthe genome is active at any moment. Wedon’t know why, in what way, or in whichcells. Similarly, complexity stalks the hos-pital. We swim so freely in the ocean ofthe hospital that we miss when thepatient and family start to drown. Theoceanic ecology of the hospital over-whelms. Patients and their families needto be the decision makers. They deter-mine our success and failure medicallyand morally. Since they can’t tell what’san emergency, an error, or fate, they can’tjudge how to adapt and cope.

A woman called: “My dad had care atSloan for five years for renal cell carcino-ma. ‘There’s nothing more to do,’ hisoncologist said. Now his legs are swellingand hurt. The oncologist won’t see him.”I get a lot of these calls. People want aninsider who can act fast. Most patientsdon’t have someone watching their back.They need it desperately. I advised, “Callback and insist.” Her appointment? Intwo weeks! I said, “Put him in a cab tothe ER.” It took daily coaching for sixdays to get end-of-life care for this totallydisempowered man, previously a lawyer toone of the biggest realtors in the world. Itwas so hard!

We need to craft, test, and perfect anew role for primary care: to release anddirect the energies, intelligence, and car-ing of the supporters of our patients. If wedo, we’ll get more help, patients will besafer, care will be more efficient, andeveryone will be more satisfied.

Another call. A colleague’s son—28, aprodigy lawyer—had fallen four floors, hithis head, and now lay comatose inBellevue. Would I check it out? I printedout my five-page handout, “When YourLoved One is in Crisis.” Step one: “Starta journal.” Working with this family formonths, we coped together as hetwitched, grayed, gasped for breath,improved, and never spoke. My goals: tomaintain their hope and help transformtheir great instincts into useful action.Every few days they improved the care.One Thursday he didn’t look right. “Heneeds a medical consult,” I said. Theytalked to the neurosurgeon. He orderedthe consult. Six hours later, the consultstill hadn’t come. The family asked,“What should we do?” We role playedeffective people-bugging. In an hour themedical consult was there. The patienthad pneumonia. The family’s involve-ment mattered. We should industrializethese competencies, formally making andequipping patients’ supporters to be partof the medical team. It will improve ourcare, and it’s the right thing to do.

When families sense a crisis in the careof someone they love, they don’t knowwhere to turn. Two weeks ago a reporter Ihad spoken with years ago called myhome. His father-in-law was hospitalizedwith renal failure, mitral disease, confu-sion, etc. The family had no prior inklingof the severity of the situation. The son-in-law asked what to do. The familyneeded information about diseases, prog-noses, and options; I gave it. But mostpatients can’t access such help. Helpingpatients understand and manage com-plexity is what defines us as generalists.We help patients make evidence-support-ed decisions consistent with their values.That’s why we’re always going to be need-ed, no matter what anyone tells you.

The Glaser Award reflects Bob Glaser’scommitment—and our Society’s—to

embracing complexity, activating patientsand their families, and combining evi-dence with common sense to support val-ues-driven care for patients and their fam-ilies. Happy warriors, our work is cut outfor us. What an opportunity to make adifference! SGIM

To provide comments or feedback about From theField, please contact Rich Kravitz atrlkravitz@ucdavis.edu.

VA REASEARCH BRIEFScontinued from page 10evaluated to ensure greater disseminationand implementation of self-managementinterventions. Innovative self-manage-ment interventions will likely be neces-sary to achieve and surpass the HealthyPeople Year 2010 goal of 50% of thosewith hypertension having adequate bloodpressure control.

References1. Bosworth HB, Olsen MK, Oddone EZ.

Improving blood pressure control bytailored feedback to patients andclinicians. Am Heart J2005;149(5):795-803.

2. Bosworth HB, Olsen MK, Gentry P, etal. Nurse administered telephoneintervention for blood pressure control:a patient-tailored multifactorialintervention. Patient Educ Couns2005;57(1):5-14.

3. Bosworth HB, Olsen MK, Dudley T, etal. The Veterans’ Study to ImproveThe Control of Hypertension (V-STITCH): A Patient and ProviderIntervention to Improve BloodPressure Control. 25th HSR&DNational meeting. 2007, Washington,DC.

4. Goldstein MK, Coleman RW, Tu SW,et al. Translating research intopractice: organizational issues inimplementing automated decisionsupport for hypertension in threemedical centers. J Am Med InformAssoc 2004;11(5):368-76. SGIM

To provide comments or feedback about VAResearch Briefs, please contact GeraldineMcGlynn at Geraldine.McGlynn@va.gov.

for conflicts to emerge among unit mem-bers. After all, when perspectives rangefrom libertarian to socialist, discussionscan get intense, and that’s nothing com-pared to the tensions between SwedishLutherans and German Catholics (aMinnesota joke). I’ve often reminded col-leagues in GIM “it’s a good thing our fac-ulty are so different—if we were all thesame we could only do one thing well.”

SGIM members bring a startling rangeof talent, energy, perspective, and enthusi-asm to our organization, and these areexpressed in a wide variety of interests.I’ve participated in several SGIM interestgroups over the years (e.g., Health Policy,Genetics in Primary Care, SocialResponsibility), but these are just a smallsampling of the almost 70 Interest Groupswe support at SGIM, ranging (alphabeti-

12

SGIM FORUM

in academic GIM. We need everyoneactive in SGIM from the newest associateto the most accomplished senior faculty.During our upcoming Council planningretreat, we will undertake the annual chal-lenge of melding our diverse perspectivesinto a coherent, manageable agenda forthe year. Despite our widely differingbackgrounds and interests, we are guidedby our mutual goal that SGIM be the pri-mary professional association for academicgeneral internists and their colleagues whowork at teaching hospitals and academicmedical centers. We need SGIM to be a“Big Tent.”

SGIM

To provide comments or feedback about President’sColumn, please contact Eugene Rich atrichec@creighton.edu.

PRESIDENT’S COLUMNcontinued from page 3

cally) from “Academic General InternalMedicine in Latin America” to “Women’sHealth Education.” In a 3,000-memberorganization, resources are finite, and justlike in a division, there are inevitablycompeting priorities. Therefore, it can bea challenge for us on Council to find theright balance of initiatives given thebreadth of concerns of our members.Hopefully, the revised SGIM Website, theupdated member survey, and the new“Requests for Action” process (describedby Malathi Srinivasan, MD, in the June2007 Forum) will enhance communica-tion between individual members, interestgroups, and our more formal national lead-ership structure of Committees, TaskForces, and the Council itself.

We have much to do to advanceresearch, education, and clinical practice

cal research and then to practice) are rel-evant to GIM. These resources could cre-ate new opportunities for doing researchusing basic laboratory information(genomics, proteomics, etc.) or develop-ing new methods for translating researchinto real world practice.

What do you think the most positiveoutcome of these awards will be (besidesa lot money)?

I think the focus on moving innovationsand evidence-based treatments intopatient care is one of the most positiveaspects of the CTSA.

Anything else you think SGIM members should know about this new initiative?SGIM members should be interested inthe CTSAs because of the major interestof the organization and members in trans-

ASK THE EXPERTcontinued from page 9

lating research into practice. It will be use-ful if SGIM members advocate at theirinstitutions for infrastructure and studiesin translating research into practice sincethere is some concern that CTSAs maynot place as much emphasis on this sec-ond phase of research translation. SGIM

To provide comments or feedback about Ask theExpert, please contact Ethan Halm atethan.halm@mountsinai.org.

MORNING REPORTcontinued from page 5

the largest available series, OSPS was themost frequent cause of nephrocalcinosis.

Patients with disease-, age-, or drug-related alterations in glomerular perfusionare at particular risk for this complicationof OSPS purgatives.

Although a rare complication, thechance of complete recovery from chronicOSPS nephropathy is low. Thus, clini-cians should consider recommendingagainst the use of OSPS purgative regi-mens for their patients who, by virtue ofage, use of ACEI/ARB/NSAIDS, or otherco-morbid conditions, are at highest risk

of this complication.If OSPS must be used in patients at

increased risk, care should be taken toensure adequate hydration during and afterthe prep, and serum calcium, phosphate,and creatinine should be monitored.

References1. Vanner SJ et al. A randomized

prospective trial comparing oral sodiumphosphate with standard polyethyleneglycol-based solution in the preparationof patients for colonoscopy. Am J ofGastroenterology 1999; 85:422-7.

2. Gonlunsen G et al. Renal Failure andNephrocalcinosis Associated withSodium Phosphate Bowel Cleansing.Arch Pathol Lab Med 2006; 130:101-6.

3. Markowitz GS et al. Acute PhosphateNephropathy following Oral SodiumPhosphate Bowel Purgative: An under-recognized cause of chronic renalfailure. J Am Soc Nephrol 2005;16:3389-96. SGIM

To provide comments or feedback about MorningReport, please contact Catherine Lucey atCatherine.Lucey@osumc.edu.

13

FROM THE SOCIETYcontinued from page 2

and residency levels. And a 2006 recipi-ent of the prestigious MacArthur Award,John A. Rich, MD, MPH, Departmentof Health Management and Policy,Drexel University School of PublicHealth, presented the Malcolm PetersonLecture describing his experiences imple-menting clinical programs to improvethe quality of care of young men in theinner city.

On Saturday afternoon, hundreds ofconference participants joined in for oneof the meeting’s most prestigious high-lights—the Awards Banquet andPresidential Address. This year, 33

awardees were recognized for a variety ofachievements. The National Award forCareer Achievements in MedicalEducation was presented to Mark D.Aronson, MD, for a lifetime of contribu-tions to medical education. Also, theJohn M. Eisenberg National Award forCareer Achievement in Research waspresented to William M. Tierney, MD, inrecognition of a senior SGIM memberwhose innovative research has changedthe way we care for patients, conductresearch, or educate our students. ThePresidential Address was presented byRobert Centor, MD, SGIM’s President,

and the awards banquet concluded withthe Passing of the Gavel to SGIMPresident Eugene Rich, MD.

Join SGIM in Pittsburgh,Pennsylvania, for the 31st annual meet-ing, tentatively titled “TranslatingResearch Into Practice: EnhancingEducation, Patient Care, and CommunityHealth,” April 9-12, 2008. We look for-ward to seeing you there!

SGIM

To provide comments or feedback about From theSociety, please contact Francine Jetton at jet-tonf@sgim.org.

POLICY CORNERcontinued from page 4

modest and their risk high. Their con-cerns largely involve fees and access topatients. Neither physician nor hospitalgroups have the political clout they hadhalf a century ago, when they held upthe creation of Medicare for years.Nevertheless, a Congress facing a poten-tially contentious dispute over a specificplan to increase insurance coveragewould be hesitant to go forward againstthe opposition of those who providecare, short of a major shift in the closely

balanced party splits in the House andSenate we have now.

The common thread here is that thosewho are doing well with the status quomay support the concept of getting morepeople health insurance but may not sup-port specific plans because they fear thoseplans will make them worse off.Candidates have designed their plans indifferent ways, often to minimize thepotential opposition. However, suchaccommodations may provoke opposition

from other interests not directly relatedto health care, such as those who fear theoverall expense of an expansive new pro-gram. Getting a program that moves usmuch or all of the way toward universalhealth insurance coverage will be a deli-cate balancing act, requiring both politi-cal courage and compromise. SGIM

To provide comments or feedback about PolicyCorner, please contact Mark Liebow atmliebow@mayo.edu.

IN TRAININGcontinued from page 8

after you leave a practice) and who isresponsible for it.

8. Have an attorney knowledgeable inHealth Law review your contract afteryou have negotiated it yourself or havehim/her negotiate it for you.

Additional resources to help you learnthe art of the deal:

1. Getting to Yes, by Roger Fisher,William L. Uri, and Bruce Patton.

2. Getting Ready to Negotiate, (Workbookfor Getting to Yes), by Roger Fisher

and Danny Ertel.3. The Power of Nice: How to Negotiate

So Everyone Wins—Especially You!,Ronald M. Shapiro and Mark A.Jankowski.

4. Her Place at the Table: A Woman’sGuide to Negotiating Five KeyChallenges to Leadership Success, byDeborah M. Kolb, Judith Williams,Carol Frohlinger.

5. Women Don’t Ask: Negotiation and theGender Divide, by Linda Babcock andSara Laschever.

6. Physician Employment Contracts, by the

American College of PhysiciansPractice Management Center,February 2007.

7. Business of Medicine, Medscape byWebMD, http://www.medscape.com/businessmedicine

8. Business of Medicine, AmericanCollege of Physicians,http://www.acponline.org/journals/news/busman.htm SGIM

To provide comments or feedback about InTraining, please contact Karran Phillips at karran.phillips@jhmi.edu.

14

CLASSIFIED ADS

Positions Available and Announcements are$50 per 50 words for SGIM members and $100per 50 words for nonmembers. These feescover one month’s appearance in the Forumand appearance on the SGIM Web-site athttp://www.sgim.org. Send your ad, along withthe name of the SGIM member sponsor, toForumAds@sgim.org. It is as-sumed that allads are placed by equal opportunity employers.

SGIM FORUM

Washington—Seeking a BE/BC hospitalist foran established 10-physician, 100% inpatientservice at a 210-bed medical facility. Theprogram is part of a highly supportive multi-specialty group that is owned by one of thelargest physician-led health systems in thePacific Northwest. One week on/one week offblock scheduling, three to four night shifts permonth with no more than two in a row.Competitive compensation package, includingsigning bonus and loan repayment. This areaenjoys an arid climate, mountains, lakes, and300 annual days of sunshine! Outdoorenthusiasts enjoy sports of every kind, makingit an exciting place to raise a family. ContactMichelle “Mickey” Conner at mconner@hortonsmithassociates.com or 866.464.3428

Position AvailableClinician-Educator

Division of General Internal MedicineDepartment of Medicine

Johns Hopkins University

Recruiting highly motivated experiencedinternist/s for a full-time Assistant Professor orAssociate Professor position.

Responsibilities include: clinical practice;executive health evaluation; medical student,resident, and fellow education; andopportunities to participate in clinical andeducational research and other scholarlyactivities.

Candidates must be Board-eligible orBoard-certified and have a Maryland medicallicense (active or pending).

Johns Hopkins is an affirmative action,equal opportunity employer.

Mail or fax cover letter and curriculumvitae to:

John A. Flynn, M.D., M.B.A.Clinical Director, Division of GeneralInternal MedicineDepartment of MedicineJohns Hopkins University601 North Caroline Street #7143Baltimore, MD 21287Fax (410) 614-1195

Medical Director—Outpatient Services,Division of General Internal Medicine,

Mount Sinai School of Medicine

The Division of General Internal Medicine ofMount Sinai School of Medicine seeks aMedical Director for its Primary Care Practice,Internal Medicine Associates (IMA). IMArecords over 50,000 visits annually and is theclinical practice site for 40 faculty, 4 fellows,and 130 residents.

The Medical Director oversees the qualityof care and the clinical educational outpatientservices for the Division. These responsibilitiesinclude all scheduling of house staff and facultyfor patient care and precepting, working closelywith the Nurse Manager and the DivisionAdministrator in these tasks. The Directorinterfaces with the Director of InpatientServices in the Division to coordinate inpatientTeaching schedules. Ongoing issues theDirector addresses include: continuity of carefrom inpatient to outpatient, curriculum etc.surrounding resident education, billing andcoding, outpatient productivity, coordinatingweekly practice chiefs meetings, developingresident research projects, and communityrelations. The Medical Director reports directlyto the Division Chief. Resume and cover letterto Thomas McGinn, M.D., Chief, atthomas.mcginn@mountsinai.org. Mount Sinaiis an Affirmative Action / Equal EmploymentOpportunity employer.

Internal Medicine

The Minneapolis VAMC has immediateopenings for full time BC/BE Internal Medicineprimary care providers at the Minneapoliscampus and at an affiliated clinic in the metroarea. Opportunities are available for teachingUniversity of Minnesota medical residents andmedical students. Will work collaborativelywith mid-level providers. The MinneapolisVAMC, a dynamic and stimulating facility, isclosely affiliated with the University ofMinnesota.

Please send a letter of interest and a CV to

Don Weinshenker, MD, General Medicine Section (1110), One Veterans Drive, Minneapolis, MN 55417,phone: 612-725-2158; fax: 612-725-2118. ORcontact Marion Johnson, Human Resources:612-725-2060; fax 612-725-2287; e-mail marion.i.johnson@va.govSorry no J1 opportunities. Equal Opportunity Employer.

Internal Medicine - Outpatient Clinic

The Department of Veterans Affairs MedicalCenter in Minneapolis, MN is seeking a fulltime internist for the Outpatient Clinic,located in the Duluth/Superior area. Thisphysician will have responsibility for a primarypatient panel. The physician should be boardcertified or board eligible in Internal Medicineand hold a current, unrestricted license. Hoursof duty are Monday through Friday with nohospital responsibilities.

Contact: Marion Johnson, fax (612) 725-2287; e-mail marion.i.johnson@va.gov; orsend CV and letter of interest to:

VAMCHuman Resources Management Service (05)One Veterans DriveMinneapolis, MN 55417EEO

General Internal Medicine Position LehighValley Hospital—Pennsylvania

Lehigh Valley Hospital, a high-performing,premier academic community hospital, has asuperb opportunity for a general internist tojoin a cohesive, academic general internalmedicine group. We seek an experiencedclinician/educator who has a passion for theunderserved and a commitment to clinicalcare and the education of medical studentsand residents. Join a group of excellentclinician-educators who see patients, teachmedical students and residents, conductresearch, and provide community service. Ourambulatory practices are located four milesapart and our patients are seen in our mainAllentown campus and at our downtowncampus where we serve a large minoritycommunity in a multidisciplinary setting.Responsibilities also include managinginpatients on our TSU (transitional skilledunit), and participating in medical studentand resident education. Lehigh ValleyHospital comprises over 800 beds on 3campuses in the contiguous cities ofAllentown and Bethlehem, and is nationallyrecognized for quality and clinical innovation.We are located in a beautiful suburban area 1hour north of Philadelphia and 1.5 hours westof New York City that has good schools,numerous colleges and diverse cultural andrecreational offerings. Interested BC internistsshould email a CV to Debbie Salas-Lopez,MD, Chief, Division of General InternalMedicine, c/o Tammy.Jamison@LVH.com, orcall (610) 969-0207 for more information.Visit our website at www.LVH.org

15

The University of Arizona, College of Medicine

The Department of Medicine, Section of General Medicine, invites applications for aGeneral Medicine Section Chief at the Associate or Professor level, tenure or non-tenure eli-gible. The Department is seeking an individual of national renown with demonstrated lead-ership in research and education with a record of funding and publications in peer-reviewedjournals. Of interest would be a candidate with research interests in Health Promotion and/orHealth Disparities, Medical Decision Making, or Information Technology. The expansion ofthe Health Sciences Campus at a second teaching hospital with a diverse ethnic and socioe-conomic demographic would provide an ideal setting for these research efforts. Strong col-laborations are possible with the UA college of Medicine in Phoenix, College of PublicHealth, the Arizona Cancer Center Cancer Prevention Program, and the Diabetes Center.The chosen candidate will guide and supervise all clinical and academic aspects of theSection of General Medicine including management of overall section operations, and thedevelopment and supervision of teaching, research, clinical, financial and human resources.This position includes a comprehensive benefits package. Tucson, AZ offers an unsurpassedquality of life with diverse cultural and outdoor activities. Department of Medicine ChairmanSteve Goldschmid, M.D. invites interested candidates to go online to: http://www.hr.arizona,click on “Applicant Resources”, “apply for jobs”, “Search Postings”, enter Job #35637, andfollow directions to apply for position. Application review will continue until the position isfilled. The University of Arizona is an EEO/AA-Employer-M/W/D/V.

DIRECTOR ACADEMIC HOSPITALIST PROGRAM

The Division of General Internal Medicine at the University ofCincinnati College of Medicine, Cincinnati, Ohio, is seeking aDirector of our Academic Hospitalist Program. This is an outstandingopportunity to manage, lead, and provide vision to our growing hospi-talist program at University Hospital. UC is one of a select group ofrecent recipients of an Education Innovation Project award thatencourages creative redesign of Internal Medicine Residency. As such,there are numerous opportunities to participate in performanceimprovement activities on both teaching and non-teaching services.The hospitalist program provides a “real world laboratory” for appliedresearch examining the impact of the program and other performanceimprovement innovations. Faculty in the Division of GIM have theopportunity to participate in a variety of clinical teaching activitieswith residents and medical students and may collaborate withresearchers in our Center for Clinical Effectiveness. Successful candi-dates will be BC/BE in Internal Medicine, have a passion for inpatientmedicine and teaching, and an interest in developing research opportu-nities in the area. Leadership experience would be helpful.

Interested applicants should submit a CV and cover letter to Mark H.Eckman, M.D., Director, Division of General Internal Medicine,University of Cincinnati Medical Center, 231 Albert Sabin Way, POBox 670535, Cincinnati, OH 45267-0535, or via e-mail toMark.Eckman@uc.edu. AA/EOE.

FORUMSGIM

Society of General Internal Medicine2501 M Street, NWSuite 575 Washington, DC 20037