American College of Physicians: Internal Medicine — Doctors for Adults ®

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Internal Medicine 2014 News



Scientific Meeting News for April 11, 2014




Highlights

Nurture a good 'marriage' with your EHR

"Selecting a new EHR [electronic health record] is kind of like dating and marriage," said Nareesa A. Mohammed-Rajput, MD, MPH, FACP. "You are going to be tied to this EHR for a while." More...

A tour of oncologic horrors in the hospital

In what he called a "whirlwind tour of the horrors of medical oncology," Christian T. Cable, MD, FACP, outlined the perils that may befall cancer patients, and what to do about them, in a session Thursday morning called "Oncologic Emergencies." More...


Breaking news

ACP offers recommendations for reducing gun-related injuries and deaths in the U.S.

A new ACP policy paper offers 9 strategies to address the societal, health care, and regulatory barriers to reducing firearms-related violence, injuries and deaths in the United States. More...

Annals of Internal Medicine publishes annual updates in internal medicine

Annals of Internal Medicine has published summaries of the most important medical studies of 2013 in the fields of women's health; hematology and oncology; endocrinology; hospital medicine; rheumatology; cardiology; geriatrics; gastroenterology and hepatology; and pulmonary, sleep, and critical care medicine, to coincide with Internal Medicine 2014. More...

Internists release policy paper on medical liability crisis

ACP released a policy paper on the medical liability crisis, which continues to have a profound effect on the medical system. "Medical Liability Reform—Innovative Solutions for a New Health Care System" provides an update of the medical liability landscape as well as state-based activity on medical liability reform and summarizes traditional and newer reform proposals and their ability to affect system efficiency and encourage patient safety. More...


For attendees

Meet the Consult Guys

Stop by the Annals of Internal Medicine booth today to meet The Consult Guys! More...

Panel session to be held today on evolution of new payment models: how to prepare and prosper

A panel session will provide an environmental scan of how physicians are faring as they transition from current fee-for-service to more value-oriented payment models such as shared savings, comprehensive payment for primary care services, and bundled payment for specialty (gastroenterological) services. More...

It's not too late to submit a profile to the ACP Job Placement Center

Looking for a job? ACP's Job Placement Center offers career opportunities during Internal Medicine 2014. Submit a Job Seeker's Profile (mini-CV) to be included in 1 of 2 booklets based on your criteria. Your profile is guaranteed to be distributed to participating employers who submit a job posting to the center. You do not have to attend the meeting to submit a profile. More...


Highlights


.
Nurture a good 'marriage' with your EHR

"Selecting a new EHR [electronic health record] is kind of like dating and marriage," said Nareesa A. Mohammed-Rajput, MD, MPH, FACP. "You are going to be tied to this EHR for a while."

Dr. Mohammed-Rajput, who is physician-electronic medical record (EMR) lead at Johns Hopkins Community Physicians in Silver Spring, Md., offered suggestions on optimizing an existing EHR, as well as deciding whether to move on to a new system, during a Thursday-morning session titled "Treating EHR Pain: Time to Replace It?"

One question to consider, she said, is "How can you make what you have work a little better for you?" Clinicians can get ideas on optimizing an existing system by working with their EHR vendor or a consultant, by going to a vendor-specific user group meeting, or by networking with other people who use the same system, Dr. Mohammed-Rajput said. She outlined 3 types of optimizations that physicians are usually looking for.

The first, a "break-fix," is when something in the system is broken or doesn't work as designed, she said. Enhancements, by contrast, are something the EHR is able to do after a patch is applied, for example, allowing the physician to see notes and labs at the same time. Vendor development issues are functionalities that aren't yet available, as Dr. Mohammed-Rajput described: "If they haven't quite yet figured out how to do it yet, they've got it in research or development or something like that, that would be a vendor development-type issue."

When you're ranking optimization requests, those that affect patient safety should be first, followed by those that affect physician productivity and those that have an impact on revenue, Dr. Mohammed-Rajput said. Other issues to consider include regulatory compliance, organizational impact, and the work effort required to build and implement the improvements, she said.

If you decide to add new features to your existing EHR, it's vitally important to back up your current data in case the EHR upgrade fails, Dr. Mohammed-Rajput said. "I can't tell you how many times that we've tried to go for an upgrade. We're all excited, we're pumped, we're ready to go, and the new upgrade completely crashes the system. Everything goes down, it's corrupted, nothing works," she said.

Also, she advised, thoroughly test the upgrade before the go-live date to make sure it works the way you want it to. "How are your new features going to affect data collection?" she asked. "How is it going to affect your workflow?"

If you decide that tweaks and additional features aren't enough and it's time for a new EHR, write a list of what you hate about your existing system and why, Dr. Mohammed-Rajput said.

"You're going to refer to that many times during the process of 'Why am I changing to a new EHR?' because it's the devil you know versus the devil you don't. If you write down all the things you hate about your current EHR, that will help remind you why you're changing," she said.

A good source of information on different available systems is AmericanEHR.com, an ACP partner. Dr. Mohammed-Rajput joked that it is "sort of like eHarmony for EHR shopping." It can help you see what's out there and what others have said about their systems, she said.

When you're deciding on a new system, keep referring to the list you made about why you hate your current EHR, Dr. Mohammed-Rajput advised. "Write it on a piece of paper. Laminate it. Keep it and look at it and refer to it all the time," she said. "You know why you hate your current EHR. Don't go looking for the same thing in another vendor."

You should consider how much it will cost to purchase a new system, how much ongoing maintenance will cost, and what your hardware needs will be, Dr. Mohammed-Rajput advised.

Another important piece of the puzzle is data conversion. "It's taken you years to populate your current EHR," she stressed. "When you open up that new EHR, it's not going to magically populate with all the data that you had historically."

Once you've found an EHR you think you might like, ask the vendor for an on-site demo, Dr. Mohammed-Rajput recommended. Analyze your office workflows and test how the EHR would work in specific situations. "It's going to be kind of hard to tell until you sit down and actually lay hands on it and run through something you'd do every day, 100 times a day," she said.

Consider also where your data will be hosted, Dr. Mohammed-Rajput said. With external hosting, the data are in the cloud and software can be accessed via the Internet. A monthly charge can be associated with this option. With internal hosting, the data are hosted on local servers and the software can be owned by the practice. "It's kind of like Microsoft Word, where you buy a copy of it and it's yours," Dr. Mohammed-Rajput said.

Another important consideration is whether the vendor owns the data or whether you do, especially in the EHR you're ditching. "If the EHR vendor owns the data, when you're getting ready to change over to your new EHR, they may not give the data to you," Dr. Mohammed-Rajput said.

If the vendor won't give you the data and you don't want to purchase them, you may need to print out patient records and manually enter all the old data into your new system, a tedious and time-consuming process, Dr. Mohammed-Rajput said.

"When you're looking for a new EHR vendor, please make sure that it's somewhere written in [the contract] that the data is yours, not theirs," she stressed.


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A tour of oncologic horrors in the hospital

In what he called a "whirlwind tour of the horrors of medical oncology," Christian T. Cable, MD, FACP, outlined the perils that may befall cancer patients, and what to do about them, in a session Thursday morning called "Oncologic Emergencies."

"What could go wrong? The short answer is, a lot," said Dr. Cable, who is the hematology/oncology fellowship director at Scott & White Healthcare in Temple, Texas, and associate professor of medicine at Texas A&M University Health Science Center in Temple. "I'll focus on the first 12 hours after patients present to the ED."

Common crises that could be thought of as mechanical include increased intracranial pressure (ICP) from brain metastases, spinal cord compression, and superior vena cava syndrome, he said.

Patients with ICP from brain metastases often present with headache, as well as nausea, sleepiness, elevated blood pressure, and low pulse. The diagnosis is made by MRI. The treatment is dexamethasone at an initial IV dose of 10 mg, with subsequent doses given orally, if swallowing ability allows. Dosing is 4 mg 4 times a day in the hospital and 8 mg twice a day once discharged, since the lower frequency improves adherence, Dr. Cable said.

Neurosurgical consultation is appropriate for patients with low-volume disease, high-performance status, and isolated metastases. A radiation oncology consultation is appropriate in cases of more extensive disease and for patients who are not good surgical candidates, he said.

"Radiotherapy requires going back and forth to the hospital 10 times for treatment," Dr. Cable said. "If someone is very sick and dying, palliative care may be the better option."

The chief symptom with spinal cord compression is usually back pain, although patients often also report a decreased ability to exercise, he said. "People will report that they used to be able to walk a mile in 20 minutes and now it takes 30, or that climbing a flight of stairs is difficult when it usually is not," Dr. Cable said.

It's important to do an MRI of the whole spine when diagnosing, because isolated cord compression is quite rare, he added. Treatment is with the same steroid dosing regimen as for brain metastases. Fit patients—i.e., those who are able to walk, not be wheeled, into the hospital—are candidates for neurological consult, he said.

The more usual intervention, though, is radiation oncology consultation. "About 1 in 10 of the spinal cord compression patients go on to surgery in our practice," he said.

Patients with superior vena cava (SVC) syndrome usually report difficulty breathing. Physical examination may show slight tachypnea and tachycardia, bilateral firm supraclavicular lymph nodes, crisp heart tones, clear lungs, prominent chest wall veins, and a plethoric face, he said.

The gold standard for SVC treatment is chemotherapy or radiotherapy directed to the tumor, Dr. Cable said. SVC is often seen in small-cell lung cancer and lymphoma (Hodgkin or primary mediastinal non-Hodgkin lymphoma), he said.

Metabolic problems that lead to emergent treatment for cancer patients include tumor lysis syndrome (TLS) and hypercalcemia.

Abnormal labs are a red flag for TLS, particularly high creatinine, high potassium with early ECG changes (hyperkalemia), and high phosphorous levels—basically "an acute metabolic mess," said Dr. Cable.

For therapy, use IV hydration, noncalcium phosphate binders, and rasburicase, which is a recombinant enzyme that dramatically solubizes uric acid, he said. "With this, your phosphorous can go from 13 to 4 in 4 hours," he said.

If the TLS patient's case is severe, he or she should have telemetric monitoring and electrolyte assessments every 4 to 6 hours until stable, he added.

Malignant hypercalcemia patients will present with decreased mentation and may be sleepy. On physical examination, they will have elevated creatinine, low albumin, and a high calcium (approximately 16, for example), with associated risk of renal failure.

The first therapeutic priority is to rehydrate; if renal failure is present, hydration will often resolve it. "And, it seems obvious, but hold the calcium supplements," Dr. Cable said. IV bisphosphonate should be given, as well. In the hospital, pamidronate can be given—it's cheaper and better for the kidneys—while zoledronic acid is usually used for outpatients because it's fast.

Mechanical and metabolic events tend to be "low frequency and high stakes," but the main infection problem in cancer patients—neutropenic fever—"is something almost all hospitalists take care of," Dr. Cable said.

Cancer patients with a temperature of at least 101° F should be examined for neutropenic fever, he said. They typically have no other signs of systemic inflammatory response syndrome (SIRS), no localizing signs of infection, no mucositis, and a clean central line exit site, he said.

Low-risk fever patients—whom the physician expects to have neutropenia for less than 7 days—can be given outpatient antibiotics. These patients often include those with solid tumors, few comorbidities, and normal renal and hepatic function or those who don't appear sick. They are typically given ciprofloxacin or levofloxacin plus amoxicillin/clavulanic acid.

"If you have a low-risk patient admitted overnight, you can switch from [initial] IV to oral antibiotics and discharge [the next day] as long as you have a good follow-up plan," Dr. Cable said.

High-risk patients, whom you expect to be sick for more than 7 days, should be started in the hospital on antipseudomonal monotherapy: cefepime, meropenem, imipenem-cilastatin, piperacillin-tazobactam, or ceftazidime. High-risk patients also should get vancomycin if they are very sick, have an infected line, and/or have bad mucositis, he said.

Certain drugs can cause toxicity in cancer patients—both the "old classic dangerous drugs, of which there are 3, and then the whole new level of hell, the new drugs," Dr. Cable said.

The old drugs conveniently follow an ABC format: adriamycin, bleomycin, and cis-platinum.

Adriamycin, or "the red devil," is used in many cancer treatment regimens and carries a congestive heart failure risk of 5% for patients at a lifetime dose of 500 mg/m2.

Bleomycin is used only to treat testicular cancer or Hodgkin lymphoma and can cause pneumonitis and fibrosis; steroids are recommended to treat the inflammation of toxicity.

Cis-platinum is used in many regimens and is an important treatment for testicular and head and neck cancer. The symptoms of toxicity from it are an inability to urinate, feel one's toes, or stop vomiting. Cis-platinum toxicity causes renal magnesium wasting "like very few other things," he said. "If the potassium goes down and you can't bring it up, it is probably because it will take more magnesium than you thought possible."

The new dangerous drugs are the "mabs" and the "nibs"—i.e., the monoclonal antibodies, like trastuzumab, and the tyrosine kinase inhibitors, like imatinib.

"Nibs" are given orally and usually have multiple targets. "These tend to be dirty drugs with multiple side effects, and they affect the QT interval," Dr. Cable said. "Ask [pharmacy] to help you with the drug interaction and med reconciliation."

"Mabs" are IV drugs that have more discreet targets and usually don't affect the QT interval. Symptoms, such as with bevacizumab, can include hypertension, proteinuria, clotting and bleeding problems, and wound perforation, he said.



Breaking news


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ACP offers recommendations for reducing gun-related injuries and deaths in the U.S.

A new ACP policy paper offers 9 strategies to address the societal, health care, and regulatory barriers to reducing firearms-related violence, injuries and deaths in the United States. "Reducing Firearm-Related Injuries and Deaths in the United States" appeared online April 10 in Annals of Internal Medicine.

Principal among ACP's 9 strategic imperatives is the recommendation to approach firearm safety as a public health issue so that policy decisions are based on scientific evidence. As such, ACP strongly supports universal criminal background checks to keep guns out of the hands of felons, persons with mental illnesses that put them at greater risk of harming themselves or others, people with substance use disorders, and others who are prohibited by current regulations from owning guns.

The United States has the highest firearm-related mortality rate among industrialized nations. ACP believes that a comprehensive, multifaceted approach is necessary to reduce this epidemic of gun violence and that physicians play a vital role.

"Patients have long trusted their physicians to advise them on issues that affect their health," said Molly Cooke, MD, MACP, president of ACP. "Physicians can play a critical role in educating the public on the risks of firearm ownership and the need for firearm safety through their encounters with their patients. ACP strongly believes the patient-physician relationship should be protected from laws that prevent physicians from initiating a discussion about guns."

To inform its policy position, ACP's Health and Public Policy Committee conducted a comprehensive review of the available data on the impact of access to firearms, mental health, state and federal firearms laws, and efforts to reduce firearms violence. ACP also surveyed a large, nationally representative panel of internists in the United States about their attitudes on firearms and firearm injury prevention.

"We concluded that firearm violence is not just a criminal justice issue, but also a public health threat that requires the nation's immediate attention," said Thomas Tape, MD, FACP, chair of ACP's Health and Public Policy Committee. "As an organization representing physicians who have first-hand experience with the devastating impact of firearm-related violence, ACP has a responsibility to participate in efforts to mitigate needless tragedies."

Survey results suggest that ACP's position is supported by internists. Eighty-five percent of internists surveyed believe that firearm injury is a public health issue and 76% support stricter gun control legislation. An overwhelming majority of respondents favor mandatory background checks, mandatory registration of all firearms, and bans on assault weapons, high-capacity magazines, and armor-piercing bullets. A full report on the physician survey was published in Annals of Internal Medicine.

Other recommendations in the policy paper include the following:

  • ACP supports appropriate regulation on the purchase of legal firearms to reduce firearms-related injuries and deaths, acknowledging that any such regulation must be consistent with the Supreme Court ruling establishing that individual ownership of firearms is a constitutional right under the Second Amendment of the Bill of Rights.
  • ACP recommends that guns be subject to consumer product regulations regarding access, safety, and design. In addition, the College supports law enforcement measures to aid in the identification of weapons used in crimes.
  • ACP believes that firearm owners should adhere to best practices to reduce the risk of accidental or intentional injuries or deaths from firearms.
  • ACP cautions against broadly including those with mental illness in a category of dangerous individuals. ACP recommends that every effort be made to reduce the risk of suicide and violence through prevention and treatment of the subset of individuals with mental illness who are at risk of harming themselves or others. ACP believes that diagnosis, access to care and treatment, and appropriate follow-up are essential.
  • ACP believes there is enough evidence to enact legislation banning the sale and manufacture for civilian use of firearms that have features designed to increase their rapid killing capacity (often called "assault weapons" or semiautomatic weapons) and large-capacity ammunition and retaining the current ban on automatic weapons for civilian use.
  • ACP supports efforts to improve and modify firearms to make them as safe as possible, including the incorporation of built-in safety devices.
  • ACP believes that more research needs to be funded on firearm violence and on intervention and prevention strategies to reduce injuries caused by firearms. Access to data should not be restricted.

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Annals of Internal Medicine publishes annual updates in internal medicine

Annals of Internal Medicine has published summaries of the most important medical studies of 2013 in the fields of women's health; hematology and oncology; endocrinology; hospital medicine; rheumatology; cardiology; geriatrics; gastroenterology and hepatology; and pulmonary, sleep, and critical care medicine. All articles were published within the last year in some of the world's most prestigious medical journals. Authors in each topic area chose articles based on novelty and quality of the research, as well as potential impact on clinical practice.

Publication of the updates coincides with Internal Medicine 2014. Each update includes detailed summaries of several articles pertaining to a particular subspecialty of internal medicine. Highlights include the following:

  • Women's health: An article published in The Lancet found that continuing adjuvant tamoxifen treatment for 10 years reduced recurrence and increased survival in women with estrogen receptor-positive breast cancer. Much of the research selected for this section focused on the importance of individualizing counseling, screening, and treatment strategies on the basis of patient characteristics.
  • Hematology and oncology: An article in Annals of Internal Medicine found that limiting D-dimer testing to patients with a low or moderate pretest probability of having a first episode of deep venous thrombosis reduces the number of tests. An article published in the Journal of Clinical Oncology found that maintenance chemotherapy benefits patients with advanced nonsquamous non-small-cell lung cancer.
  • Endocrinology: An article published in the Journal of Clinical Endocrinology and Metabolism showed that minimally invasive therapy is safe and effective and can be used for symptomatic benign thyroid nodules. In addition to thyroid, articles on diabetes practice and bone medicine were also included in the update.
  • Hospital medicine: Articles selected were practice-changing. Among them, a study published in the New England Journal of Medicine found that fecal microbiota transplant is more effective than vancomycin for recurrent Clostridium difficile infection. An article published in Annals of Internal Medicine showed that aspirin is noninferior to low-molecular-weight heparin for venous thromboembolism prevention after elective hip replacement.
  • Rheumatology: Many of the articles selected focused on high-value care. Comparisons of traditional methods of treating rheumatoid arthritis to novel (and more expensive) therapies showed traditional methods to be more effective. An article published in Annals of Rheumatic Diseases showed fish oil to be an effective adjunctive therapy for recent-onset rheumatoid arthritis.
  • Cardiology: Many of the articles selected focus on high-value care. Advances were particularly significant in the field of hypertension. New treatment guidelines increase the percentage of patients with hypertension control and aim to reduce the risk of cardiovascular disease, stroke, heart failure, atrial fibrillation, and diabetes.
  • Geriatrics: An article in Annals of Internal Medicine found that brief screening instruments can help detect dementia in the primary care setting. In addition to dementia, articles selected for this section address cognitive impairment, hospital readmissions, adverse drug events, and falls.
  • Gastroenterology and hepatology: An article in the New England Journal of Medicine found that a restrictive transfusion strategy reduced mortality in patients with acute upper gastrointestinal bleeding. An article published in Clinical Gastroenterology and Hepatology suggested that individuals who consume a high-fiber diet and have more frequent bowel movements are at greater risk for having diverticulosis.
  • Pulmonary, sleep, and critical care: An article published in the New England Journal of Medicine suggested that using a risk stratification model for computed tomography screening of lung cancer significantly improved the rate of false-positive results per cancer deaths prevented. An article in the Journal of the American Medical Association found that highly trained primary care physicians can effectively treat some cases of obstructive sleep apnea. Also in JAMA, investigators found that adding vasopressin and steroids significantly improved survival in patients who develop cardiac arrest while hospitalized.

Summaries of all of the update articles can be accessed online.


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Internists release policy paper on medical liability crisis

ACP released a policy paper on the medical liability crisis, which continues to have a profound effect on the medical system. "Medical Liability Reform—Innovative Solutions for a New Health Care System" provides an update of the medical liability landscape as well as state-based activity on medical liability reform and summarizes traditional and newer reform proposals and their ability to affect system efficiency and encourage patient safety.

"While medical liability premiums have leveled off in the past few years, physicians still fear litigation, expect lawsuits, and feel the psychological burden of navigating the complex medico-legal system," said Molly Cooke, MD, MACP, president of ACP. "Patients harmed by medical negligence also suffer under the existing medical liability system."

Medical liability claims may take years to be decided, and verdicts and award amounts may hinge on the laws and legal climate of the state in which they are filed. ACP's previous policy paper on medical liability reform in 2003 was published in the wake of a medical liability crisis seemingly brought on by surging plaintiff awards and court costs, which in turn propelled liability premiums to historically high levels. That paper reflected ACP's support for a number of federal medical liability reforms, including caps on noneconomic damages, limitations on punitive damages, and a sliding scale for attorney's fees.

Many of those reforms were included in the Help Efficient, Accessible, Low Cost, Timely Health Care (HEALTH) Act of 2002, but the bill was never passed, indicating the lack of Congressional action and the polarized nature of the issue. The HEALTH Act continues to languish in Congress; the latest version was introduced in April 2012.

While traditional medical liability reforms may currently have little chance of passing at the federal level, states have taken action to approve laws that not only establish caps on noneconomic damages but also delve into alternative dispute resolution, injury funds, and statute of limitations on the time frame during which injury claims can be filed.

"Perhaps more promising is the testing of innovative liability protection models, such as health courts, enterprise liability, safe harbor protections, and disclosure laws, which seek to break through the political impasse and create a system that encourages the prevention of errors, improved patient safety, and timely resolution of legitimate claims," Dr. Cooke noted. "Both proponents and opponents of tort reform must realize that the existing health care system allows for too many preventable injuries and that fear of liability undermines the patient-physician relationship"

As outlined in the paper, evidence suggests that traditional tort reforms, particularly noneconomic damage caps, may help reduce liability claims and health care costs. Yet even in states where stringent tort limits have been enacted, physicians remain concerned about medical liability, which may undermine career satisfaction and influence their relationship with patients. It remains unclear whether traditional tort reform improves patient safety and outcomes.

There has been a renewed focus on medical liability reforms that move beyond traditional tort reforms toward creating alternatives to jury trials in favor of quick decisions made by judicial experts, enhanced liability protection for physicians who follow established clinical guidelines and take responsibility for errors, and risk management efforts that focus on ensuring patient safety.

"While preventing errors should remain the paramount goal, these reforms may help lessen physician's liability fears while ensuring that patients are adequately and fairly compensated for any errors that do occur," Dr. Cooke continued. "Promising strides have been made since ACP's last position paper on medical liability was released in 2003."

A solution to the broken medical liability system in the U.S. should include a multifaceted approach, because no single program or law by itself is likely to achieve the goals of improving patient safety, ensuring fair compensation to patients when they are harmed by a medical error or negligence, strengthening rather than undermining the patient-physician relationship, and reducing the economic costs associated with the current system. A multifaceted approach should allow for innovation, pilot-testing, and further research on the most effective reforms.

The American College of Physicians paper provides 9 approaches that should be incorporated into a multifaceted medical liability reform initiative:

  • continued focus on patient safety and prevention of medical errors,
  • passage of a comprehensive tort reform package, including caps on noneconomic damages,
  • minimum standards and qualifications for expert witnesses,
  • oversight of medical liability insurers,
  • testing, and if warranted, expansion of communication and disclosure programs,
  • pilot-testing a variety of alternative dispute resolution models,
  • developing effective safe harbor protections that improve quality of care, increase efficiency, and reduce costs,
  • expanded testing of health courts and administrative compensation systems, and
  • research into the effect of team-based care on medical liability, as well as testing of enterprise liability and other products that protect and encourage team-based care.


For attendees


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Meet the Consult Guys

Stop by the Annals of Internal Medicine booth today to meet The Consult Guys!

Geno J. Merli, MD, MACP, and Howard H. Weitz, MD, MACP, will be available to answer questions or discuss future episode ideas at the Annals booth in the ACP Resource Center in the Exhibit Hall today from 1:00 p.m. to 2:00 p.m. More information on The Consult Guys is online.


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Panel session to be held today on evolution of new payment models: how to prepare and prosper

Payers both in the public and private sector are promoting a transition from current fee-for-service to more value-oriented payment models. A panel session will provide an environmental scan of these changes and offer first-hand advice from physicians who are currently participating in these new payment approaches. Specific models to be discussed include shared savings, comprehensive payment for primary care services, and bundled payment for specialty (gastroenterological) services.

This panel session is scheduled today from 2:15 p.m. to 3:45 p.m. in Room 230. Speakers will include Charles A. Accurso, MD; Donald E. Casey, MD, MPH, MBA, FACP, FAHA; and Bruce Nash, MD, MBA.


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It's not too late to submit a profile to the ACP Job Placement Center

Looking for a job? ACP's Job Placement Center offers career opportunities during Internal Medicine 2014. Submit a Job Seeker's Profile (mini-CV) to be included in 1 of 2 booklets based on your criteria. Your profile is guaranteed to be distributed to participating employers who submit a job posting to the center. You do not have to attend the meeting to submit a profile.

All physicians who submit a Job Seeker's Profile (limit, 1 mini-CV per physician) will be eligible for a drawing for a $100 Amazon gift card on April 12. Winners will be contacted by e-mail.

The Job Placement Center, located in the Exhibit Hall, Booth 1075, provides physicians with tools to assist in job searches, as well as the opportunity to meet with potential employers.

Submit your profile online today.





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