1

Vol. 37

Num. 5

May 14

To Promote Improved

Patient Care, Research, and

Education in Primary Care and

General Internal Medicine

InspireInformConnect

CONTENTS

1. Health Policy Corner: Part I . . . . . . 1

2. Health Policy Corner: Part II . . . . . . 2

3. President’s Column . . . . . . . . . . . . 3

4. From the Editor . . . . . . . . . . . . . . . 4

5. Outpatient Morning Report . . . . . . 5

6. From the Regions . . . . . . . . . . . . . 6

7. Editorial . . . . . . . . . . . . . . . . . . . . . 7

8. Sign of the Times . . . . . . . . . . . . . . 8

9. Commentary . . . . . . . . . . . . . . . . . 9

10. New Perspectives . . . . . . . . . . . . 10

SGIMFORUMThe Society of General Internal Medicine

HEALTH POLICY CORNER: PART I Hill Day Recap: Telling Stories andAdvocating for Primary CareTheodore Long, MD

Dr. Long is a Robert Wood Johnson Clinical Scholar in the Yale School ofMedicine.

On March 12, 2014, 63 SGIM members assembled in Washington, DC,for the annual Hill Day. While this was my first Hill Day, there was a

palpable sense of excitement among the leadership that so many peoplehad come. With this many people, we knew we would have a significantvoice. I started the day with meeting the other members of my advocacyteam: a seasoned attending, another physician fresh out of residency, anda fourth-year medical student. As we began our meetings, the questionson my mind were what we could offer to the representatives and how wecould help inform them about health care. To put it another way, I wantedto communicate ideas from ourunique perspective, something thatonly we could discuss with authority.

We started our first two meet-ings with health policy advisors byemphasizing that SGIM supports re-peal of the sustainable growth rate(SGR). Judging by their knowledge-able responses, it was clear that thiswas not the first time a physicianhad advocated for SGR repeal tothem. We were quick to acknowl-edge it, as well as our own vestedinterest in getting the SGR repealed.The brevity of our SGR discussion did not mean the issue was unimpor-tant to us—we brought it up first for a reason. However, the implicitmessage was that this was not the issue about which we as representa-tives of SGIM had exclusive authority.

As each of the first two meetings proceeded, we transitioned to aconversation about our views on the primary care workforce from theperspectives of general internists in varying stages of career develop-ment. As we began to talk about how our experiences in training had im-pacted our decisions about entering primary care, I could tell that we hadcaught their interest. When we described SGIM’s progressive stance ofpromoting accountability in graduate medical education to address thecurrent primary care workforce shortage due to the implementation of

continued on page 11

As we began to talkabout how ourexperiences in traininghad impacted ourdecisions about enteringprimary care,I could tell that we hadcaught their interest.

OFFICERSPresidentWilliam P. Moran, MD, MS Charleston, SCmoranw@musc.edu (843) 792-5386

President-ElectMarshall Chin, MD, MPH Chicago, ILmchin@medicine.bsd.uchicago.edu (773) 702-4769

Immediate Past-PresidentEric B. Bass, MD, MPH Baltimore, MDebass@jhmi.edu (410) 955-9871

TreasurerMartha Gerrity, MD, MPH, PhD Portland, ORgerritym@ohsu.edu (503) 220-8262

SecretaryGiselle Corbie-Smith, MD, MSc Chapel Hill, NCgcorbie@med.unc.edu (919) 962-1136

Secretary-ElectSaid A. Ibrahim, MD, MPH Philadelphia, PAsaid.ibrahim2@va.gov (215) 823-5800

COUNCILDavid W. Baker, MD, MPHChicago, ILdbaker1@nmff.org(312) 503-6407

Hollis Day, MD, MSPittsburgh, PAdayh@upmc.edu(412) 692-4888

Ethan A. Halm, MD, MPHDallas, TXethan.halm@utsouthwestern.edu(214) 648-2841

LeRoi S. Hicks, MD, MPHWorcester, MAleroi.hicks@umassmemorial.org(508) 334-6440

Michael D. Landry, MD, MSNew Orleans, LAmlandry@tulane.edu(504) 988-5473

Marilyn M. Schapira, MD, MPHPhiladelphia, PAmschap@upenn.edu(215) 898-2022

Health Policy ConsultantLyle DennisWashington, DCldennis@dc-crd.com

Executive DirectorDavid Karlson, PhD1500 King St., Suite 303Alexandria, VA 22314karlsond@sgim.org(800) 822-3060; (202) 887-5150, 887-5405 Fax

Director of Communicationsand PublicationsFrancine Jetton, MAAlexandria, VAjettonf@sgim.org(202) 887-5150

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Which patients will be eligible forCCM code billing?Any Medicare patient, “expected tolive 12 months or until death,” withtwo or more chronic conditions willbe eligible for CCM services. Thiscode “may be billed for periods inwhich the medical needs of the pa-tient require establishing, imple-menting, revising, or monitoring thecare plan.” This is a “primary care-centric” definition that would applyto a broad range of Medicare pa-tients. Though CMS cannot prohibitany physician from billing for thisservice, the intention is clearly tosupport the myriad of primary careNF2F tasks.

What will be the patient paymentimplications?The service would be subject to a20% copayment (or covered as partof a Medicare Part B supplement).Unlike other Medicare services,monthly CCM billing continues with-out face-to-face contact.

To bill for the services, the fol-lowing are required:

• Documentation in the patient’smedical record that all of thechronic care managementservices were explained andaccepted by the patient;

• A written agreement thatelectronic communication of thepatient’s information with othertreating providers is part of carecoordination;

• Information about the availabilityof the services from thepractitioner; and

• A written or electronic copy of thecare plan that is provided to the

The Centers for Medicare andMedicaid Services (CMS) created

a new service code to pay for thenon-face-to-face (NF2F) care man-agement needs of Medicare benefi-ciaries beginning January 1, 2015.As with other primary care-directedcodes such as the annual wellnessvisits (AWVs) and the transitionalcare management (TCM) codes,CMS has detailed service expecta-tions. CMS recognizes the deficien-cies of the evaluation andmanagement (E/M) service codesused by primary care physicians(PCPs). The post-visit time for themost common E/M service code,99214, is 10 minutes. This vastlyunder recognizes the NF2F workof PCPs—work that includes an-swering patient phone and elec-tronic messages, sorting throughformulary changes, responding tolabs or consultation recommenda-tions, and providing weekend andnight emergency coverage.

HEALTH POLICY CORNER: PART II

Medicare’s Chronic Care Management (CCM)Code: Prepare now for 2015John Goodson, MD, and Jeannine Engel, MD

Dr. Goodson is associate professor of medicine at the Harvard MedicalSchool, Massachusetts General Hospital, in Boston, MA, and Dr. Engel isassistant professor of medicine at Huntsman Cancer Hospital and physicianadvisor to the Health Care Compliance Office at the University of UtahMedical Center, in Salt Lake City, UT.

SOCIETY OF GENERALINTERNAL MEDICINE

continued on page 12

EX OFFICIO COUNCIL MEMBERS

Chair of the Board of Regional LeadersDaniel G. Tobin, MD, FACP Waterbury, CTdaniel.tobin@yale.edu (203) 568-6348

ACLGIM PresidentTracie C. Collins, MD, MPH Wichita, KStcollins2@kumc.edu (316) 293-2630

Co-Editors, Journal of General Internal MedicineMitchell D. Feldman, MD, MPhil San Francisco, CAmfeldman@medicine.ucsf.edu (415) 476-8587

Richard Kravitz, MD, MSPH Sacramento, CArlkravitz@ucdavis.edu (916) 734-1248

Editor, SGIM ForumPriya Radhakrishnan, MD Phoenix, AZpradhakri@chw.edu (602) 406-7298

Associate Member RepresentativeBrita Roy, MD, MPH Birmingham, ALbritaroy@uab.edu (248) 506-1511

Early in my career, Dr. BryantKendrick, a former navy corps-

man, ordained Baptist minister, as-sociate program director for primarycare, and mentor, suggested thatwe use a “ropes course” to buildteam spirit among our primary careinterns before they began their ar-duous first year of training. “Ropes”is a day-long team-building exercise,challenging a group to think andwork together to solve a series ofphysical challenges. Five nervoussoon-to-be-interns, several resi-dents, and the program directorswere challenged physically andmentally to overcome a series ofobstacles in a wooded course. Earlyin the day, our ropes instructors toldus that we needed to trust and relyon each other and work as a teamto successfully complete thecourse. One of the first challengeswas a “trust fall” whereby a teammember stood on a 5-foot-high plat-form and, with arms folded, fellbackwards off the platform to becaught by the rest of the team.Everyone needed to complete thetrust fall before we moved to thenext task, but as a team we asked asmaller team member to be first.Standing with palms up and armsinterlaced “like a zipper,” the teamlined up and tensed as the firstteam member nervously fell back-wards into the group, and we wereall relieved when we successfullycaught and lowered our team mem-ber to the ground. Bryant was lastto make the trust fall. Bryant wasnot a small man. A former football

lineman, Bryant weighed a shademore than 240 pounds and, not un-aware of his girth, calmly ascendedthe platform. Five feet up, Bryantloomed over us, and I suspect fiveinterns silently feared the conse-quences of dropping the program di-rector, which seemed very likely.Standing with arms interlaced, theteam tensed as Bryant confidentlyfell backwards…and the team heldand caught him! Every year for al-most a decade, Bryant confidentlyascended the platform, and everyyear the team, including five newnervous interns, learned they werestronger than they thought. SadlyBryant passed away in 2000, butwhen I look at his picture on my of-fice shelf, I remember how confi-dent Bryant was in the strength ofhis teams.

Maybe more daunting than the“trust fall,” academic general in-ternists face a challenging future ofrising clinical productivity demands,more patients as a result of healthcare reform, the challenge of elec-tronic health records (EHRs) and“meaningful use,” and the incredi-ble complexity of our patients.“Ropes” and Bryant taught me thatpeople working in teams are morepowerful than a group of individu-als, which brings me to the themethe 2015 SGIM Annual Meeting inToronto—Generalists in Teams:Adding Value to Patient Care, Re-search, and Education—scheduledfor April 22-25, 2015. Health carereform focused on high-value pa-tient-centered care is driving team-

PRESIDENT’S COLUMN

Bryant and the Strength of TeamsWilliam P. Moran, MD, MS

Integration and coordination ofphysician efforts with non-physicianprofessionals and patients is criticalto the success of generalists andhealth care reform.

continued on page 11

based delivery system redesignacross the breadth of SGIM mem-ber interests. Team-based modelsof patient care—inpatient, outpa-tient, long- term, and transitionalcare—are rapidly evolving. The edu-cation and training experiences ofgeneral internal medicine physi-cians need to include knowledge ofteam member roles and responsi-bilities; new skills, such as teamleadership; informatics; and qualityand patient safety measurement.1,2

We need to develop and evaluateinterprofessional training venuesand encourage our own team mem-bers to participate in SGIM. Re-search methods will continue toevolve to provide high-value teamperformance information from ex-isting and new data sources. Inte-gration and coordination ofphysician efforts with non-physicianprofessionals and patients is criticalto the success of generalists andhealth care reform.

3

EDITOR IN CHIEFPriya Radhakrishnan, MD Priya.Radhakrishnan@DignityHealth.org

MANAGING EDITORChristina Slee, MPH tinaslee@me.com

EDITORIAL BOARDChayan Chakraborti, MD cchakra@gmail.comDeepa Bhatnagar, MD dbhatnag@tulane.eduMichele Fang, MD michele-fang@uiowa.eduPatty Harris, MD, MS patricia.harris.md@gmail.comFrancine Jetton, MA jettonf@sgim.orgMike Landry, MD, MS mlandry@tulane.eduDenise Millstine, MD Denise.Millstine@DignityHealth.orgDouglas Olson, MD olson.douglas@gmail.comLeigh Simmons, MD lhsimmons@partners.orgMadhusree Singh, MD m6singh@ucsd.eduNeeraj Tayal, MD Neeraj.Tayal@osumc.eduChristopher Wong, MD cjwong@uw.eduCharmaine Wright, MD smich@mail.med.upenn.edu

The SGIM Forum is a monthly publication of the Society ofGeneral Internal Medicine. The mission of The SGIM Forum isto inspire, inform and connect—both SGIM members and those in-terested in general internal medicine (clinical care, medicaleducation, research and health policy). Unless specifically noted,the views expressed in the Forum do not represent the official po-sition of SGIM. Articles are selected or solicited based ontopical interest, clarity of writing, and potential to engage the read-ership. The Editorial staff welcomes suggestions from the reader-ship. Readers may contact the Managing Editor, Editor, or EditorialBoard with comments, ideas, controversies orpotential articles. This news magazine is published by Springer. TheSGIM Forum template was created by Phuong Nguyen(ptnnguyen@gmail.com).

SGIM Forum

Several times this past week, Ihave heard this question in com-

pletely different contexts. Review acolleague’s work. See an extra pa-tient. Attend a meeting. Give anopinion. Of the hundreds of tasksthat we perform both at work and athome, few really give us a sense ofdeep fulfillment. We cover call forcolleagues when they are sick, offerto critique a project with fresh eyesor ears, or simply help others con-nect with mentors. As educators,we edit, rather painstakingly, draftmanuscripts for students and resi-dents. It is part of the job. However,it is not common to hear our ilk turnaround and ask, “What’s in it forme?” I wondered whether this waspart of a new trend, generationalgap, or simply the so-called Februaryeffect—as residents, physicians, andeveryone else for that matter, weare tired and disgruntled.

The last time I heard this ques-tion was during a 7 pm run to Star-bucks. I was grumpy, having spentan extra hour at work reviewing alast-minute report. This was yet an-other late day. I was feeling greatpity for my tired self as I stood inline, hunched over my iPhone, pon-dering whether to have pastries orsalad for dinner. Forget the salad, I

than any Venti coffee drink. Herewas a group of kids, late in theevening, also lamenting a busyday’s work that culminated in morework. They figured out that saying“yes” was the right thing to do,simply because it was part of thework they had signed up for. Need-less to say, by the time I made myway to the front of the line, I wasready to forgo the pastries in favorof passion tea and salad.

The teens reinforced my beliefthat we all do things to help oth-ers—just because it is part of ourjobs. We try to coach colleagues,residents, and students with goodintentions. As we rush headlong intothe land of pay-for-performance andoutcomes-based measures, wemust not forget that there are somethings that go way beyond any tan-gible measurable outcomes. Saying“no” is appropriate many times, butasking “what’s in it for me?” maybe a cry for help that all of us shouldheed. As a profession, we are thesum of our experiences. Sometimesdoing things to make life easier forothers is the right thing to do.

And learning often comes fromunexpected sources; one has to beopen minded.

SGIM

said, adopting the perfect Victimpersona. I was mentally chastisingmyself for helping the colleaguewho couldn’t see that I was buck-ling under the strain of a full clinicday where every patient showedup. In my mind, no one worked ashard as I did.

I was enjoying these feelings ofunder-appreciation when a nearbydiscussion piqued my interest. Thegroup of teenagers in front of mewas boisterous, loud, and debatingthe pros and cons of a last-minuteproject they had been given. Specif-ically, the teenagers were talkingabout doing some additional “busywork” in English class. Why shouldI do this project? What’s in it forme? The questions and answersflew back and forth. Becoz. Youwant an A. An all-nighter won’t killyou, man. By the end of the conver-sation, they decided, with goodhumor, that the teacher—while nottheir favorite—had treated them asadults and that they would gra-ciously do the extra work. “Becoz.”This was so contrary to my beliefsystem; aren’t teenagers the oneswho make decisions by the seat oftheir pants? Just standing behindthis group with their positive mojohad a more profound effect on me

4

FROM THE EDITOR

What’s in it for me?Priya Radhakrishnan, MD

An 18-year-old female withanorexia nervosa and irritable

bowel syndrome presents to clinicas a new patient with a complaint ofabdominal pain after eating. Shestates that she experiences severeabdominal pain after eating anddrinking even small amounts of foodor liquid. Associated symptoms in-clude postprandial fullness, bloating,and nausea. The patient states thatshe feels as if the food “just sits inher stomach.” She has a six-yearhistory of anorexia nervosa requiringseveral hospitalizations for intensivemanagement. This woman currentlypurges daily and states that self-in-duced vomiting helps to relieve herabdominal pain and anxiety. In addi-tion to the abdominal pain, she com-plains of weakness, recent weightloss, nausea, vomiting, diarrhea,constipation, amenorrhea, and anxi-ety. Her medications include colace,ducosate, omeprazole, K-Lor, andseroquel.

This patient presents with likelycomplications from a long history ofanorexia nervosa (AN). AN is a com-mon psychiatric disorder most preva-lent among female adolescents andyoung women. This disorder affectsup 1% of college-aged women andhas a female to male ratio of 20:1.1

AN is characterized by an inability orunwillingness to maintain a weightthat is normal or expected for ageand height. This is associated with adistortion in body image and an in-tense fear of gaining weight. AN isdivided into two subtypes: restrictingtype and binge-eating/purging type.In restricting AN, individuals maintaina low body weight by limiting caloricintake or exercising excessively.Binge-eating/purging AN is character-ized by episodes of excessive eatingand/or purging behavior, includingself-induced vomiting and inappropri-

sents as chest pain or palpitations inthese individuals.1,2

Functional cardiovascular changesinclude bradycardia, hypotension, ar-rhythmias, and QT prolongation.Sinus bradycardia is the most fre-quently encountered cardiovascularabnormality in AN. This representsan adaptive response of the heart toa decrease in caloric intake and isthought to be due to increased vagalactivity. These patients present withweakness and lightheadedness sec-ondary to decreased cardiac output.In the setting of coexisting arrhyth-mias or QT prolongation, however,serious complications, including sud-den death, may occur. There is con-troversy as to whether QTprolongation in the setting of AN isdirectly associated with AN or due toan associated electrolyte abnormalityor underlying congenital long QT syn-drome. Regardless, QT prolongationpredisposes individuals to life-threat-ening ventricular arrhythmias, includ-ing torsade de pointes.2 Due tocardiac arrest secondary to such ar-rhythmias, AN has the highest mor-tality rate of all mental disorders.1

Thus, these patients need to beclosely monitored and treated appro-priately to prevent cardiovascular-as-sociated mortality. Mostcardiovascular abnormalities associ-ated with AN eventually resolve withweight restoration and correction ofelectrolyte abnormalities.1,2

Prior to her last admission threemonths ago, the patient was foundto have several electrolyte abnormali-ties, including hypokalemia, hy-pophosphatemia, and hypochloremicmetabolic alkalosis.

Electrolyte abnormalities arecommon in binge-eating/purging AN,while electrolytes in restricting ANare generally normal. Hypokalemia is

ate use of laxatives or diuretics.2 Themanagement of patients with AN canbe a real challenge for physicians dueto its often persistent course, psychi-atric co-morbidities, medical compli-cations, and high mortality. Thus, it isimportant to be familiar with AN, themedical complications that may arise,and the treatment available for thesepatients.

Physical examination reveals avery thin woman who appearsyounger than her stated age with ablood pressure of 111/75 mmHg,heart rate of 98 beats/minute, weightof 82 lb, and BMI of 15.49 kg/m2.Nine months prior, she had a docu-mented weight of 109 lb. On physi-cal exam, the patient appearscachectic with bitemporal wasting.Other pertinent findings include ascaphoid abdomen with epigastrictenderness to deep palpation. Re-view of her records shows a historyof hospital admissions due to malnu-trition and related complications, in-cluding bradycardia and variouselectrolyte abnormalities.

Cardiovascular complications con-tribute to the high mortality in pa-tients with AN. These complicationsmay present with both structural andfunctional abnormalities of the cardio-vascular system. Structural abnormal-ities include decreased ventricularmass and size, pericardial effusions,and an increased incidence of mitralvalve prolapse (MVP).2 Extremeweight loss in patients with AN leadsto atrophy of the myocardium and aresulting decrease in both heartmass and ventricular size. This re-sults in decreased cardiac output, hy-potension, decreased capacity forexertion, and fatigue.2 MVP is alsocommon due to atrophied my-ocardium in the presence of mitralvalve structural tissue that remainsunchanged in size. MVP often pre-

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OUTPATIENT MORNING REPORT

Postprandial Abdominal Pain in a Young Anorexic WomanKevin Quinn, MS4 (presenter); Mohamed Zghouzi, MD (discussant, in italic); and Priya Radhakrishnan, MD

Dr. Quinn is a fourth-year medical student from Creighton University rotating through St. Joseph’s Hospital & Med-ical Center, and Dr. Zghouzi is a second-year resident in internal medicine at St. Joseph’s Hospital & Medical Centerin Phoenix, AZ. Dr. Radhakrishnan served as senior author on this case.

continued on page 13

The Northwest chapter of SGIMopened the year in style at the

elegant Hotel 1000 in downtownSeattle with the annual regionalmeeting on February 7, 2014. Witha diverse, increasing number of par-ticipants from Boise, Seattle,Tacoma, Spokane, and Portland, wehave outgrown the capacity of ourprevious venue near the Universityof Washington campus.

An unusually severe wintersnowstorm hit Portland and south-west Washington the day before themeeting, making Interstate 5 nearlyimpassable. Still, many membersmanaged the hazardous journeyfrom Portland or, in one case, impro-vised a video-conference for the co-leaders of the patient-centeredmedical home workshop.

Bookending the meeting wereour annual clinical updates. MatthewHollon, MD, MPH (Spokane, WA),and Mary Pickett, MD (Portland, OR),jumpstarted the program with theUpdate in Ambulatory Medicine, nav-igating through new guidelines andrisks of commonly used drugs.Susan Hunt, MD (Seattle, WA), con-cluded the day with material that sheand Courtland Childers, MD (Port-land, OR), developed for the Updatein Hospital Medicine, discussing con-troversies surrounding treatments ofacute stroke and hypertension.

We had two outstanding plenarysessions at this year’s meeting. DawnDewitt, MD, MSc (Vancouver, BC), in-spired us to activate and observelearners based on her worldwide ex-perience in different educational set-tings. Additionally, David Hickam, MD,MPH (Washington, DC), from the Pa-tient-Centered Outcomes Research In-stitute (PCORI) imparted guidance onwriting successful applications forPCORI-funded research. MarthaGerrity, MD, MPH, PhD (Portland, OR,and SGIM treasurer-elect), and

6

FROM THE REGIONS

Northwest Regional SGIM Meeting 2014: Teaching,Patient-centered Outcomes, and Clinical CareChristopher Wong, MD

Dr. Wong is a member of the Forum editorial board and can be reached at cjwong@u.washington.edu.

continued on page 11

. . . many members managed the hazardous journey from

Portland or, in one case, improvised a video-conference for the

co-leaders of the patient-centered medical home workshop.

77

Football season and its endless adsgot me thinking about all the ad-

vertising messages that come ourway. Even though I do not admit towatching “too much” television, myheart sinks every time I hear about acertain erectile dysfunction drug orhow effective a certain “Low T”drug is. These ads are all over TV,magazines, and billboards, so I’msure that these drugs are front andcenter in a lot of my patients’ minds,especially with the added nudge of“ask your doctor about _____”.

At least a few of my patientswant to know their testosterone lev-els, as they think that their fatiguemay be related to “Low T.” We thenend up having a conversation aboutthe possible causes of fatigue, oftenfocusing on sleep quality and quan-tity; nuances of checking testos-terone levels; and the risks andbenefits of treatment, if it is indi-cated. Needless to say, this can taketime away from other importantmedical issues. Again, advertisinghas made a disease popular whileoverlooking the nuances that med-ical decision making requires. Thereis no relationship between publichealth needs and the direct-to-con-sumer (DTC) advertising that we seearound us (http://archinte.jamanetwork.com/article.aspx?articleid=1726956).

A recent article in JGIM talksabout the lack of truth in advertisingmedications to patients and foundthat DTC advertising leads to mis-conceptions in patients (http://onlinelibrary.wiley.com/doi/10.1046/j.1525-1497.1999.01049.x/full). All thismisinformation likely leads to highercosts in health care, too. Anecdo-tally, I can tell you that if I got a dimefor every time a patient asked for adrug by name, I would not need togo to work. Luckily, I work for theVeteran’s Hospital, so we have astrict formulary that usually offers

2. Show patients reliable websitesfor health information—sites likeMedline Plus and the NationalLibrary of Medicine. These sitesare typically run by respectedgovernment, academic, medical,and non-profit organizations.

3. Understand the health educationconnected to electronic healthrecords. The health care teamshould be aware of theseresources and use themappropriately.

4. Tailor health messages to yourpatients, even though this willtake time and energy. Iremember a patient discussingthe use of bitter gourd extractinstead of usual care for type 2diabetes; when I asked thepatient where he found thisinformation, he said that it wasfrom the site where he boughtthe extract. Our patients willhave varying levels ofskepticism, sophistication, andeducation (just like us). In myexperience, tailored educationleads to important downstreamgains, as patients who areinvolved in their health caremake more informed decisions.

5. Involve the health care team.PCPs have many helpfulresources that can be used forpatient education, including peereducators.

6. It is so important that it bearsrepeating—be skeptical. Ifsomething sounds too good tobe true, it probably is. All thepretty pictures on televisionmake each disease look entirelycurable with the right pill. Asclinicians, our job is to help ourpatients understand theirillnesses, deal with theuncertainty that goes along withill health, and support theirunique journey.

SGIM

the best value for the patient. Mostoften, when a patient requests a cer-tain medication by name, I have tounpack the request and figure outwhat exactly he/she is thinking.Needless to say, this requires timethat most primary care physicians(PCPs) do not have. I have noticedthat even the World Health Organiza-tion sees this as a problem and thatperhaps the tide is slowly turning(http://www.who.int/bulletin/volumes/87/8/09040809/en/).

As we begin thinking seriouslyabout costs of care and ways to makehealth care both rational and cost-ef-fective, as a society we will have tore-think the way we view DTC adver-tising. We are doing our patients nofavors by allowing byte-sized, mislead-ing advertising. I am looking forwardto the day when broccoli is advertisedduring the Super Bowl, but I know I’mdreaming.

This also leads me to think aboutall the information that our patientsget from various sources—especiallythe Internet. Our patients have manyoptions for gathering information,and as PCPs we have a duty to helpthem find their way around this bravenew world.

Here is a short list of things thatwe can encourage our patients to dowhen they seek health information.Of course, the list is subjective, and Iencourage Forum readers to addtheir recommendations:

1. Be skeptical. Our patients vary intheir level of health literacy, butduring ill health and times ofstress they may be less able tofigure out hype from reality. Weneed to get back to the root ofour profession. “Doctor”originates from the Latin rootdocere, meaning to teach. Weneed to be able to teach ourpatients how to take care ofthemselves.

EDITORIAL

Truth in Advertising…Or NotMadhusree Singh, MD

Dr. Singh is a member of the SGIM Forum editorial board and can be reached at m6singh@ucsd.edu.

The Accreditation Council for Grad-uate Medical Education’s Next

Accreditation System has ushered inthe era of competency-based med-ical education (CBME) by describingthe behaviors, attributes, and perfor-mance standards for residents. Thetransition from a time-based to anoutcomes-based system is a chal-lenging paradigm shift and has sig-nificant systemic implications foreducators. Aside from changes inprogram structure, reporting, and ac-creditation, there are monumentalshifts in how faculty practice the artof teaching and assessment. In-deed, faculty development is cur-rently the limiting factor in theimplementation of CBME.1

Beyond medical knowledge ex-pertise, faculty must refine their pro-ficiencies in teaching and assessingall the core competencies. More-over, faculty need to develop skillsin critically observing learners on afrequent and regular basis. Addition-ally, they must link observations tolarger and more definable profes-sional activities while developingconsistency between multiple ob-servations of individual learners andimproving inter-rater reliability. Fac-ulty need to effectively and effi-ciently learn and incorporate newassessment methods and be able toprobe and evaluate critical thinkingand reasoning skills.

There has been little research onthe ideal structure of faculty devel-opment, but real world examplescan provide some direction for start-ing and refining programs, as thereare no one-size-fits-all models.

as a train-the-trainer system, whereattendees are expected to teach therest of the faculty. Using a mix of di-dactic and interactive sessions, thisretreat can provide in-depth expo-sure to CBME in a bolus format,beginning with an “Overview ofMilestones” plenary followed bysmall-group breakout sessions.These sessions provide an intensiveeducation on how to incorporatemilestones into each rotation andhow to complete evaluation forms.They can introduce new assess-ment tools or observation skills.These retreats provide an opportu-nity for standard setting among di-verse faculty and create a sharedmental model for appropriate as-sessments of learners. For pro-grams seeking input on how tochoose milestones for assessment,these sessions can be used to meetthat need. Participants can be askedto q-sort milestones based on levelof learner and rotation learning ob-jectives.2 The intensive nature of

When designing a program, con-sider the necessary time and logis-tics for faculty to participate, costand space availability, existing skilllevels of the faculty, and the mecha-nism by which faculty will need todirectly observe learners. Anothervariable is the regularity and fre-quency of faculty contact withtrainees. Is there a limited group offaculty who engage with the sametrainees regularly to allow for morelongitudinal experiences, or do fac-ulty have irregular and intermittentcontact with trainees? Four modelscurrently in use are described inTable 1.

The Bolus ModelThis model is organized as a large,one-time-only department-wide fac-ulty development retreat. This re-treat, spanning multiple days, canoccur either on site or off site. Alter-natively, a smaller scale retreat canbe offered to core faculty and clini-cal competency committee mem-bers. These sessions may be used

8

SIGN OF THE TIMES

The Next Accreditation System: Faculty Development Needs inCompetency-based Medical EducationPete Yunyongying, MD; Kerri Palamara, MD; Margaret Lo, MD; Reena Karani, MD, MHPE; Eva Aagaard, MD; andMichael Rosenblum, MD

Dr. Yunyongying is associate professor at the University of Texas Southwestern Medical Center; Dr. Palamara is as-sociate program director for Ambulatory Training and Faculty Development at Massachusetts General Hospital; Dr.Lo is associate program director, Medicine Residency Program, Department of Medicine, Division of Internal Medi-cine, at the University of Florida College of Medicine; Dr. Karani is associate dean for UME and curricular affairs andassociate professor of medical education, geriatrics and medicine at Icahn School of Medicine at Mount Sinai; Dr.Aagaard is director of the Academy of Medical Educators, professor of medicine, and assistant dean for lifelonglearning at the University of Colorado; and Dr. Rosenblum is director of the Baystate Internal Medicine ResidencyProgram and assistant clinical professor at Tufts University School of Medicine.

continued on page 15

Table 1. Characteristics of Competency-based Models

Bolus Recurring Just-In-Time EmbeddedModel Model Model Model

Large faculty Small individual Individual learning No extraretreat sessions sessions sessions

One time only Recurrent Recurrent

Plenary sessions Variable: can Largely didactic,with small-group include didactics or passive learningbreakout small-group

breakouts

In-depth and Introducing new Reinforcing already Ongoing teachingintensive course skills briefly learned skills

Requiresongoing auditingand individualfeedback tofaculty

Mindfulness is not a new con-cept. Its modern conception

dates back decades, and its premisehas been around for centuries.Briefly explained, mindfulnessmeans being present in the currentmoment without judgment. The con-cept is simple, but the practice cantake a lifetime to master—if ever.

Still, what’s old is new again.The cover story for the February 3,2014, Time magazine is, “The Artof Being Mindful.”1 In 2014 alone,there have been 139 PubMed cita-tions regarding mindfulness. Why?It seems to be working.

Mindfulness has been studied innearly every population you canimagine. Most notably, its effectshave been assessed in soldiers; stu-dents; physicians; nurses; and pa-tients living with cancer, stress, andmood disorders. For anyone with ahistory of trauma, it seems to work.For those of us distracted by ourwork, family, home, and social re-sponsibilities or notifications con-stantly “binging” onto our mobiledevices and medical records, mind-fulness can provide solace in themiddle of the storm. Mindfulnesscan be applied to eating, walking,praying, meditating, and, according

you enhance your experience of theworld. By setting intentions of grati-tude, compassion, acceptance, andforgiveness, you become kinder,gentler, and more joyful. The brainquiets, and you calm. Do you knowanyone who would not benefit fromthat?

Our American lives are stress-ful, and our happiness tends to below. This remains true even whenexternal threats are lacking. Mostof us are not surviving natural dis-asters or being chased by preda-tors. Still, our sympathetic nervoussystems are on overdrive from re-sponsibilities, deadlines, projects,and dreams. Perhaps we havestarted to realize that. Perhaps weare tired of being drained of energyfrom this excessive worry. Perhapsthis is why mindfulness has foundits time.

References1. Pickert K. The art of being

mindful. Time 2014; 183(4):40-8.2. Goyal, et al. Meditation

programs for psychologicalstress and well-being: asystematic review and meta-analysis. JAMA Intern Med2014; 174(3):357-68. SGIM

to Time magazine, even managingour spending.

Physicians and health careproviders have known the benefitsof meditation for years. Studieshave proven it to be helpful instress, insomnia, anxiety, depres-sion, pain, obesity, and other condi-tions.2 Somehow, only a minority ofpatients—and ourselves for thatmatter—are successful with tradi-tional meditation as a longitudinalpractice. If we know it will make ushealthier, why can’t we do it?

According to Amit Sood, MD,professor of medicine at the MayoClinic and author of The MayoClinic Guide to Stress-Free Living,the brain is a very busy place.Within its “default mode,” thebrain has countless connections ofneurons and hundreds of neuralnetworks that are firing frequentlyand constantly. This backgroundbrain chatter makes quieting themind difficult for those untrainedand inexperienced. The associatedfrustration leads to the abandon-ment of meditation practice.

Instead, Dr. Sood’s program—and mindfulness in general—placesthe focus outward with intention.By focusing on your surroundings,

9

COMMENTARY

Mindfulness: Why All the Hype?Denise Millstine, MD

Dr. Millstine is a member of the SGIM Forum editorial board and can be reached at Millstine.Denise@mayo.edu.

Much like medical students whoacquire the skills to take a his-

tory and physical assessment, thescience and art of negotiation re-quires a similar approach. Generalinternists in particular can identifywith this approach given their edu-cation and practice in assessingmultiple organ systems. In thissame way, performing a review ofsystems as part of any negotiationcan provide invaluable informationin achieving a desired outcome.

A tool found to be effective isreferred to as Spotting and Chang-ing the Game,1 based the develop-ment of the seven-elementframework by the Harvard Negotia-tion Project.2 Like any “H&P” tem-plate, a tool that seeks to aid inidentifying a patient’s signs andsymptoms, these elements informthe negotiator of opportunities inmaking a diagnosis and devising acourse of action or treatment.These seven elements are: 1) inter-ests, 2) legitimacy, 3) relationship,4) alternatives, 5) options, 6) com-mitments, and 7) communication.

Recently, I was working with amedical director to develop the clini-cal schedule for the next year. Indoing so, one of the medical direc-tor’s interests was distributing holi-day assignments across all faculty.When the notification went out, oneof the faculty questioned the legiti-macy of the holiday assignments

the senior colleague, leader, or evenadministrator who uses the elementof communication to convey my in-terests, in the absence of reciproc-ity—I will often invoke silence as aconvenience for an agreement or acommitment. This interplay oftenleads to misunderstandings and canalso fray the relationship element.So not only is awareness of theseelements essential but the way inwhich each is used or not used canhave an effect on the outcome. Inthe end, clarity of agreement is re-quired to achieve the best long-term result.

Negotiation is a process, apractice, and a skill—not a disease.General internists should have confi-dence in the ability to incorporatethis kind of systems approach to ne-gotiation. Your education and trainingprovides the prerequisite skills tosuccessfully incorporate it into prac-tice. The approach itself is a para-digm much like learning the “why”and “how” to performing a good his-tory and physical assessment—onethat (like negotiation) requires under-standing and practice. Reflect oninstances and situations you experi-enced recently and the seven ele-ments that you and your counterpartused or did not use and how youcould have changed the situation.Consider using these elements andthe tool Spotting and Changing theGame1 the next time you find your-self negotiating for a new position,requesting additional resources foryour area, or just maintaining whatyou already have!

References1. Spotting and changing the game.

Boston: Vantage Partners, 2003.2. Hughes J, Weiss J, Kliman S,

Chapnick D. Negotiation systemsand strategies. Boston: VantagePartners, 2007.

SGIM

given that his clinical duties wereonly a small fraction of others. It wasfelt that these holiday assignmentsshould be proportional to attendings’clinical duties in the number of holi-day assignments per year and thefrequency of being assigned anyspecific holiday from year to year.Reaching agreement, however, re-quired the medical director to com-municate these expectations. Inquestioning the legitimacy of theseexpectations, the faculty memberproposed an option. Because the op-tion was fair, an agreement wasreached while maintaining the colle-giality of the relationship.

To use this technique in othersituations, spot the elements thatare specifically being used or notbeing used. These signs and symp-toms will inform you in diagnosingthe causes, purposes, and how youcontributed to the response. Bydoing so, you can devise a plan orstrategy to change the direction ofthe negotiation in reaching a satisfy-ing outcome. In deciding upon yourplan, ask yourself:

• How can I change the way aparticular element is being usedby my counterpart?

• How can I shift the focus to adifferent element?

• How can I call out mycounterpart’s “game” altogetherand propose a new approach?

In my experience, people (includ-ing general internists) are eitherquite active or vocal about callingout a counterpart’s game or passiveto the point of eroding morale overtime. Being vocal is acceptable aslong as the person understands thatthis can come at a price to the rela-tionship element. Conversely, pas-sivity is the lack of appreciation forthe communication element. If I amthe negotiator—or in many cases

10

NEW PERSPECTIVES

A Systems Approach to NegotiationEric Linson, MBA

Mr. Linson is the division administrator of general internal medicine at the University of Iowa Hospitals and Clinics.

11

the Affordable Care Act, I knew thatwe had found a topic that could ben-efit from our unique perspective.

The common tactic going into anadvocacy or lobbying meeting is totry to tell a story based on your expe-riences. Using personal experienceand anecdotes lends credibility toyour words and creates a dialoguethat the person you are speakingwith will remember. Based on ourexperience with Hill Day, I would addthat your story should involve an

HEALTH POLICY CORNER: PART Icontinued from page 1

issue that you are passionate aboutand that you have a unique or per-sonal perspective on. As we contin-ued to go to our meetingsthroughout the day, our team sponta-neously and without previous plan-ning or discussion began tellingstories about training in primary care.We used these experiences todemonstrate our take-home pointthat graduate medical educationfunding should support training thatgrows the primary care workforce.

At the end of the day, we had alltold our stories and excited some in-terest from the representatives wemet. I was impassioned by our abil-ity to reach out to representativesand health advisors and am alreadylooking forward to repeating the ex-perience next year. In the mean-time, I will continue to reflect on thestories my team told and the inter-section between our experiencesand policymaking.

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David C. Thomas (chair) andSharon Straus (co-chair) will leadthe 2015 Annual Meeting ProgramCommittee. They have assembledtheir own incredible team to planthe meeting focused on how teamsincrease value. There is a dearth ofdata about the structure, function,training, roles, and accountability ofinterprofessional teams in new pri-mary care delivery system modelssuch as the patient-centered med-ical home and VA’s patient-alignedcare team—not to mention inpatientcare teams focused on quality, pa-tient safety, and care transitions.3

The Association of Chiefs and Lead-ers in General Internal Medicine(ACLGIM) is considering a programfor interprofessional team leader-ship,4 and a critical ingredient will bemethods to include patients andother stakeholders in team-basedcare. We hope SGIM members willalso hear how many organizationsare now developing payment and fi-nancing strategies to support team-based care in the form ofaccountable care organizations andprovider networks. SGIM membersare involved in innovative informat-ics applications supporting teamsthat provide high-value patient careand health services research toevaluate team impact on the valueof care provided to patients. Finally,SGIM and other organizations are

PRESIDENT’S COLUMNcontinued from page 3

participating in building coalitions tocontinue delivery system transfor-mation to teams that provide high-value care to patients, high-valueresearch, and team-centered educa-tion. Please consider submitting tothe 2015 meeting in Toronto, andespecially consider volunteering tohelp the Annual Meeting ProgramCommittee plan an outstandingSGIM annual meeting.

References1. Mitchell P, Wynia M, Golden R,

McNellis B, Okun S, Webb CE,Rohrbach V, Von Kohrn I. Coreprinciples & values of effectiveteam-based health care.Washington, DC: Instituteof Medicine, 2012:www.iom.edu/tbc.

2. Doherty RB, Crowley RA. Healthand Public Policy Committee ofthe American College ofPhysicians. Principles supportingdynamic clinical care teams: anAmerican College of Physiciansposition paper. Ann Intern Med2013; 159(9):620-6.

3. Reisman A. Taking one for theteam. Ann Intern Med 2013;159(9):640-1.

4. Huddle TS. Fumbling toward thefuture: internal medicine andclinical care teams. Ann InternMed 2013; 159(9):644-5.

SGIM

Melissa Hagman, MD (Boise, ID, andNorthwest SGIM regional president),gave the national and regional updatesover lunch, discussing SGIM’s focuson the regions, communication, tech-nology, and SGIM’s advocacy efforts.

Along with these sessions, themeeting included five workshops, aposter session, and the always-pop-ular oral clinical vignette presenta-tions from associates. We received atotal of 70 submissions from aroundthe region. Winners of the posterand vignette session were AdamRodman, MD (Best Clinical VignettePoster); Joseph Simonetti, MD (BestResearch Abstract Poster); TiffanyChen, MD (Best Clinical InnovationsPoster); and Mitra Barahimi, MD(Best Oral Clinical Vignette). The re-gional awards were bestowed toMelissa Hagman, MD (Clinician-Edu-cator Award), and Devan Kansagara,MD (Clinician-Investigator Award).

Thank you to all those who at-tended, our reviewers, the planningcommittee (Moe Hagman, Bill Wepp-ner, Todd Korthuis, Kay Johnson,Carol Sprague, Betsy Haney, SusanMerel, Paula Wichienkuer, ChrisWong, Scott Smith, Julie Silverman,Danielle Orchard), the national officesupport (Katherin Cooper, TraceyPierce, Kay Ovington), and all ourjudges and distinguished faculty.

See you in 2015 in Portland!SGIM

FROM THE REGIONScontinued from page 6

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services (CMS may provide jobdescriptions),

• The need for detailed writtenprotocols, and

• Patient-centered medical homeor the equivalent certification.

What will be the RVU value of theCCM code?The most critical issue will be therelative value units (RVUs) as-signed to the CCM service codeand how they are distributed be-tween work RVUs (the clinicianshare) and practice expense RVUs(the payment for the care manage-ment provided and the infrastruc-ture). Since there is no riskadjustment and only one servicetime expectation, practices willhave to consider how to amortizethe costs so that those patientswho consume higher resources arebalanced by those who consumefewer resources, knowing that allpatients will receive a minimum 20minutes of care every 30 days.

The AMA’s CPT has developedthree CCM service codes forpatients, but these codes weredesigned for patients with muchhigher levels of instability and in-cluded face-to-face care. CMS hasno requirement to resolve thesedifferences. Non-Medicare carriershave no obligation to pay for CMSor CPT-defined services.

CMS has established the frame-work for the CCM code, thoughthere are important details yet tocome. Now is the time to addressthe workflow, personnel, documen-tation, and payment considera-tions. Some combination of thesefactors together will influence eachpractice or enterprise’s decision ofwhether to support this servicecode.

Recommended Readinghttps://www.federalregister.gov/

articles/2013/12/10/2013-28696/medicare-program-revisions-to-payment-policies-under-the-physi-cian-fee-schedule-clinical-laboratory#h-310 (pages 186-198)

SGIM

HEALTH POLICY CORNER: PART IIcontinued from page 2

beneficiary and recorded in theelectronic health record (EHR).

The CCM code cannot be billedconcurrently with home health care(VNA) supervision (HCPCS G0181),hospice (HCPCS G0182), TCM ser-vices (99495-6), and all servicecodes applicable to patients in a fa-cility (e.g. nursing home). E/M, AWV,and initial preventive physical exami-nation (IPPE, Welcome to Medicare)service codes can be billed, butnone of these is required.

What are the stipulated servicesfor CCM billing?CMS has provided only a partial listof the services required. The final listwill be available at the end of 2014.A physician or a non-physician clini-cian (e.g. NP, PA, clinical nurse spe-cialist, certified nurse midwife) canbill as long as the state’s scope ofservice license permits independentbilling. CCM services provided in thename of the non-billing clinicianmust be performed by an employeeof the billing clinician or an employeeof a practice. This effectively pre-cludes the outsourcing of certain ele-ments of CCM services to contractemployees or care management cor-porations or services.

CCM will be a time-basedcode—20 minutes of service forevery 30 days of billing (CMS im-plies a strict 30-day billing cycle).Documentation tools will have torecord both time and services pro-vided. CMS expects the followingfrom CCM clinicians:

• Continuity of care with a clinicianor practice

• Care management that providesthe following:• A systematic assessment

of medical, functional, andpsychosocial needs

• A system-based approachfor timely delivery ofpreventive services

• Medication reconciliation,both prescription and non-prescription, and a review ofinteractions and adherence

• The creation of an updatablepatient-centered plan of carethat:

Addresses all health careissues (including but notlimited to the following: “aproblem list, expectedoutcome and prognosis,measurable treatmentgoals, symptommanagement, plannedinterventions, medicationmanagement, communityand/or social servicesordered, how the servicesof agencies and specialistsunconnected to thepractice will bedirected/coordinated,identification of theindividuals responsible foreach intervention, periodicreview and, whenapplicable, revision”)Is congruent with patientvalues and choicesIs based on a physical,mental, cognitive,psychosocial, functional,environmentalassessmentIs based on an inventoryof resources andsupports

• Management of all caretransitions (the TCMstipulated services, TCMcannot be billed separately)

• An EHR that is available 24/7• Opportunities for patient-to-

provider communication viatelephone or secureasynchronous NF2Fmessaging (e.g. secureInternet messaging)

CMS is considering even moreservice expectations, but manyprofessional organizations havecomplained about the level of CMSintrusion into the details of practicemanagement. The unresolved stip-ulations are the following:

• Higher EHR standards,• Precise expectations for the

non-clinicians who deliver CCM

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continued on page 14

relatively common and is a result ofexcessive vomiting and diuretic orlaxative misuse. Hypochloremicmetabolic alkalosis often occurswith hypokalemia in individuals whovomit excessively or abuse diuret-ics. However, in the setting of laxa-tive abuse, the loss of excessivepotassium and bicarbonate in thefeces leads to hypokalemic, hyper-chloremic metabolic acidosis.3 Hy-pophosphatemia, hypomagnesemia,and hypocalcemia may also occur asa result of AN or as part of therefeeding syndrome.3 Additionally,patients with AN may have a re-duced glomerular filtration rate, lead-ing to an inability to concentrate theurine and subsequent dehydration.Prior to refeeding, patients shouldbe properly rehydrated, and elec-trolytes should be repleted.2

Further history and workup re-veals a several-month history ofamenorrhea, hypoglycemia, and ab-normal thyroid function testing (T4

4.5 ug/dL, T3 53 ng/dL, and TSH4.86 mU/L).

Amenorrhea is present in morethan 95% of all females with AN.1

In patients with AN, the normalpulsatile release of gonadotropin re-leasing hormone from the hypothal-amus is reduced. This leads todecreased follicle-stimulatinghormone and lutenizing hormonerelease from the pituitary and ulti-mately to decreased levels of estro-gen. This functional hypothalamicamenorrhea prevents ovulation.2 Thebest way to restore menses isweight gain, although 10% to 30%of patients remain amenorrheic de-spite return to normal weight.1,2

A number of other endocrinecomplications are associated withAN. Mild hypoglycemia is commondue to depleted hepatic glycogenstores and disruption of hepatic glu-coneogenesis as a result of dietaryrestriction, weight loss, and exces-sive exercise.2 Although usuallyasymptomatic, severe hypoglycemiasuggests a poor prognosis.1 Thyroidfunction test abnormalities are alsocommon. This typically presents aseuthyroid sick syndrome, which con-

OUTPATIENT MORNING REPORTcontinued from page 5

sists of low to normal serum T4 andT3, normal TSH levels, and increasedlevels of reverse T3. Thyroid replace-ment therapy is not indicated in thissetting, as these abnormalities cor-rect with weight gain.1

Upon further review, a DEXAscan in the last year shows the pres-ence of osteoporosis in the patient’slumbar spine and osteopenia in herleft hip.

Osteoporosis is seen in up to50% of females with AN and is ofbig concern due to potentially perma-nent complications, including an in-creased risk of debilitating fractures.1

The lumbar spine is the most af-fected site, and bone loss in patientswith AN is thought to occur at a rateof 4% to 10% per year.2 The patho-genesis of osteopenia and osteo-porosis is multifactorial. The severityof bone density loss appears to beclosely linked to amenorrhea age ofonset and duration along with the de-gree of weight loss.4 In addition tohypoestrogenemia, however, otherfactors attributed to the developmentof osteoporosis include severe mal-nutrition, decreased calcium intake,excessive exercise, hypercorti-solemia, and decreased levels of IGF-1. It is recommended that anypatient with AN and amenorrhea formore than six months should un-dergo testing for baseline bone min-eral density with a DEXA. Repeattesting should be done every twoyears.1,2 The most important treat-ment is early weight restoration andresumption of menses. Other thera-pies include supplemental calciumand vitamin D. Although controver-sial, supplemental estrogen and bis-phosphonates may have a role inmore severe cases.1,4

Due to chronic postprandial ab-dominal pain, the patient is referredto a gastroenterologist and eventuallyundergoes an upper endoscopy toassess the nature of her dyspepsia.EGD shows mild gastritis and poorgastric fundus accommodation likelysecondary to AN.

Gastrointestinal complications arecommon in AN. Frequent complaintsinclude constipation, abdominal pain,

bloating, early satiety, and nauseaafter eating. Many of these symp-toms are the result of impairment inthe upper part of the GI tract, leadingto gastroparesis, or delayed gastricemptying, and prolonged GI transittime.4 Gastroparesis occurs with foodrestriction and with weight loss of 10to 20 lbs. Typically gastroparesis re-solves with weight restoration in fourto six weeks. In the meantime, how-ever, it can be managed conserva-tively with early ingestion of liquidfood supplements, multiple smallmeals, and avoiding excessive fiber.Metoclopramide, which increasesgastric emptying and motility, mayalso be useful.2 Constipation that fre-quently accompanies weight loss inAN may also be managed conserva-tively with hydration, low doses offiber, polyethylene glycol, and os-motic laxatives, such as lactulose, asa last resort.1,2 Although both gastro-paresis and constipation typically re-solve with weight restoration, theaccompanying symptoms of pain andbloating may hinder weight gain bydiscouraging eating.2

Despite regular follow-up involv-ing several health professionals, thispatient has continued to strugglewith her AN. She continues to bingeand purge regularly and has a currentweight of 84 lb.

Management of AN is often diffi-cult due to its protracted course andvarious medical and psychiatric co-morbidities. Thus, this disease isbest managed with a multidiscipli-nary approach, consisting of a pri-mary care physician, psychiatrist, anddietitian, among other specialists.Despite this approach, prognosis re-mains poor, as 16% of patients stillmeet criteria for AN 10 years afterinitial diagnosis.1 Mortality rates forall causes of death have been re-ported to be up to six times higherthan for the general population.4

Typically, AN can be managed onan outpatient basis with close followup. However, in more severe casesor when certain complications arepresent, inpatient management maybe necessary. Although no set guide-

14

lines exist, there are several gener-ally accepted indications for inpatienttreatment, including body weight25% to 30% below ideal bodyweight, rapid and severe weight lossthat fails outpatient management,heart rate less than 35 to 40beats/minute, symptomatic hypoten-sion, syncope, arrhythmias, or QTprolongation.5

As mentioned throughout, treat-ment for AN and its multitude ofmedical complications centers onweight restoration. Target goal weightis typically within 90% of ideal bodyweight.1 To achieve this goal, outpa-tients and inpatients are encouragedto gain 1 lb and 2 to 3 lbs per week,respectively.1 During this time, pa-tients should be monitored veryclosely with weight checks and fre-quent measurements of electrolytesto avoid refeeding syndrome.1

OUTPATIENT MORNING REPORTcontinued from page 13

Key Points• AN is a fairly common

psychiatric disorder that maypresent with a number of acuteand chronic medical conditionsinvolving many organ systems. Itis important to be familiar withthese complications, availabletreatment options, andindications for inpatientmanagement.

• The most important treatmentfor AN is nutritionalreplenishment, as many of theassociated medicalcomplications resolve withweight restoration.

• Management of patients withAN requires a multidisciplinaryapproach, with activeinvolvement of a primary carephysician, psychiatrist, anddietitian, among others.

References1. Mehler PS, Krantz M. Anorexia

nervosa medical issues. JWomen’s Health 2003; 12:331-40.

2. Mehler P. Anorexia nervosa inadults and adolescents: medicalcomplications and theirmanagement. In: Yager J, ed.UpToDate. Waltham, MA: 2013.

3. Winston AP. The clinicalbiochemistry of anorexianervosa. Ann Clin Biochem2012; 49:132-43.

4. Meczekalski B, Podfigurna-StopaA, Katulski K. Long-term conse-quences of anorexia nervosa.Maturistas 2013; 75:215-20.

5. Mehler PS. Diagnosis and care ofpatients with anorexia nervosa inprimary care settings. Series inPrimary Care Internal Medicine2001; 134:1048-59. SGIM

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these retreats may be ideal for fac-ulty who do not have a strong back-ground in the new assessment skillsrequired of CBME. These sessionswould need to be facilitated by fac-ulty who have expertise and couldrequire significant time, space, andfinancial resources that may be pro-hibitive for some programs.

The Recurring ModelThis model is organized into shorter,more frequent sessions deliveredon a recurring basis (e.g. quarterly).These sessions provide an overviewof milestones, explanation of thenew evaluations, review of expecta-tions for direct observation, andtime for questions. They are idealfor introducing new concepts brieflyor reinforcing skills for faculty withsolid foundations in CBME skillsand principles. They are less timeand cost intensive than retreats butstill require recurrent involvementfor faculty development leaders andmay not provide active faculty en-gagement. If there is inconsistentfaculty attendance, it can be difficultto build on foundational knowledgeand skills over time. It may becomefrustrating for faculty who consis-tently attend who must learn withthose who intermittently attendsessions.

The Just-In-Time ModelThe Just-In-Time Model is based onpoint-of-care or just-in-time training.

SIGN OF THE TIMEScontinued from page 8

These sessions can be very short(e.g. 15 to 30 minutes) and are con-ducted just before an evaluationcycle. They can be live or pre-recorded as webinars or podcastsand distributed to faculty electroni-cally before their assigned evalua-tions. During these online learningevents, faculty are given mini-tutori-als on CBME, how milestones areused to assess residents’ develop-ment throughout their training, ex-pectations for direct observation,and how to complete the evalua-tion. These sessions are ideal at re-inforcing already learned skills andcan be used to reach large numbersof faculty quickly and easily. How-ever, they require faculty buy-in andwillingness to engage with thetechnology, as well as adequate in-frastructure to deliver the content.

The Embedded ModelThis model embeds faculty develop-ment within the structure of theevaluations. As assessments foreach rotation are developed by acore group of engaged educators,so are anchors and questions thatclearly state how to observe learn-ers. The assessment tools areguides for faculty without the needfor the major time and cost invest-ments of the previous three mod-els. However, this model doesrequire faculty to have reviewed theevaluation form prior to the start ofrotations. After embedding, the

competency committee and pro-gram leaders audit evaluations toidentify outliers and provide feed-back to calibrate faculty and im-prove their skills. Monitoring andfeedback must be performed in anongoing way to train new facultyand reinforce or adjust behavior inthose who are more experiencedwith the system. This feedbackprocess can be time consuming forthe competency committee andprogram leadership.

We anticipate these models willprovide a guide for programs lookingto design new faculty developmentprograms or refine existing ones tomeet CBME needs and require-ments. More than one model maybe needed to effectively address theunique needs of a program. Furtherresearch is needed to determine thehighest-priority learning objectivesfor faculty. Moreover, new researchshould assess the relative impact ofeach faculty development program.

References1. Homboe E, et al. Faculty

development in assessment: themissing link in competency-basedmedical education. Acad Med2011; 86(4):460-7.

2. Meade L, et al. Playing withcurricular milestones in theeducational sandbox: Q sortresults from an internal medicineeducational collaborative. AcadMed 2013; 88(8):1142-8. SGIM

If you have not renewed your 2014 SGIM membership, thiswill be your last issue of Forum. To ensure that Forum andother membership benefits continue, please be sure youpay your dues today. Membership benefits include yourmonthly issues of both Forum and the Journal of General In-ternal Medicine (JGIM) and your access to the online com-munity—GIMConnect.

As you know, SGIM’s backbone is our membership andtheir commitment to research, education, and providing pa-tients with the best care available. We hope you continue

your commitment and rejoin your peers by renewing yourmembership today!

How do I renew online? To renew, please log into

http://www.sgim.org/home/Members-Login.

From here, please log in and click“Pay Dues/Make Donation” and follow the prompts.

If you have questions regarding your membership,please contact Jillian Gann, Director of Membership,at gannj@sigm.org or 800-822-3060.

Don’t let this be your last issue of Forum!

16

Society of General Internal Medicine1500 King Street Suite 303Alexandria, VA 22314202-887-5150 (tel)202-887-5405 (fax)www.sgim.org

SGIMFORUM

The ISSN for SGIM Forum is: Print-ISSN 1940-2899 and eISSN 1940-2902.

University of Michigan Health System

Department of Internal Medicine

North Campus Research Complex

2800 Plymouth Road, Building 16, 400S

Ann Arbor, MI 48109-2800

Assistant Chair for Primary Care Ambulatory ProgramsAssociate Division Chief for Ambulatory Operations

The University of Michigan Department of Medicine and Division of General Medicine are recruitingfor an Assistant Chair for Primary Care Ambulatory Programs/Associate Division Chief for Ambula-tory Operations. The successful candidate will qualify as a faculty member at the Assis-tant/Associate/Professor level, and will devote 50% time to reconfiguring healthcare delivery in theprimary care setting and 50% time to clinical care. The position will focus on enhancing the Univer-sity’s ability to provide high quality, efficient care, with attention to both clinically relevant outcomesnecessary for quality measurement as well as clinical efficiency. Enhancements to the current sys-tems should be identified and implemented in a manner that allows the faculty to actively engage inthe associated process and quality improvements, and ensures their professional satisfaction.

The successful candidate will work with the Division Chief for General Medicine, the DepartmentChair for Internal Medicine, the General Medicine Associate Division Chief for Clinical Programs andAmbulatory Care’s leadership team to develop and operate an integrated clinical delivery model, uti-lizing the precepts of the advanced medical home. She/he will facilitate the ambulatory clinical andeducational goals of the Division of General Medicine and the Department of Internal Medicine. Ad-ditionally, this individual will collaborate with Department and Division leadership to identify and re-move barriers to innovative approaches to the delivery of primary care in an academic setting.

Interested individuals should forward their curriculum vitae via email to Laurence McMahon, MD,MPH, Chief, Division of General Medicine (lmcmahon@umich.edu). Application review will continueuntil the position is filled. The University of Michigan is an affirmative action, equal opportunity em-ployer, dedicated to the goal of building a culturally diverse and pluralistic faculty and staff commit-ted to teaching and working in a multicultural environment and strongly encourages applicationsfrom women, minorities, individuals with disabilities and covered veterans. For more information,contact Susan Patrell at (734) 936-5216.