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

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Internal Medicine 2014 News



Scientific Meeting News for April 12, 2014




Highlights

Disclosing errors the right way

If a waiter told you he was sorry you thought your food was cold, then hurried off to another table, would it feel like a sincere apology? That's why it's important to choose your words carefully when disclosing medical errors to patients, one speaker said. More...

Smoking cessation more about controlling urges than quitting cold turkey

Frank T. Leone, MD, FACP, said he sees a lot of ambivalence about smoking cessation among the patients in his clinic. He advised physicians to think of smoking as a disorder of motivation not to quit. More...

Make quality metrics work for you

Quality metrics are key to achieving fame and fortune as a hospitalist, attendees learned Friday morning from Win Whitcomb, MD, a hospitalist and chief medical officer. More...

Consider country, culture when caring for Latino patients

Cultural competence can be defined as patients and doctors coming together to talk about their concerns without cultural barriers, Olveen Carrasquillo, MD, MPH, told attendees at Thursday's panel on "Special Issues in Providing Care to Hispanic and Latino Patients." More...


Breaking news

ACP launches care coordination toolkit to improve communication between primary care, subspecialists

ACP has unveiled a High Value Care Coordination Toolkit designed to enable more effective and patient-centered communication between primary care and subspecialist doctors. More...


For attendees

ACP to conduct Annual Business Meeting

All members are encouraged to attend ACP's Annual Business Meeting to be held today during Internal Medicine 2014. Current College Officers will retire from office and incoming Officers, new Regents and Governors will be introduced. More...

Session shines light on the Sunshine Act

A panel session will provide an overview of a provision of the Affordable Care Act that requires the public reporting of specified transfers of value by health care industry to physicians and teaching hospitals from the perspectives of industry, teaching hospitals, practicing physicians, and ethicists. More...

Panel to examine the role of subspecialists in the PCMH neighborhood

The literature reflects significant problems regarding communication and coordination of services between primary care and subspecialty practices—the transition between the patient-centered medical home (PCMH) and its medical "neighborhood." 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. More...


Highlights


.
Disclosing errors the right way

If a waiter told you he was sorry you thought your food was cold, then hurried off to another table, would it feel like a sincere apology?

Probably not. We know what a sincere apology feels like, and patients do, too. That's why it's important to choose your words carefully when disclosing medical errors to patients, said Wendy Levinson, MD, FACP, a professor in the department of medicine at the University of Toronto Institute of Health Policy, Management and Evaluation, in a Friday session titled "Disclosing Medical Errors to Patients: Considering Where, When and How."

In an error disclosure, patients want to hear an explicit statement that an error occurred, what happened and the implications for their health, why it happened, and how recurrences will be prevented in the future for themselves and other patients.

"And they want an apology. Not a statement of regret like, 'I'm sorry this happened to you,' but a statement such as 'I'm sorry I caused you harm,'" Dr. Levinson said.

Several groups around the world have studied the optimal way to disclose errors, she added. This work, from organizations such as the U.S. National Quality Forum, the Canadian Patient Safety Institute, and the U.K.'s National Patient Safety Agency, tends to have the following guidelines in common:

Begin by stating you regret to say there has been a mistake (or error);

  • Describe the course of events, using nontechnical language;
  • State the nature of the mistake, consequences, and corrective action;
  • Express personal regret and apologize;
  • Elicit questions or concerns and address them; and
  • Plan the next step and next contact (with the patient).

"This is harder than it sounds," Dr. Levinson said. "I've run workshops with fake patients where the physicians are sweating as they practice this. I encourage you to do some role playing around error disclosure."

One tricky issue is whether and how to disclose errors made by other clinicians. Ideally, your institution should offer guidance in how to handle this situation, and you feel comfortable approaching your colleagues to discuss situations that arise.

The disclosure strategy for errors by a colleague likely will depend on the clinical situation, such as whether it involved a physician with whom you were co-managing, or a trainee, or a clinician who didn't have direct contact with the patient.

In the case of co-managing physicians, both should participate in the disclosure regardless of who made the error. In the case of a trainee error, the attending physician and the trainee both should be involved, Dr. Levinson said.

Attendings also should handle disclosure of errors made by a clinician who didn't have direct contact with the patient, although the clinician who made the error should be invited to join if desired, she said.

If the error occurred at another institution or is unrelated to current care, the disclosure should be handled by the medical director at the institution currently caring for the patient, after consultation with the clinician who made the error and/or with the outside institution, she said.

It's important to remember, too, that the actions following an apology are as important as the words used in the apology, said co-speaker Thomas Gallagher, MD, FACP, professor of medicine and of bioethics and humanities at the University of Washington School of Medicine in Seattle.

"We've often been too focused on the words we say to patients but in some respects what's more important are the broader set of actions that follow," Dr. Gallagher said.

Those actions can include institutional changes. Knowing that those are in the works can be a great comfort to patients, who often want to believe that their experience might lead to a positive change for others, he said.

Still, clinicians are often fearful about disclosing errors, he added. "They are anxious about an unpredictable, punitive response by institutions, regulators, and malpractice insurers. And [this fear] hampers efforts to learn and prevent recurrence," he said

Institutions have begun to embrace the idea that errors are their responsibility as well as the responsibility of individual clinicians, Dr. Gallagher said. "Communicating with patients after an unanticipated outcome is now seen as a broader part of how we think about high-quality health care; it isn't just about risk management," he said.

To make their disclosures high quality, institutions should be candid and transparent about unanticipated outcomes, conduct a rapid investigation, offer a full explanation, and apologize as appropriate, Dr. Gallagher said. Furthermore, where appropriate, the institution should seek to provide for the patient's and family's financial needs resulting from the error without requiring recourse to litigation.

Finally, the institution should build systematic patient safety analysis and improvement into its risk management plan, he said.

"Currently, ours is often a system of accountability that doesn't adequately service the patient's need for information, for our accepting responsibility, for timely compensation [when appropriate], and for a sense that we've learned from the mistake," said Dr. Gallagher. "We need to demonstrate to the patient and the public that learning is happening; in many ways, this is the most important thing we miss."


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Smoking cessation more about controlling urges than quitting cold turkey

Frank T. Leone, MD, FACP, said he sees a lot of ambivalence about smoking cessation among the patients in his clinic.

"I want to want to quit," a patient once told him.

His reaction and advice to attendees of his "Smoking Cessation in Primary Care" at Internal Medicine 2014 on Friday morning was, "Think about smoking as a disorder of motivation: not a disorder that's a deficit of motivation to quit, but rather, as a disorder characterized by excess motivation not to quit."

Dr. Leone, who is an associate professor of medicine and director of the Comprehensive Smoking Treatment Program at the University of Pennsylvania in Philadelphia, explained how to turn patient ambivalence into action.

He explained that nicotine works on not the conscious part of a person's thinking, but the survival system of the brain located in the cortex to midbrain. Nicotine creates long-term changes in the brain, including:

  • an increase in neuronal arborization as the patterns linking neurons to one another are altered,
  • an increase in the density of nicotine receptors, and
  • changes in gene expression.

Brain cells maintain these changes, which can result in relapses for years after quitting.

And, nicotine hijacks these brain systems to create a sense of safety and calm. Taking it away causes a negative reaction, and this is what Dr. Leone says he sees in his clinic.

"It's an uncertainty, a visceral uncertainty that stopping now is the right thing to do," he said. "So there's a conundrum. The thinking part of [the patient] says to quit, the visceral part of [the patient] says not today. And [the patient] is stuck between those 2 sides going back and forth, back and forth."

He continued, "I think of this as the cardinal sign of the illness, the same way I think of wheezing as the cardinal sign as asthma or COPD. When I see ambivalence to quit, I'm not afraid of that. I'm not repelled by that. I can't use that as my signal not to treat because it's the cardinal sign."

He offered suggestions on using drugs and devices to help patients control their urges to smoke using nicotine replacement therapy.

Nicotine patches offer a way to deliver controller medications that may reduce the frequency and intensity of the compulsions to smoke. The urges don't disappear, but they become more manageable, he said.

He suggested starting with a high dose to get control and then tapering it. Package inserts say to taper the patch over 8 to 10 weeks, but there are a lot of data that support treating patients longer for better patient response, he noted. While treating for 6 months is good, Dr. Leone said, doing so for 12 months works as well. Using the patch compared to placebo will increase a patient's sensation of control about twofold.

The time frame should be chosen in conjunction with the patient. "If [the patient] is still jonesing at 10 weeks, she's going to come into the office and say should I stop the patch now. That to me is an expression of a misunderstanding on [the patient's] part. She thinks she's supposed to quit, not get control."

The most common side effect of nicotine patches is local irritation, either from the nicotine itself or the adhesive used on the patch. If it's about the adhesive, the redness will be wider than the patch. If it's the nicotine, the redness will be under the patch. Either way, a little dab of hydrocortisone cream before application will cure those 2 side effects, Dr. Leone said.

Patients who smoke on the patch may ask about smoking while on the patch. In the doctor's mind, that means the patient won't smoke. More likely, it means the patient won't use the patch, Dr. Leone said. Tell the patient regardless of smoking to leave the patch on. "Smoking on the patch results in … um … how do you say it? 'Nothing,'" he said.

Patients using nicotine replacement therapies who continue to smoke change their smoking behavior. They take fewer puffs, they take smaller puffs, and their baseline nicotine levels remain the same, Dr. Leone said.

Gums and lozenges are placed next to the oral mucosa and are used instead of a cigarette when patients want to smoke. They generally increase sensation of control by about 50%. Dr. Leone advises patients to use these products like chewing tobacco, not chewing gum, because chewing releases acid to the stomach and makes the patient feel nauseated. Also, the product doesn't get absorbed and it's rendered useless, Dr. Leone said.

Inhalers aerosolize nicotine to the back of throat via a plastic tube and a liquid nicotine cartridge. There are 450 different versions of these products, which are popular with patients, in the U.S., ranging from options that allow people to mix their own cartridges to disposable units found at convenience stores to much more expensive computerized kits.

"None of them have any data on efficacy, how you use them, or how often you use them," Dr. Leone cautioned, adding that there are also no safety data about what happens when patients absorb other products they contain, such as propylene glycol, for years of use.

Two drugs started prior to quit attempts may help patients succeed, Dr. Leone said. Bupropion improves odds of sensations of control 2-fold, he said. While package labels say to start the drug 7 to 10 days before quitting, a lot of data suggest using it 4 weeks prior actually works better.

In the clinic, he tells patients to start bupropion and then "Don't quit smoking."

He added, "I've removed a total obstacle for her not using the medication, because now, it's not about her quitting, it's about how she feels on the inside, and all she has to do is take a pill."

The same is true for varenicline. While it's prescribed for 1 week prior to quitting, it could require 4 weeks to reach effect. The drug comes in a blister pack marked with an arrow indicating that patients should quit smoking on the seventh day of use. Again, he tells patients to ignore that instruction and to keep smoking until the next check-in. Data suggest that going for a total of 5 weeks helps control later urges to smoke, he said.

Contrary to lay media reports about psychiatric disturbances, varenicline simply doesn't cause them, Dr. Leone said. While the drug was associated with a 10-fold increase in sleep disorders, these can be alleviated by taking the drug with food at breakfast and dinner, and not at bedtime, he noted.


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Make quality metrics work for you

Quality metrics are key to achieving fame and fortune as a hospitalist, attendees learned Friday morning from Win Whitcomb, MD, a hospitalist and chief medical officer for Remedy Partners, a health care services company in New York City that administers bundled payments.

It probably won't be celebrity-level fame and fortune—although Dr. Whitcomb did point out that both U.S. News & World Report and Consumer Reports publish hospital ratings—but measures are beginning to carry real money and the chance "to be publicly embarrassed or publicly made to look wonderful," he said.

Readmissions penalties and value-based purchasing (VBP) are scheduled to affect an increasing percentage of hospitals' Medicare payments over the next few years, and hospital-acquired conditions will attract new penalties beginning in 2015. The numbers may be small right now, but they will add up.

"By the time we get to 2017, with these 3 programs, a medium-sized hospital will have $5 million at risk," said Dr. Whitcomb.

Those numbers may frighten hospital executives, but hospitalists who provide high-value care could actually benefit, because their efforts will be essential to hospitals' financial success. "I see this as a major opportunity for hospitalists," Dr. Whitcomb said.

Hospitalists will also be involved in CMS's new effort to evaluate and reward health care efficiency. The measure, which debuts in 2015 but will actually be based on 2013 data, compares all Medicare Part A and B spending per beneficiary from 3 days prior to a hospitalization to 30 days after discharge. "It's actually a lot like a bundled payment," said Dr. Whitcomb.

Another change to quality measures is that they're going to begin affecting physician income, and not just as a trickle-down from hospital charges. Medicare's Value-Based Payment Modifier (VBPM) will raise or lower physician payments by 1% or 2%, starting with groups of 100 or more doctors in 2015 and including all doctors in 2017.

That's not a lot of money, Dr. Whitcomb noted, and the Physician Quality Reporting System (PQRS), on which the VBPM is based, has only lured 30% of physicians to participate. "It's been a hard program to participate in," said Dr. Whitcomb, who showed calculations indicating that a typical hospitalist with $450,000 in annual charges would only gain about $700 in the PQRS program.

The VBPM measures relevant to hospitalists include things like prescribing antiplatelets to patients with coronary artery disease, screening for dysphagia after stroke, and treating atrial fibrillation with warfarin. "You and I can decide whether these are our picture of what a great hospitalist is or not," said Dr. Whitcomb.

That debate is the biggest problem with quality metrics, said Dr. Whitcomb, whose talk was subtitled "The Good, the Bad and the Ugly." Critics have charged that the qualities of hospitalists that really count—including timely diagnosis and treating complicated patients—aren't measured.

And it's clear that documentation decisions have a major impact on results. For example, concern over hospital-acquired conditions will likely drive your hospital's coding experts to flag any catheter-associated infections you note, if they haven't started already. "Think about what you write in the chart," said Dr. Whitcomb advised.

Another challenge is the difficulty of measuring the performance of any individual physician, which there will be an increasing push to do. "Any outcome measure that's applied at the individual physician [level] is very tough to do," Dr. Whitcomb said.

He showed the audience an example of his own Joint Commission-required Ongoing Professional Practice Examination (OPPE) report, describing the statistics on it as "mysterious." This measurement, which compares one's resource utilization and metrics like 30-day mortality to an unspecified peer group, is meant to eventually determine physician credentialing, but how that would work is "very vague right now," he said.

Then there's patient satisfaction scoring. The HCAHPS were never meant to assess satisfaction with individual physicians, and even more targeted surveying, such as that done by Press Ganey, poses problems when hospitalists are compared to other physician specialties.

According to such surveys, "Patients are least satisfied when they are on the psychiatry inpatient service. Next to that it's us," Dr. Whitcomb said, to laughs from the audience. Patients admitted through the emergency department also have particularly low satisfaction, meaning that hospitalists are very likely to score low in across-specialty comparisons. "We really need to be compared to like physicians," he said.

Dr. Whitcomb encouraged his audience to push their hospitals for hospitalist-specific satisfaction surveying. He also suggested they investigate the metrics they're being measured on, asking questions like "If you're being measured on a process measure, is it something that affects outcomes? If it's an outcome, is the sample size big enough to be valid?" and "Is it something you have influence over?"

In answer to that last question, it may necessary to broaden your perspective to encompass new, more expansive concepts of team care, such as accountable care organizations. "I think we have to get past that thing of 'We have no control over it,'" said Dr. Whitcomb. "Maybe you do have control if you work as a team."

And, finally, whether you're evaluating, reviewing, or just complaining about quality metrics, don't forget the whole reason for their existence. "Quality metrics to me don't mean all that much if we don't move past measurement to improvement," said Dr. Whitcomb. "Isn't that the real reason why we're here? Let's not lose sight of that."


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Consider country, culture when caring for Latino patients

Cultural competence can be defined as patients and doctors coming together to talk about their concerns without cultural barriers, Olveen Carrasquillo, MD, MPH, told attendees at Thursday's panel on "Special Issues in Providing Care to Hispanic and Latino Patients."

Doctors did their own version of that during the session, airing concerns related to caring for Latino patients. (The terms Hispanic and Latino are mostly interchangeable, Dr. Carrasquillo noted, although Hispanic is more prevalent in Texas and Latino in California, and the latter term is preferred by some because it has less of a colonial connotation.)

Dr. Carrasquillo, a professor of medicine at the University of Miami, started the session by offering some background on Latino demographics. Latinos are a rapidly growing ethnic group (not a race, since the definition is based on country of origin rather than skin color, he noted) in the U.S., expected to comprise 1 in 3 Americans by 2060.

The bad news in Latino health is that many Latinos lack insurance coverage, and the decision of many Latino-heavy states to refuse Medicaid expansion means that relatively few will gain coverage under the Affordable Care Act. "If we include the undocumented, it's about 40% to 50% of Latinos that are not going to benefit from health insurance expansion," said Dr. Carrasquillo.

The good news is that U.S. Latinos continue to live longer than their peers despite limited access to care and higher rates of some conditions, including obesity and diabetes, a phenomenon known as "the healthy Latino," Dr. Carrasquillo said.

"Hispanics have much lower death rates than blacks and even non-Hispanic whites," he said. Researchers have thoroughly examined this decades-long disparity in life expectancy and have still not found an answer, he reported.

More answers have been found, however, about the best ways to make a medical practice welcoming to Latino patients. Brendaly Rodriguez, a health communication specialist at the University of Miami, offered some general suggestions.

"It's not a checklist, because it could lead to oversimplification and thinking that all Mexicans believe [this or] that," she said. Physicians should try to learn specifically about the patients they're treating by collecting information about race, ethnicity, primary language spoken, and even the history of the patient's country of origin.

"To know about Dominicans, you need to know about the Trujillo years," Ms. Rodriguez gave as an example, referring to the dictator Rafael Trujillo, who controlled the Dominican Republic from 1930 to 1961.

She encouraged clinicians to ask open-ended questions, investigate patients' barriers to care, and use community health workers. She also strongly urged practices to use professional translators, rather than relying on friends and family (whose stake in the conversation could lead them to distort the translation) or one's own less-than-fluent language skills.

One audience member asked about learning more medical Spanish to communicate with his patients, and the panelists lauded his intentions but cautioned him not to tackle any complex conversation. "Patients greatly appreciate you making any effort to speak their language, but you really shouldn't wing it," Dr. Carrasquillo said.

Another audience member asked for any advice on improving patient satisfaction scores among Hispanic patients, who tend to rate satisfactory care at a lower number. Dr. Carrasquillo said he hasn't found a good solution yet, having seen 1 hospital instruct patients to give 5s and others lobby the measurement companies to adjust Hispanic patients' scores. "Often their anchoring point is around 3 or 4," he said.

Palliative care may be another area where clinicians notice differences in how Latino patients respond. "There's more honesty about end of life. We try less futile care," said panelist Moises Auron, MD, FACP, a hospitalist at the Cleveland Clinic. "The main thing is being very open with the patient and the family and explaining what palliative care means. When they understand it is not throwing in the towel, it is changing the context of medical care, it is very welcome."

The importance and influence of family should be a major consideration in planning end-of-life discussions, the experts agreed. Family involvement affects a number of aspects of medical care, they said, from weight loss plans (if you want a patient to exercise, make classes open to the whole family and don't give a healthy Mexican cookbook to Salvadorans) to prescriptions (an elderly patient's adherence may depend on her daughter's ability to afford medications).

But, finally, there are some differences that a physician just has to accept. One audience member asked whether she should call the FDA about her concern: "The patients are going to these Hispanic supermarkets, and the stores are selling antibiotics and other medications that are not controlled."

Dr. Carrasquillo advised that if you want to effectively engage the community it may be better not to call the authorities. "It would create high levels of community distress and you would never be able to walk into a bodega again," he said. Instead, talk to those selling the medications about your concerns and try to work together toward your mutual goal of good health for Latino patients.



Breaking news


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ACP launches care coordination toolkit to improve communication between primary care, subspecialists

ACP has unveiled a High Value Care Coordination Toolkit designed to enable more effective and patient-centered communication between primary care and subspecialist doctors.

"Physicians need specific information to do their jobs effectively," said Molly Cooke, MD, MACP. "The High Value Care Coordination Toolkit facilitates clear communication between primary care and subspecialist practices so that doctors can provide seamless, coordinated, and quality care to their patients."

The toolkit was developed collaboratively through ACP's Council of Subspecialty Societies (CSS) and patient advocacy groups. CSS acts as a forum for the exchange of ideas between ACP and subspecialty organizations on matters affecting medicine in general and subspecialty societies in particular. The High Value Care Coordination Toolkit includes 5 components:

  • a checklist of information to include in a generic referral to a subspecialist practice,
  • a checklist of information to include in a subspecialist's response to a referral request,
  • pertinent data sets reflecting specific information in addition to that found on a generic referral request to include in a referral for a number of specific common conditions to help ensure an effective and high-value engagement,
  • model care coordination agreement templates between primary care and subspecialty practices and between a primary care practice and hospital care team, and
  • an outline of recommendations to physicians on preparing a patient for a referral in a patient- and family-centered manner.

These resources are the latest components in ACP's High Value Care initiative, which is designed to help doctors and patients understand the benefits, harms, and costs of tests and treatment options for common clinical issues so they can pursue care together that improves health, avoids harms, and eliminates wasteful practices.

Health care expenditures are currently 17% of the U.S. gross domestic product, and many economists consider this spending unsustainable. Up to 30%, or $765 billion, of health care costs were identified as potentially avoidable, with many of these costs attributed to unnecessary services.



For attendees


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ACP to conduct Annual Business Meeting

All members are encouraged to attend ACP's Annual Business Meeting to be held today during Internal Medicine 2014. Current College Officers will retire from office and incoming Officers, new Regents and Governors will be introduced.

The meeting will be held today in Room 315 at the Orange County Convention Center from 12:45 to 1:45 p.m., with outgoing ACP President Molly Cooke, MD, MACP, presiding. Robert A. Gluckman, MD, FACP, will present the Annual Report of the Treasurer.

A key feature of the meeting is the presentation of ACP's priorities for 2014-2015 by Executive Vice President and Chief Executive Officer Steven E. Weinberger, MD, FACP. Members will have the opportunity to ask questions following Dr. Weinberger's presentation.


.
Session shines light on the Sunshine Act

A provision of the Affordable Care Act requires the public reporting of specified transfers of value by health care industry to physicians and teaching hospitals. A panel session today, "Shining Light on the Sunshine Act: Everything You Need to Know," will provide an overview of this provision from the perspectives of industry, teaching hospitals, practicing physicians, and ethical perspectives, including how this provision can affect internists and how to make sure the information reported is accurate.

Data collection for 2013 began on Aug. 1, 2013, and is scheduled for public reporting on Sept. 31. 2014. While physicians have no formal obligations regarding this legislation, they will have the right to review and dispute any industry-reported information prior to public display.

The session is scheduled from 11:15 a.m. to 12:45 p.m. in room 311 EH. Speakers will include Aaron S. Kesselheim, MD, JD, MPH (Harvard); Pamela L. Mason, BS, CCMEP, FACME (AstraZeneca); and Frederick G. Savage, JD (Johns Hopkins).


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Panel to examine the role of subspecialists in the PCMH neighborhood

The literature reflects significant problems regarding communication and coordination of services between primary care and subspecialty practices—the transition between the patient-centered medical home (PCMH) and its medical "neighborhood." In a panel session today titled "The Role of Subspecialists in the PCMH Neighborhood," experienced clinicians will focus on several ongoing approaches of addressing this issue and facilitating more effective and efficient referral engagements, including:

  • the development of a care coordination toolkit through a collaboration of members of ACP's Council of Subspecialty Societies and patient advocates,
  • the use of and physician attitudes regarding "preconsultation" exchanges, and
  • the use of e-consultations and e-referrals as a complement and alternative to traditional face-to-face consultations.

The panel is scheduled from 2:15 p.m. to 3:45 p.m. today in room 311 EH. Speakers include Deidra C. Crews, MD, ScM, FASN; David C. Kendrick, MD, MPH, ACP Member; and Justin L. Sewell, MD, MPH, FACP.


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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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