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Vol. 34

Num. 1

Jan 11

To Promote Improved

Patient Care, Research, and

Education in Primary Care and

General Internal Medicine

InspireInformConnect

CONTENTS

1. New Perspectives . . . . . . . . . . . . . 1

2. Essay . . . . . . . . . . . . . . . . . . . . . . . 2

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

4. Morning Report . . . . . . . . . . . . . . . 4

5. Researchers’ Corner: Part I . . . . . . 5

6. Researchers’ Corner: Part II. . . . . . 6

7. Practice Innovations . . . . . . . . . . . . 7

8. Policy Corner . . . . . . . . . . . . . . . . . 8

9. From the Society . . . . . . . . . . . . . . 9

SGIMFORUMThe Society of General Internal Medicine

NEW PERSPECTIVESGrassroots Primary Care Advocacy: FromCrisis to Opportunity at HarvardAndrew Morris-Singer, MD

Dr. Morris-Singer is the founder of Primary Care Progress and an internistat Brigham and Women’s Hospital in Boston, MA.

continued on page 13

The last couple years have been truly exciting for the primary care com-munity at Harvard Medical School (HMS), starting in the spring of

2009, when Harvard defunded its division of primary care. In medicalschool terms, it wasn’t a lot of money—$200,000—and the school in-sisted it was merely reexamining where primary care belonged in itsoverall programming. But, to many, it felt like the final nail was beingpounded into the coffin of the local primary care community.

To others, though, especially many of us early in our training whowere excited about careers in primary care, the defunding seemed likean opportunity—a chance to rally our community. Our residents and stu-dents were energized by the stories of primary care delivery transforma-tion we were reading about in the national media, inspired by theclinicians we met in our training, and excited by a growing coalition wesaw developing to support primary care in the midst of the nationalhealth care reform debate. Eventually, as we banded together with localclinicians and faculty, we took to calling ourselves “Primary CareProgress.”

We set out to harness the incredible passion, energy, and ideas of ourdiverse community to see if we could convince the school to refocus onprimary care. Essentially, we saw a special opportunity in the administra-tion’s assertion that it was “reconsidering” its relationship to primarycare programming. We decided to mobilize the collective voice of thecommunity in a grassroots-style campaign.

First, members of Primary Care Progress organized a petition ofnearly 1,200 people asking Harvard to recommit to primary care. Thatwas followed by a letter campaign to HMS signed by the leaders of Har-vard’s primary care community. In response, HMS Dean Jeffrey Flier con-vened an advisory group to provide concrete recommendations on howHarvard could revitalize primary care education, research, and care deliv-

2

think about this rather archaic, restric-tive system and realize that, in myopinion, it is more designed to makestudents run the gauntlet than preparethem to be well-rounded successfulphysicians in today’s modern world.While I have nothing against calculus, Icannot recall the last time I needed toperform a derivative or integral on anill patient in order to ameliorate his suf-fering. While organic chemistry termsand concepts occasionally seep intoour daily lexicon, I am not sure howimportant they really are. Certainly,they are helpful to know when therare patient with acute promyelocyticleukemia receives all trans-retinoicacid, but is understanding what thetrans configuration represents reallyworth the scores of hours spentsweating and toiling over the toughestcourse in college?

Again, I have nothing againstsome of the subjects that arepresently required to apply to mostmedical schools. However, there aremany other subjects that also are im-portant in laying down a foundationto produce well-rounded, culturallycompetent, compassionate, and ef-fective physicians. For example, withall the literature about racial or gen-der disparities in care and the needto improve our cultural conscious-ness, can’t one argue that sociologymay be more practical than physics?Who could argue about the impor-tance of psychology as we employmotivational interviewing or healthcoaching and learn the importance ofbody language? Similarly, I have notmet one physician out of residencywho said that medical education orresidency prepared him/her for thebusiness or economics of medicine.

Each says no one has a crystalball—or one that can actually foreseethe future. While I’m not really surewhether my son will be successful inhis journey—either as a potential rap-per or physician—I can see that ourpresent system is somewhat stiflingand needs to be redressed if we in-tend to produce the best well-rounded physicians possible. SGIM

My father is a retired physician, mybrother and wife are both physi-

cians, and I am a physician. You couldimagine my astonishment when myonly son informed me two years agothat he intended to be a musician—and a rapper, at that. While thereclearly is a dearth of Jewish half-Chi-nese rappers, I secretly wished he’dhave desired to follow in the familyfootsteps and not enter a professionthat I, rightly or wrongly, associatewith the “fast life” and tattoos. In highschool, countless hours were spent inhis “studio” writing and recordingmusic instead of volunteering in hospi-tals, doing research, or shadowingsome of my physician friends.

With this background, you canalso understand my amazementwhen, three months ago over dinner,he proclaimed that after realizing howdifficult it is to be successful in themusic profession, he would keep hisoptions open by pursuing a pre-medpath during his freshman year at col-lege. He saw how much his parentsenjoyed their work and were able toimpact the lives of patients in a man-ner that most other professions can-not match. Not only that, he actuallysought our counsel on course selec-tion during that pivotal freshman year.

My wife and I were shocked thatmedical school requirements haven’treally changed since we went throughthe process more than 30 years ago. I

OFFICERS President

Gary E. Rosenthal, MD Iowa City, IAGary-rosenthal@uiowa.edu (319) 356-4241

President-ElectHarry P. Selker, MD, MSPH Boston, MAhselker@tuftsmedicalcenter.org (617) 636-5009

Immediate Past-PresidentNancy A. Rigotti, MD Boston, MA nrigotti@partners.org (617) 724-4709

TreasurerCarol K. Bates, MD Boston, MAcbates@bidmc.harvard.edu (617) 667-4877

SecretaryMonica L. Lypson, MD Ann Arbor, MImlypson@med.umich.edu (734) 764-3186

Secretary-ElectJean S. Kutner, MD, MSPH Denver, COjean.kutner@ucdenver.edu (303) 724-2240

COUNCIL

Carlos A. Estrada, MD, MSBirmingham, ALcestrada@uab.edu (205) 934-3007

Thomas H. Gallagher, MD Seattle, WAthomasg@uw.edu206-616-7158

Arthur G. Gomez, MDLos Angeles, CAartgomez@ucla.edu(818) 891--7711

Nancy L. Keating, MD, MPHBoston, MAkeating@hcp.med.harvard.edu(617) 432-3093

Somnath Saha, MD, MPH Portland, ORsahas@ohsu.edu503-220-8262

Laura Sessums, MD, JDWashington, DCLaura.Sessums@us.army.mil(202) 782-5560

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

Executive DirectorDavid Karlson, PhD2501 M Street, NW, Suite 575Washington, DC 20037KarlsonD@sgim.org(800) 822-3060; (202) 887-5150, 887-5405 Fax

Director of Communicationsand Publications

Francine JettonWashington, DCjettonf@sgim.org(202) 887-5150

EX OFFICIO COUNCIL MEMBERS

Regional CoordinatorMichael D. Landry, MD, MS New Orleans, LAmlandry@tulane.edu (504) 988-6128

ACGIM PresidentThomas G. McGinn, MD, MPH New York, NYthomas.mcginn@mssm.edu (212) 241-5451

Editors, Journal of General Internal MedicineMitchell 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 ForumRobert Centor, MD Birmingham, ALrcentor@uab.edu (205) 934-3007

Associate Member RepresentativeBradley H. Crotty, MD Boston, MAcrotty@post.harvard.edu 617-575-9304

ESSAY

Why Choose Medicine?Daniel G. Federman, MD

SOCIETY OF GENERALINTERNAL MEDICINE

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Last October, I had the opportunityto visit Cuba on a mission with 25

other members of my temple con-gregation from Iowa City. A largepart of the trip was spent visiting thesmall but vibrant Jewish communi-ties in Havana, Cienfuegos, andSanta Clara; touring several syna-gogues and Jewish cemeteries; andvisiting a number of other historicalsites from the colonial and pre- andpost-revolutionary periods.

The visit was eye opening from anumber of perspectives. Cuba maybe best described as a land ofanachronisms. After passing throughcustoms at Jose Marti Airport in Ha-vana, one encounters a legion of1950s-vintage US cars, serving bothas family cars and taxis. While theengines have been replaced withdiesel engines to improve fuel econ-omy, the bodies and interiors havebeen remarkably well maintained.The walk to our tour bus was likebeing in a living museum.

Moving out of the airport, themarked poverty that grips most ofthe country was clearly recognizable.

Houses in the hillsides surroundingHavana consisted of crumblingwooden or rusted metal shacks.Many people rely on horse- or burro-drawn carts for transportation. Theadjacent agricultural fields wereplowed by ox, while the abundantsugar cane fields were harvestedwith machetes. Nowhere did we seethe combines and other machinerythat dot the Iowa landscape.

Arriving in central Havana, one isstruck by the wonderful prevailing ar-chitecture of colonial-style stone andcement row houses, mansions, andpublic buildings. Nearly all were builtprior to the Cuban revolution, andmany date back more than 150years. While there has been a majoreffort to restore some of these build-ings to their original state, many aredilapidated, and a large number havebeen reduced to stone exterior fa-cades, resembling post-World War IIscenes of Europe. Unlike many othercapital cities of the world, very littlemodern construction can be found.In many ways, Cuba is a land stuckin time.

PRESIDENT’S COLUMN

Reflections on a Week in CubaGary Rosenthal, MD

Perhaps what has evolved in theUnited States reflects our collectivevalues as a society—the importancewe place on individual freedoms andthe basic distrust of many Americanstoward social programs andgovernment regulations.

continued on page 12

EDITOR IN CHIEFRobert Centor, MD rcentor@uab.edu

MANAGING EDITORChristina Slee, MPH cakuenneth@ucdavis.edu

EDITORIAL BOARDCaleb Alexander, MD, MS galexand@uchicago.eduYvette Cua, MD ycua@emory.eduErin Egan, MD, JD erin.egan@uchsc.eduMolly Emott, MD memott@thocc.orgDaniel Federman, MD daniel.federman@va.govMonica Ferguson, MD Monica.Ferguson@uphs.upenn.edu Deepthiman Gowda, MD, MPH dg381@columbia.eduAdam Gordon, MD, MPH adam.gordon@va.govPaul Haidet, MD, MPH phaidet@bcm.tmc.eduPatricia Harris, MD, MS pfharris@usc.eduMark Henderson, MD mark.henderson@ucdmc.ucdavis.eduFrancine Jetton, MA jettonf@sgim.orgCraig Keenan, MD craig.keenan@ucdmc.ucdavis.eduStefan Kertesz, MD, MSc skertesz@mail.dopm.uab.eduKarran Phillips, MD, MSc phillipsk@nida.nih.govShalini Reddy, MD sreddy@medicine.bsd.uchicago.eduAndrew Schutzbank, MD, MPH aschutzb@bidmc.harvard.eduHannah Shacter, BA hshacter@gmail.comMobin Shah, MD ShahM@uasomh.uab.edu

The SGIM Forum is a monthly publication of the Society of General Internal Medicine. The mission of The SGIM Forum is to inspire, inform and connect—both SGIM members and those in-terested in general internal medicine (clinical care, medical education, 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 on topical 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 or potential articles. This news magazine is published by Springer. TheSGIM Forum template was created by Phuong Nguyen(ptnnguyen@gmail.com).

SGIM Forum

Our guide, who accompanied us forthe week, was remarkably candid aboutthe harsh conditions that face mostCubans. The government controlsnearly all activities with a vise-like grip;

A24-year-old white woman at 25weeks of gestation presents to

the emergency department with dis-orientation, unsteady gait, and bilat-eral lower-extremity weakness forthe past 48 hours. The patient wasdiagnosed with hyperemesis gravi-darum during her second trimesterand has been hospitalized severaltimes with dehydration and elec-trolyte abnormalities. She has lost 50pounds during the pregnancy. The re-view of systems is positive for nau-sea, vomiting, and chronic diarrhea.The diarrhea started after a cholecys-tectomy early in her first trimesterand consists of four to five non-bloody bowel movements daily. Shedenies any other symptoms such asfever, chills, shortness of breath,chest pain, cough, rash, or joint pain.

Her medical history is otherwiseunremarkable. Her only medicationsare ondansetron and a multivitamin.She does not use alcohol, tobacco,or illicit drugs and denies any history

nous thrombosis, and compressiveneuropathies. The latter really wouldnot explain these symptoms, butvascular causes remain in the differ-ential diagnosis.

At this point, a careful exam— es-pecially the neurologic examinationand simple laboratory studies (e.g.electrolytes, glucose, BUN, creati-nine, calcium, magnesium, phospho-rus, CBC, TSH)—would be the nextimportant step.

Physical examination reveals aregular heart rate of 122; all othervital signs are within normal limits.She is in no acute distress but hasdry mucous membranes. The neuro-logical exam is significant for disori-entation to time and place andimpaired short- and long-term mem-ory. She has horizontal nystagmusand ataxia (wide-based gait withslow, short-spaced steps). She has anegative Romberg sign, normal ten-don reflexes, normal cerebellarexam, and no motor or sensorydeficits. The remainder of the physi-cal exam is unremarkable.

The exam is notable for evidenceof volume depletion; an absence offever; an absence of focal evidence ofinfection; and the presence of disori-entation, nystagmus, and ataxia. Ofcourse, these latter findings are theclassic triad of findings seen in WE:encephalopathy, oculomotor dysfunc-tion (nystagmus, lateral rectus palsy,and/or conjugate gaze palsy beingmost common), and ataxia. Nystag-mus is usually horizontal and is themost frequent ocular finding in WE.Considering the ataxia further, thereare no findings suggestive of othercerebellar disease (e.g. stroke or hem-orrhage) or of peripheral neuropathy,which would be other commoncauses. Of note, there was no demon-strable weakness on the objective

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A Young Pregnant Woman Presenting with Two Days of Confusion and AtaxiaRolando Sanchez, MD; Rosei Skipper, MD (presenters); and Craig R. Keenan, MD (discussant, in italic)

Dr. Sanchez is an internal medicine resident at the University of Alabama at Birmingham, Dr. Skipper is a psychiatryresident at the Mayo Clinic at Rochester, and Dr. Keenan is associate professor of medicine at the University ofCalifornia, Davis.

MORNING REPORT

of high-risk sexual behaviors or bloodtransfusions.

This young pregnant woman withsevere hyperemesis gravidarum (HG)presents with acute alteration in hermental status and complaints oflower extremity weakness andataxia. This illness script brings tomind a quick differential of severeelectrolyte disturbance (due to herconstant vomiting and diarrhea), in-fection (due to pregnancy and likelyimmunosuppression from her malnu-trition), and even the rare hy-pokalemic periodic paralysis. (HG isassociated with hyperthyroidism, andhyperthyroidism can lead to severehypokalemia and acute lower ex-tremity paralysis.) I have learnedthrough experience, however, that al-tered mental status is often multifac-torial and requires a systematicapproach in order to avoid early clo-sure or the failure to consider impor-tant diagnoses. I learned amnemonic for this approach in resi-dency that has served me very wellover the years: MOVE STUPID (Table1). For this patient with HG, themetabolic causes, electrolyte distur-bances, and infectious possibilitiesappear most likely. I do recall thatWernicke’s encephalopathy (WE) is aknown but rare complication of HGthat could cause acute confusion.Also, severe pre-eclampsia cancause neurologic symptoms butwould be unusual in this womanwho has had no apparent pre-eclampsia up until this time.

I do not treat pregnant womenvery often. Recognizing this, I re-ferred to a text to review HG and itscomplications as well as to reviewother possible neurologic disorders inpregnancy that I may not have con-sidered. Based on this, other disor-ders that are more common inpregnancy are stroke, cerebral ve-

Capital Campaign Progress

continued on page 10

Conflicts surrounding authorshipoften arise because individuals

have different expectations regard-ing who is to be included as an author or how the ordering of authorship should occur. Fortunately,there are explicit criteria for author-ship that have been developed bythe International Committee of Med-ical Journal Editors (ICMJE), in whichauthorship requires: “1) a substantialcontribution to conception and de-sign, acquisition of data, or analysisand interpretation of data; 2) partici-pation in drafting the article or revis-ing it critically for importantintellectual content; and 3) approvalof the final version to be published.”A number of other guidelines pro-vided by the ICJME are also rele-vant, including that: “1) acquisitionof funding, collection of data, or gen-eral supervision of the researchgroup alone does not constitute au-thorship; 2) all persons designatedas authors should qualify for author-ship, and all those who qualifyshould be listed; and 3) each authorshould have participated sufficientlyto take public responsibility for ap-propriate portions of the content”(http://www.icmje.org/index.html).

Being familiar with these criteria,and keeping them in mind early inthe course of a paper, is importantfor two reasons. First, they allow forone to actively ensure that all authorsfulfill formal criteria. For example, cir-culating a fairly polished draft of amanuscript to someone is not thetime to invite them to join as an au-thor. Second, the criteria provideclear guidance to support decisionsabout whom to include. What aboutindividuals who don’t qualify for au-thorship but still made a helpful con-tribution to the report? Theseindividuals can be warmly ac-

recognized in the authorship order.Two key things should be consideredin this setting. First, as one’s careerdevelops, there is little meaningfuldifference between various positions“buried in the pack”; thus, other thanfirst or last author, the ordering of in-dividuals is relatively unimportant.Second, no single paper or scientificreport makes or breaks a career. Noone ever died and said, “I wish that Ihad published [or been first author]on that paper.” One does well toheed the Dalai Lama’s advice—”Don’t let a small matter ruin a goodrelationship.”

A related idea here is to be gener-ous with authorship, looking forchances to create opportunities forothers. During this process, it is im-portant to note that just as formal au-thorship criteria and order differ byfield (economists will generally listfewer authors and in alphabeticalorder), so too do individuals’ thresh-olds for including others as authors.For example, should an undergradu-ate research assistant be included forher project management duties on asingle-center randomized controlledtrial? Should a resident be includedas an author on a project in which heconducted chart reviews to study thequality of diabetes care among hospi-talized elders? In some ways, theseare trick questions. One need justask whether, in these roles, the indi-viduals fulfilled formal ICJME criteriafor authorship. Gathering of dataalone is insufficient for authorship, soleaders or intellectual owners of agiven project should work with po-tentially eligible authors to ensuretheir active participation on eachphase of manuscript developmentand production if they are to be in-cluded as co-authors.

knowedged (after obtaining theirwritten permission), and indeed allcontributors that do not fulfill formalcriteria for authorship should be ac-knowledged in the published manu-script.

Look for the “Win-Win”Many challenges with authorshiparise because two or more peoplefeel that they deserve a certain levelof recognition on a paper or becausethere are parallel papers that maycover overlapping material and theappropriate designation of authorshipis not clear. These potential conflictsalmost always offer an opportunity indisguise. One resolution is whenmore than one academic product canresult from the work, in which caseindividuals can take turns in more visi-ble authorship roles (e.g. first author,last author). Another potential solu-tion is that one individual steps upand takes greater responsibility forthe conduct of the research or prepa-ration of the manuscript, thus helpingto ensure that greater authorship visi-bility is commensurate with the effortcontributed to the manuscript. Rarely,one sees “co-first-authorship” notedon a curriculum vitae, whereby twoindividuals attempt to equally sharethe credit and intellectual ownershipassociated with a first-author position.Despite being a laudable attempt toevenly attribute the credit associatedwith first-author work, such sharing isfairly unusual and in some ways in-variably the first of the first authorlisted remains more visibly associatedwith the academic product.

Don’t Let a Small Matter Ruin aGood RelationshipAt times, the determination of au-thorship may lead one to feel thatone’s contribution is not appropriately

5

RESEARCHERS’ CORNER: PART I

Authorship: Talk Early and OftenG. Caleb Alexander, MD, MS

Few areas of scientific publication pose as perennial a set of hurdles as issues of authorship. The more that onepublishes, the more opportunities one has to manage the challenges that arise with collaborative work whereownership lines are often unclear, the potential for bruised egos high, and the guidelines for navigatingdeterminations of authorship difficult to apply. Here I address some of the common questions that arise, as well asgeneral principals that may help junior investigators, and even their more senior counterparts, consider and navigateauthorship as smoothly as possible.

continued on page 11

Due to a combination of over-crowding and underfunding, the

Institute of Medicine recently de-scribed emergency departments(EDs) as “at the breaking point.”1

Many patients identify the ED astheir usual source of care, and theED is an important focus of general-ist research. Example topics of inter-est to generalist researchers includeunderstanding ambulatory care condi-tions managed in the ED (e.g. antibi-otic prescribing for upper respiratoryinfections), disparities (e.g. racial andethnic differences in treatment ofpain), and management of time-sen-sitive conditions (e.g. acute myocar-dial infarction). In this article, wehighlight three datasets for use in EDresearch, including two managed bythe Healthcare Cost and UtilizationProject (HCUP). We conclude withsome helpful links to database re-search offered by HCUP.

The National Hospital AmbulatoryCare Survey (NHAMCS) comprise na-tionally representative surveys of am-bulatory ED visits and ambulatorysurgery centers in the United States.ED staff complete the survey basedon chart data. Data are obtained on demographic characteristics of patients, expected source(s) of payment, patients’ complaints, diag-noses, diagnostic/screening services,procedures, medication therapy, disposition, types of provider seen,causes of injury, and certain charac-teristics of the facility (e.g. geographicregion and metropolitan status). Theexpert user who commented onNHAMCS for the SGIM DatasetCompendium stated, “NHAMCS is awonderful resource. The data areeasy to access and use, and the web-site provides highly useful documen-tation about how to program Stata,SAS, and SPSS to adjust for surveyclustering, stratification, and weight-ing.” NHAMCS is free to downloadfrom the Web.

(http://www.hcup-us.ahrq.gov/tech_assist/centdist.jsp) and is ac-companied by online comprehensivedocumentation about the databasesand using the data in SAS and SPSS(http://www.hcup-us.ahrq.gov/db/state/sedddbdocumentation.jsp).

The NEDS is the largest publiclyavailable, all-payer ED database in theUnited States and provides a snap-shot of hospital-based EDs in theUnited States beginning in 2006. Con-structed from the SEDD and SID, theNEDS approximates a 20% stratifiedsample of hospital-based EDs in theUnited States, with weights providedto calculate national estimates formore than 120 million ED visits in2007. The large sample size of theNEDS enables analysis across hospi-tal types and the study of relativelyuncommon disorders and procedures.Data elements in the NEDS includediagnoses and procedures, dischargestatus from the ED, patient demo-graphics, payment source, totalcharges, and hospital characteristics(e.g. ownership and metropolitan sta-tus), in addition to other variables. TheNEDS is available for purchase fromthe HCUP Central Distributor(http://www.hcup-us.ahrq.gov/tech_assist/centdist.jsp), and online com-prehensive documentation providesinformation about the databases andusing the data in SAS, SPSS, andStata (http://www.hcup-us.ahrq.gov/db/nation/neds/nedsdbdocumentation.jsp).

HCUP-US provides a variety ofother resources related to ED care athttp://www.hcup-us.ahrq.gov/. HCUP-net (http://hcupnet.ahrq.gov/) is a free,online query system based on HCUPdatabases. HCUPnet users can createnational, regional, and state-specificstatistics from the SEDD, SID, andNEDS to enhance their research. TheHCUP Supplemental Files for RevisitAnalysis enable users to track patients

The Healthcare Cost and Utiliza-tion Project (HCUP) is a family ofhealth care databases, softwaretools, and products for advancing re-search. A Federal-State-Industry Part-nership sponsored by the Agency forHealthcare Research and Quality(AHRQ), HCUP includes the largestall-payer, encounter-level collection oflongitudinal health care data (inpa-tient, ambulatory surgery, and ED) inthe United States. It began in 1988and has expanded in coverage to 43 State Partners in 2010. HCUP includes two ED data sets: the StateEmergency Department Databases(SEDD) and the Nationwide Emer-gency Department Sample (NEDS).

The SEDD have been releasedannually since 1999 and consist ofstate-specific data files with dis-charge information on all ED visitsthat do not result in a hospital admis-sion. Information on patients initiallyadmitted to the emergency room andthen discharged to the hospital is in-cluded in the State Inpatient Data-bases (SID). The SEDD are a valuabletool to analyze state-specific emer-gency care issues; compare ED visitsacross states; and assess trends inED use, access, charges, and out-comes. The SEDD data consist ofmore than 100 clinical and non-clini-cal variables present in a hospital dis-charge abstract, including diagnosesand procedures, patient demograph-ics, hospital characteristics (e.g. own-ership and metropolitan status),expected payer, and total charges. Tofurther enhance the data, the SEDDcan be combined with resources likethe American Hospital Association(AHA) Annual Survey Database usingthe AHA Linkage Files. Furthermore,combining SEDD data with HCUP’sSID or State Ambulatory SurgeryDatabases (SASD) can produce amore complete picture of care. TheSEDD is available for purchase fromthe HCUP Central Distributor

6

RESEARCHERS’ CORNER: PART II

Datasets for Emergency Department ResearchAlex Smith, MD, MS, MPH, and Claudia Steiner, MD, MPH

This is the fourth in a series of articles highlighting large, publicly accessible datasets of interest to SGIM researchers.

continued on page 8

Can you share how you improved access and

continuity at Northwestern?Our practice differs in important waysfrom early successful implementersof open- or advanced-access pro-grams who were largely full-time clin-icians. Some academic practices havereported difficulty adopting thismodel. The average faculty memberin our practice has less than fourclinic sessions a week in ambulatorycare, and the average resident hasless than four clinics a month at ourpractice site. To compensate, wegrouped physicians into four to sixfaculty and resident teams constitut-ing approximately two clinical full-time equivalents (FTEs). With thisformat, patients unable to see theirprimary care physicians (PCPs) arestill seen by team physicians in a fa-miliar area with their regular nurses.

Our pilot physician team began inMay 2007 with rollout to our six otherteams every one to two months.Many physicians had strong bondswith triage nurses after working withthem for several years, and we triedto keep these nurse-physician teamsintact as much as possible. Facultywere given the opportunity to choosetheir own teams. The teams werethen adjusted to provide as muchcoverage across the week as possi-ble. Our initial expectation was thatphysicians on a team would see all oftheir patients. Eventually we compro-mised and stated that this would bethe ideal and that we would try tomeasure the team’s ability to accom-plish this task.

Despite challenges of implement-ing advanced access within our prac-tice, we were able to achievedramatic improvement in time tothird available return appointment for2007 compared to 2006 (Figure 1).This declined even further in 2008.We have seen an improvement in

sues. If we see an unfamiliar patient,these other issues are either not addressed or re-ferred back to a patient’s PCP. By im-proving access, we also believe thatwe have made our practice more at-tractive to patients. All too often, aca-demic practices, especially residentpractices, appeal to patients with lim-ited options. By allowing patients tobe seen by a more intimate team, asopposed to a group of more than 100physicians, we have been able tominimize patient turnover.

patient satisfaction over all aspectsof our practice since the implementa-tion of our program. Patients are notonly happier with the improved ac-cess but also happier with our nurs-ing staff, our non-clinical staff, andour physicians (Figure 2).

Our financial performance hasbeen aided by the move to advanceaccess. As a practice we are billingat a higher level for return encoun-ters. We believe that when physi-cians see a familiar patient, they areoften able to address other long-standing and potentially neglected is-

7

PRACTICE INNOVATIONS

Improving Access and ContinuityDan Dunham, MD, in conversation with Christine A. Sinsky, MD

Dr. Dunham is associate professor of medicine at Northwestern University Feinberg School of Medicine inEvanston, IL. Dr. Sinsky is affiliated with the Department of Internal Medicine at Medical Associates Clinic andHealth Plans in Dubuque, IA.

continued on page 9

Figure 1

Figure 2

As we know, our representativeshave hectic schedules. Without

“staffers” to guide Congresspeoplethrough their days, lawmakingwould be impossible. The next fewarticles will delineate the role of thevarious key staffers in your repre-sentatives’ offices.

In the House and the Senate, thestructure of staff differs greatly,largely depending on whether amember of Congress chooses toemphasize constituent service orlegislation; whether legislative is-sues are divided up by subject mat-ter or the lawmaker’s committeeassignments; or other factors. Asenator’s staff may range in sizefrom fewer than 20 to more than60. A representative’s staff is limitedto 18 full-time and four part-timestaffers. Additionally, senators andrepresentatives are often assistedon legislative matters by staff of thecommittees and subcommittees onwhich they serve.

A major responsibility of a mem-ber’s personal staff, especially in theHouse, is to provide service to peo-ple back in the state or congres-sional district. Staffers respond tomany constituent requests; amongother duties, they untangle bureau-cratic snarls in collecting Social Se-curity or veterans’ benefits, theyanswer questions about federal stu-dent loans and other governmentaid, they help home state or districtorganizations navigate red tape forlanding federal grants, they respondto constituent mail on legislative andnational issues, and they producenewsletters and other mailings.

Such services are important notonly for the benefits they provide toconstituents but also for the rela-tionships they help foster. Juniormembers of Congress tend to focusmore attention on constituent ser-vice than their more senior col-leagues, and representatives oftenspend more time on constituent ser-vice than senators.

sitions—those that actually influencehow a Representative or Senator responds to issues. Senior staff willbe the subject of the next article inthe health policy primer series. SGIM

Who is Involved?A variety of staff people assistmembers of Congress. A descrip-tion of roles is provided below.

Staff Assistant/Receptionist. The staffassistant/receptionist is most often lo-cated at the front desk of a member’soffice and is responsible for greetingguests and answering the phones.Other responsibilities include fieldinggeneral requests such as arrangingWhite House tours for constituents.

Caseworker. Most offices have sev-eral caseworkers that divide up thefederal agencies and deal with con-stituent questions and problems(e.g. a lost Social Security check, adenied veteran’s benefit, etc.) asso-ciated with those agencies’ pro-grams. Some caseworkers also dolegislative research or correspon-dence on matters relating to theagencies in which they have special-ized. They also may go by the titleof research assistant or staff assis-tant. Although casework operationsmay be centered either in the dis-trict/state office or in Washington,the majority of caseworkers arehoused in the district office.

Legislative Correspondent (LC). Thisindividual is responsible for monitor-ing all incoming mail and drafting responses to constituent letters concerning pending legislation. Insome offices, legislative assistants(LAs) draft letters in their own issueareas; in others, the LC drafts lettersfor the LAs regardless of the subject.

Grants staff. The grants staff is re-sponsible for assisting organizations(e.g. state and local governmentagencies, businesses, educationalinstitutions, etc.) and individuals thatare seeking federal grants.

These entry-level positions incongressional offices are the train-ing grounds for the more senior po-

8

POLICY CORNER

The Role of Congressional Staff: General StaffLyle Dennis, edited by Patricia Harris, MD

Mr. Dennis is a partner at Cavarocchi-Ruscio-Dennis Associates, LLC, in Washington, DC.

RESEARCHERS’ CORNER: PART IIcontinued from page 6

across time and hospital settings ex-clusively in the SID, SASD, and SEDD,while maintaining patient privacythrough the use of artificial patientidentifiers. This tool can be used in arange of analysis topics, includingtracking repeat ED use, studying hos-pital readmissions, and studying pat-terns of ED use for chronic conditions.The HCUP Supplemental Files for Re-visit Analysis are available for data year2003 and after and are free of chargefrom the HCUP Central Distributor, as-suming the user has purchased thecorresponding SID, SASD, or SEDDfile and has completed the requireddata use online training and Data UseAgreement, which can be accessed at(http://www.hcup-us.ahrq.gov/tools_software.jsp).

Various published reports relatedto ED care are also available from the Reports section of HCUP-US(http://www.hcup-us.ahrq.gov/reports.jsp). For example, HCUP Statistical Briefs provide simple, descriptive statistics on a variety offocused topics, including ED utiliza-tion (http://www.hcup-us.ahrq.gov/reports/sb_emergency.jsp).

More information on these andother datasets and resources can befound in the SGIM Research DatasetCompendium at www.sgim.org/go/datasets. Good luck!

References1. Berger E. Breaking point: Report

calls for Congressional rescue of hospital emergencydepartments. Ann Emerg Med2006; 48(2):140-2. SGIM

The Society of General InternalMedicine (SGIM) is receiving a

large holiday gift this year—our newnational offices located in Old TowneAlexandria, Virginia, approximately 10miles outside of Washington, DC.The property, to be housed at 1500King Street, is comprised of two side-by-side office condos that have beenrenovated and updated to fit theneeds of the 12 SGIM and ACLGIM(Association of Chiefs and Leaders ofGeneral Internal Medicine) nationalstaff who will work there.

In 2009, SGIM and ACLGIMlearned that the lease on the rentalproperty that they had held for 13years would not be renewed. Aftermuch careful deliberating, the Coun-cil and Executive Leadership, in con-junction with the leaders of ACLGIM,decided to purchase property tohouse the organizations’ national of-fices. There were many factors thatled to this decision: it’s a good timeto acquire property, it’s financiallysound for the organization (we willactually pay less a month in mort-gage than we did in rent for the oldspace), and investing in property willprovide SGIM with equity that willserve as part of the Society’s invest-

is a quick five-minute walk from theMetro subway system and other pub-lic transportation. Through the pur-chase of this property, SGIM hopesto secure the future of the Societyand ensure the future of GIM. Allevi-ating the burden of rent will help theSociety create innovative and lastingprograms for you, its members.

There is still time to make a dona-tion to the SGIM Capital Campaign.Your contribution is tax-deductible, asSGIM is a 501(c)3 nonprofit organiza-tion. Visit www.sgim.org/go/donatefor more details or call the nationaloffice at 800-822-3060. SGIM

ment portfolio. As the mortgage ofthe property is reduced and eventu-ally eliminated, SGIM will further itsability to expand programs that sup-port members’ professional growth.

In order to accomplish our goal ofpurchasing a new property, SGIM un-dertook a Capital Campaign—the firstof its kind for the organization. Led byThomas Inui and formally begun atthe 2010 annual meeting in Min-neapolis, the Capital Campaign chal-lenged SGIM and ACLGIM membersto donate to help raise the $450,000down payment for the property. Asecondary goal—to have 50% ofmembers donate—was also estab-lished. Members responded, and asof this writing, the campaign hasraised almost $403,000. We are stillshort of both goals, however, andhope to have raised the final amountby the end of the Campaign—the2011 annual meeting in Phoenix.

In addition to the office space atthe new location, there will be a largeconference room for Council andcommittee meetings and a donor-recognition wall in the common sit-ting area. The surrounding area ishome to local small businesses,restaurants, and boutique hotels and

9

FROM THE SOCIETY

Moving Our Home, Building Our FutureFrancine Jetton, MA

continued on page 11

Identifying a patient’s PCP is critical to improving care coordination. How did you “clean up” the PCP designations in your EHR?Another priority in our practice wasto improve coordination of care.Most of our patients expect us tocommunicate with the consultantsthey see and want to discuss theconsultants’ findings and recom-mendations with us. To do this ef-fectively and efficiently requiresoutstanding communication sys-tems between PCPs and consul-tants. However, within a largemedical group like ours, it is often

PRACTICE INNOVATIONScontinued from page 7

not easy to discern whether a pa-tient has a PCP and who the PCPis—even with an EHR.

To accurately identify the PCP, ourinitial step, paradoxically, was to re-move all data from the PCP field inour EHR. We then assigned a PCP ifthe patient’s most recent non-acutevisit was a “new” patient visit or ifthe last two follow-up visits werewith the same physician. We madethe PCP field visible in the header ofpatients’ records and empowerednurses to update this field whenrooming patients. Currently, 83% ofpatients seen at least once in GIM inthe last 18 months have a desig-

nated PCP. Nevertheless, attributingPCPs remains an ongoing challenge.

How have you used exemptionsto limit false alarms and registryfatigue?In early 2008, we began using theEHR to generate individualized listsfor each physician for select metrics.Physicians are able to select a med-ical or patient reason for exemptionand will not be notified in the futureabout this patient. Capturing excep-tions is critical to avoid incorrectlyidentifying quality deficits. Too many“false positives” create alert fatigue,

10

exam, so periodic paralysis or otherdisorders like Guillain-Barre syndromeare essentially ruled out. This examand her history of HG strongly sug-gests that this is indeed WE and thatshe should start therapy immediatelywith high dose IV thiamine—especiallyprior to receiving any glucose-contain-ing solutions, which can worsen WE.Of course, she may have other elec-trolyte or metabolic abnormalities, so Istill await the laboratory results.

Laboratory studies show a hemat-ocrit 30%, MCV 95, albumin 2.2g/dL, and ESR 30 mm/h. The basicmetabolic profile, blood count, TSH,liver enzymes, urinalysis, urine drugscreen, serum ammonia, vitaminB12, and folate levels are all withinnormal limits. Blood, urine, and stoolcultures are sent. Chest x-ray andbrain MRA/MRI are normal. EEGshows a pattern consistent withmild-to-moderate encephalopathy.

Surprisingly, there are no othermajor metabolic or electrolyte distur-bances found. Also, there is still noevidence of infection. Typical MRIfindings of WE are symmetric lesionsin the mamillary bodies, hypothala-mic nuclei, periaqueductal gray mat-ter, and superior cerebellar vermis.The normal MRI does not rule outWE, as the sensitivity of MRI for WEis about 50% (in limited studies). Atthis point, volume repletion, IV thi-amine, and consideration of enteralnutrition for the HG are in order.

Upon arrival to the ER, the pa-tient received rehydration therapywith “banana bags.” Her symptomsof volume depletion improved, butshe remained confused and weak.The patient was started on high-dose IV thiamine (500 mg threetimes daily for two days, followed by500 mg once daily for another fivedays, and then 100 mg orally oncedaily). The patient improved signifi-cantly within the first 48 hours of ini-tiating treatment and had almostcomplete resolution of her symp-toms after two weeks of therapy.Her long-term memory remainedmildly impaired until discharge. Herchronic diarrhea was attributed to bil-iary malabsorption, and she wasstarted on cholestyramine. With theexception of positive fecal fat, stoolstudies were negative.

Wernicke’s encephalopathy isclassically associated with chronic al-coholism, but it can develop in manyother clinical settings. This case illus-trates one of those—hyperemesisgravidarum. WE can complicate anysituation where nutritional status iscompromised, such as post-bariatricsurgery, patients on chemotherapy,eating disorders, AIDS, hemodialysis,or chronic nausea and vomiting fromany cause. Thiamine stores can bedepleted within three weeks of poorintake. This patient presented withthe classic triad, but most patients donot. In addition, patients can present

MORNING REPORTcontinued from page 4

with pupillary abnormalities, pa-pilledema, coma, psychosis, polyneu-ropathy, hypotension, or hypothermia.

The diagnosis of WE is generallyclinical. No specific laboratory testscan make the diagnosis, and serumvitamin B1 levels are not readily avail-able and are not reliable indicators ofbody stores. As mentioned above,MRI imaging can be helpful but isnot sensitive.

Treatment is with high dose IVthiamine, as per the regimen given tothis patient. Treatment failures havebeen seen with lower doses (e.g.100 mg IV daily). Untreated WE hasa mortality approaching 20% and canlead to the chronic Korsakoff syn-drome, which is characterized by se-vere anterograde amnesia andemotional disturbances. Classically,patients with Korsakoff syndromehave confabulation, but this oftenabates after the acute setting. Kor-sakoff syndrome does not respondwell to thiamine replacement, soearly treatment to prevent its devel-opment is critical. The oculomotorfindings of WE often respond withinhours of thiamine administration.This rapid response to therapy maybe a useful diagnostic clue. Theataxia and mental status changes re-spond within days to weeks. Up to60% of patients have residual impair-ments, including nystagmus, ataxia,or memory disturbances.

Table 1: Differential Diagnosis of Acute Altered Mental Status

Metabolic (e.g. hyper- or hypothyroidism, adrenal insufficiency, hypercortisolism, diabeticketoacidosis, hyperosmolar nonketotic state, hypoglycemia, vitamin B1 or B12 deficiency)Oxygenation (e.g. hypoxia from any cause)Vascular (e.g. stroke, myocardial ischemia)Electrolytes (e.g. hypo- or hypernatremia, hypercalcemia, hypermagnesemia)Seizure (e.g. post-ictal state, status epilepticus)Tumor or trauma (e.g. brain mass, subdural hematoma, epidural hematoma)Uremic or hepatic encephalopathyPsychiatricInfection or inflammation (e.g. meningitis, encephalitis, systemic infection, sepsis, CNS vasculitis)Drugs (e.g. intoxication or withdrawal from drugs of abuse, medication side effects or overdose, poisons)

continued on page 13

Heed the Red Flag!Several challenges can arise late inthe stage of manuscript develop-ment. These are important to identifyas red flags when they occur so thatthey can be expeditiously addressed,thereby decreasing the potential formiscommunication or festering con-flict. For example, one author may beunresponsive to repeated queries re-garding the project, essentially hold-ing the rest of the research teamhostage. In another scenario, a man-uscript may be circulated and largelydeveloped before authorship inclu-sion and order is discussed, leavingthe co-authors clueless as to the ulti-mate group and ordering of authorsto be proposed. In another case, amanuscript may be developed with a

last author who may have the great-est seniority but who did not activelyprovide “on the ground” project su-pervision and leadership. While thesecases are not exhaustive, they andothers like them can be exhaustingto adjudicate. Each has a unique so-lution, but none can be resolvedwithout honest and thoughtful dia-logue among the affected parties. Inthe first case, one has to wonderwhy the manuscript is being held atbay and whether reasonable time-lines and co-author accountabilitywere discussed during manuscriptproduction. The second case high-lights the importance of establishing(provisional) authorship inclusion andorder early, and the third casetouches upon the importance of cre-

11

RESEARCHERS’ CORNER: PART Icontinued from page 5

ating opportunities for recognitionand career advancement as well asavoiding a pro forma “he/she is lastauthor because he/she has the mostgrant funding or is the oldest” with-out considering the active leadershipand mentoring for the project athand.

Concluding ThoughtsIn addition to the guidelines above,as with other aspects of academicmedicine, occasional consultationwith a trusted colleague can be in-valuable in times of uncertainty,doubt, or outright conflict with a col-laborator. It is important to recognizethat potential conflicts with author-ship are often inevitable, but howthey are managed is not. SGIM

thus hindering efficacy of clinical de-cision support in the EHR.

Can you describe your approachto teaching residents about qual-ity improvement?The goals of introducing quality met-ric feedback to residents were equalparts education, preparation for prac-tice, and improved patient care. Ourcurriculum includes a quarterly qualityconference as well as quarterly pre-continuity clinic discussions, focusingon defining standard ambulatory carequality metrics, the evidence behindthese metrics, use of an electronicmedical record, national movementtowards pay for performance, and therisks and benefits of such a system.

In conjunction with the educa-tional curriculum, residents are

PRACTICE INNOVATIONScontinued from page 9

given individual feedback on theircontinuity patients not meeting stan-dards of care in coronary heart dis-ease, congestive heart failure,diabetes, and preventative care. Em-phasis is placed on performancefeedback as a tool to improve pa-tient care and not as a report card.

Where are you going next with QIat Northwestern?We view routine quality measure-ment and quality improvement usingEHR data as an essential step for im-proving primary care delivery andachieving the goals of the PCMH.Our early work found that quality dataextractable from the EHR were accu-rate for most measures when com-pared to review of physicians’ notes.However, the EHR data frequently

missed patient reasons and medicalreasons (“exceptions”) for not satis-fying a measure. Despite this limita-tion, we began giving physiciansquarterly reports on their perfor-mance on a set of 16 quality mea-sures using only EHR data.Importantly, this process identifiedsome areas of low performance (e.g.pneumococcal vaccination for pa-tients 65 and older) that showed thevalue of monitoring quality across abroad set of measures. By using qual-ity measurement, feedback to physi-cians, and clinical decision support,we were able to raise pneumococcalvaccination rates from 44% in Janu-ary 2006 to 84% in January 2009.

We have also targeted medica-tion reconciliation for patient safetyinitiatives for the future. We are cur-rently generating a list of medica-tions for patients to review andcorrect when they arrive for a visit.The nurse reviews the medicationreconciliation sheet in the examroom, makes changes in the EHR,and notes problems or questions forthe physician. Initial pilot testingfound that this process took an aver-age of 15 to 20 seconds.

SGIM

All too often, academic practices, especially resident

practices, appeal to patients with limited options. By

allowing patients to be seen by a more intimate team,

as opposed to a group of more than 100 physicians,

we have been able to minimize patient turnover.

12

official salaries range from $10 to$30 per month for most positions, in-cluding physicians. While the countryhas a widespread educational sys-tem and a literacy rate that is higherthan the United States’ rate, there islittle economic reward for personswith advanced degrees. Physicians,engineers, and university professorsbring home far more income frommoonlighting as taxi drivers thanfrom their day jobs. Food is highly ra-tioned, and many food items, includ-ing beef, are beyond the reach ofmost Cubans. Security is extremelytight, and police can be seen pa-trolling every few blocks on mostmain streets. On a ride back fromSanta Clara to Havana, our bus wasstopped while a Cuban was detainedfor illegally selling beef. Our guideexplained that the person in questionwas probably facing a prison sen-tence of 10 years for this offense.

Yet, in spite of the harshness ofthe political and economic environ-ments, the Cubans we met were in-credibly resilient and retained aremarkable entrepreneurial spirit. Ourguide explained that the Cuban econ-omy in reality has multiple compo-nents—the official governmentsector, which provides meagerwages as noted previously; a growinglegal private sector; a longstandingblack market; and funds that comeinto the country from relativesabroad. Music and art seem to flour-ish. A wide variety of music—includ-ing traditional Cuban, classic andmodern jazz, and Caribbean—can beheard in the numerous clubs and

plazas, and impromptu galleries dotthe cityscape. Young people gathereach night by the Malecón—the largeseawall that stretches along the At-lantic for most of Havana. Every cou-ple of hundred feet, we came uponsmall groups of musicians with gui-tars and bottles of rum—many injeans and tee shirts that looked asthough they came from Aeropostleand Abercrombie and Fitch. It wasvery easy to join in on the impromptufestivities.

While in Cuba, I also had time tosit by the pool and read Tracy Kidder’sMountain by Mountain, which docu-ments the work and life of PaulFarmer, a Harvard physician, medicalanthropologist, and founder of Part-ners in Health. Farmer is a truly re-markable individual who hasconducted landmark research of theadverse effects of poverty on health.He has launched a number of miracu-lous initiatives to bring basic medicalcare to the central plateau region ofHaiti and to establish programs toeradicate multi-drug resistant TB andHIV in Peru, Siberia, and other regions.

One of the book’s chapters de-scribes Farmer’s interactions withCuban health authorities and his ob-servations on the Cuban health sys-tem, in particular the robust publichealth infrastructure that has led tolow rates of most communicable dis-eases. Farmer also noted that life ex-pectancy in Cuba is roughly equivalentto that in the United States, that in-fant mortality is lower, and that Cubahas twice the per capita number ofphysicians that the United States has.

PRESIDENT’S COLUMNcontinued from page 3

Given the tremendous economicdisparities between the two countriesand the widespread poverty that oneencounters in Cuba, I found thesedata astonishing and sought confirma-tion. Going to the WHO website, Ifound that the available data present amixed picture. While life expectancyand healthy life expectancy are onlyslighter higher in the United Statesthan in Cuba (78 vs. 77 years and 70vs. 69 years, respectively), maternalmortality is more than three timeslower in the United States (13 vs. 47per 100,000 live births). While infantmortality is indeed higher in theUnited States, further research sug-gests that the difference reflects themuch larger number of low birth-weight infants who are born here.Other recent reports have chronicledthe depressing conditions and thelack of basic medical supplies in manyclinics and hospitals in Cuba, particu-larly those outside Havana.

Nonetheless, the relatively similarlife expectancies in the United Statesand Cuba in the face of vastly differ-ent health care expenditures andstandards of living pose powerfulquestions about the value of the UShealth care system and its technolog-ical focus. The data also highlight theimportant balance between medicalcare and public health and the unfor-tunate uncoupling of these two vitalelements in the United States.

While most SGIM members arelikely familiar with the large amountof data demonstrating that healthcare outcomes in the United Statesfall, at best, in the middle of the packamong industrialized nations, visitingCuba—a nation that has for all in-tents and purposes been stuck in a50-year economic malaise—caststhings in a much different and starkerreality. Perhaps what has evolved inthe United States reflects our collec-tive values as a society—the impor-tance we place on individualfreedoms and the basic distrust ofmany Americans toward social pro-grams and government regulations.But after reflecting on a truly uniqueweek spent in Cuba, somehow Ithink we can do better. SGIM

13

Thiamine requirements are in-creased during pregnancy, so it is notsurprising that WE develops inwomen with HG. Additionally, hyper-thyroidism can accompany HG,which may further increase thiaminedemands. Women with severe HGmay require enteral nutrition (whichis preferable to parenteral nutrition) ifefforts to control the vomiting fail.Those efforts usually include avoidingtriggers of nausea; eating frequentsmall, low-fat meals; avoiding anempty stomach (which exacerbatesnausea); hypnosis and acupuncture;vitamin B6; and/or antiemetics (e.g.antihistamines, promethazine, on-dansetron). In women with HG whohave significant difficulties eating, thi-amine supplementation should beconsidered prior to administration ofrehydration with glucose-containingsolutions to avoid precipitating WE.

Teaching Points1. Wernicke’s encephalopathy (WE)

is a well-recognized complicationof hyperemesis gravidarum.

2. The triad of altered mentation,oculomotor dysfunction, and gaitataxia is present in only one thirdof patients with WE. Thepresence of any leg of this triadshould raise suspicion of WE.

3. Though classically associatedwith alcoholism, WE can developin any patient with nutritionalcompromise.

4. If WE is considered, thethreshold for therapy should below, given the low risk oftreatment complications and thehigh potential benefit of therapy.

References1. Sechi G, et al. Wernicke’s

encephalopathy: new clinicalsettings and recent advances indiagnosis and management.Lancet Neurol 2007; 6:4422.

2. Chiossi G, et al. Hyperemesisgravidarum complicated byWernicke encephalopathy:background, case report, andreview of the literature. ObstetGynecol Survey 2006; 61:255.

SGIM

NEW PERSPECTIVEScontinued from page 1

ery. In partnership with that group,we worked to make the dialogue asinclusive and transparent as possible,mobilizing a series of town hall meet-ings that brought together hundredsof community members. Thosemeetings included practicing commu-nity clinicians, residents, students,and faculty. People who knew Har-vard well told us that this was an un-precedented show of support and aunique convergence of such a broadswath of our community.

These town hall meetings wereremarkable in both their inclusivityand the open forum they fostered.The gatherings also reminded us ofall of the fantastic work being doneby the people in our community andof the wonderful ideas and commit-ment that we all shared—things thatsome of us may have forgotten. Forprimary care-oriented trainees whohad been exposed to years of dis-couraging admonishments to avoidprimary care careers at all costs,these community experiences werean incredible breath of fresh air.

The town hall meetings culmi-nated in the creation of a set of am-bitious and comprehensiverecommendations to the school thatincluded the creation of a primarycare hub—something we at PrimaryCare Progress were overjoyed tosee Harvard act upon in October2010. With the help of a $30 millionanonymous donation, HMS an-nounced its new “Center for Pri-mary Care,” which is intended to bea global “touchstone” for primarycare education, research, and inno-vation. In creating the center, theschool emphasized that primary careis important to our society and thata school like Harvard has an oppor-tunity and a responsibility to partici-pate in how we prepare providers.

Clearly, the success of such aventure will require a committed ad-ministration as well as the continuedcollaboration by the local and na-tional primary care communities. Tobe fair, Harvard has a great deal tolearn from other institutions aboutwhat top-notch primary care traininglooks like and how schools can and

should invest in the field. Addition-ally, we believe it will also be impor-tant for family medicine to finally begiven a real seat at the HMS table.We at Primary Care Progress are in-credibly optimistic about the futureof primary care at Harvard.

Primary Care Progress is apply-ing many of the lessons we learnedthrough our experience at Harvardto support other primary care com-munities around America. The mostfundamental of these lessons is thatwe don’t need to recruit studentsinto primary care careers—we justneed to keep those who are inter-ested and curious from getting dis-couraged. The data show that manystudents start medical school with astrong desire to pursue primary carecareers but that they ultimately endup getting turned off by a number offactors, including huge disparities insalary, challenging practice condi-tions, and explicit discouragementfrom mentors. From our experience,these students are a lot less likely toget discouraged by these thingswhen they also have positive experi-ences to anchor to—like exposureto exciting innovations in care deliv-ery and inspiring providers who areengaged in reinventing our systemsof care.

A second thing we learned isthat there is much to be gained bygetting trainees involved in care de-livery innovation efforts. Studentsand residents have important skillsand fresh perspectives—not to men-tion energy—that they can use toaccelerate local care delivery trans-formation.

Finally, we realized that in our ef-forts to return primary care to a cen-tral, valued position in our healthcare system, local primary care com-munities are a powerful, relativelyuntapped resource. Our grassrootsefforts in Boston and the responsewe have received from other com-munities have shown us the incredi-ble value of empowering theseenergetic, creative, and passionatecommunities, and we look forwardto continuing in this rewarding work.

SGIM

MORNING REPORTcontinued from page 10

14

Position AvailableClinicianEducator

Division of General InternalMedicine

Department of MedicineJohns Hopkins University

Recruiting highly motivated experiencedinternist/s for a fulltime Assistant Pro-fessor or Associate Professor position.

Responsibilities include: clinicalpractice; executive health evaluation;medical student, resident, and felloweducation; and opportunities toparticipate in clinical and educationalresearch and other scholarly activities.

Candidates must be Boardeligible orBoardcertified and have a Marylandmedical license (active or pending).

Johns Hopkins is an affirmativeaction, equal opportunity employer.

Mail or fax cover letter andcurriculum vitae to:

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

General internist clinician-educator, UTHSC at San AntonioSeeking a BC/BE general internist for anon-tenure track appointment in anacademic Division of General Medicine.Responsibilities include teaching internalmedicine residents and medical studentsin the clinics of the University HealthCenter-Downtown, and assisting in thedevelopment of curricula. All facultyappointments are designated as securitysensitive positions. Send CV and coverletter to:

Andrew Diehl MD, Chief, Division ofGeneral Medicine, MSC 7879,University of Texas Health ScienceCenter at San Antonio, San Antonio TX 78229-3900, or to Diehl@uthscsa.edu. The University of Texas Health ScienceCenter at San Antonio is an EqualEmployment Opportunity/AffirmativeAction Employer.

Positions Available and Announce-ments are $50 per 50 words forSGIM members and $100 per 50words for nonmembers. These feescover one month’s appearance inthe Forum and appearance on theSGIM Web-site at http://www.sgim.org. Send your ad, along with thename of the SGIM member spon-sor, to ForumAds@sgim.org. It isas-sumed that all ads are placed byequal opportunity employers.

Clinical/Health ServicesResearchers. Division of General

InternalMedicine, University of Texas South-western Medical Center, Dallas, TX isseeking MD or PhD-trained researchersat Assistant/Associate Professor level.Great research infrastructure: university/safety net health systems with sameEPIC EMR, CTSA, KL2, research cores(informatics, biostatistics, social sci-ence, CBPR). Areas of interest: epi-demiology, outcomes, health servicesresearch, quality, patient safety, chronicdisease management, adherence,disparities, CBPR, informatics, hospitalmedicine, geriatrics, palliative care.Salary/rank commensurate with exper-ience. Send letter/cv to:

Ethan Halm, MD, MPH, University of Texas SouthwesternMedical Center, 5323 Harry Hines Blvd, Dallas, TX75390-8889 or email:Ethan.Halm@utsouthwestern.edu Equal opportunity/affirmative actionemployer.

Innovative primary care practicein San Francisco/Marin.

We are a paperless office in beautifulSan Francisco (with another office justnorth of SF in Marin), looking for aprogressive internal medicine physicianwho believes there’s a better way topractice medicine. Balanced lifestyle,reasonable income, working withacademically-trained MDs. Started byoriginal designer of Epocrates. If inter-ested, please send a brief intro and CVto: jobs@onemedical.com.

Modern primary care practice in New York City.

We are a paperless office located in theheart of Manhattan, looking for aprogressive internal medicine physicianwho believes there’s a better way topractice medicine. Balanced lifestyle,reasonable income, working withacademically-trained MDs. Started byoriginal designer of Epocrates. If inter-ested, please send a brief intro and CVto jobs@onemedical.com.

Academically Oriented InternistsHennepin County Medical

Center (HCMC) Hennepin Faculty Associates

(HFA) Division of GeneralInternal Medicine Department of

Medicine Academic Internists

HCMC—Minnesota’s premier Level ITrauma Center—a University ofMinnesota affiliated teaching hospital,and HFA are seeking academicallyoriented internists. Responsibilitiescould include providing direct patientcare on both inpatient and outpatientservices and educating/supervisingmedical students and housestaff in bothof these settings. Candidates shouldpossess excellent clinical skills; acommitment to teaching is also valued.Part-time positions also available.Candidates eligible for academic rank atthe University of Minnesota com-mensurate with experience. HCMC,HFA, and the University of Minnesotaare EOE. Please send letter of interestand CV to:

Mark Linzer, M.D., Director Division of General Internal MedicineDepartment of MedicineHennepin County Medical Center701 Park AvenueMinneapolis, MN 55415Mark.Linzer@hcmed.org Phone: 612-873-4059 Fax: 612-904-4262

Associate/Full Professor,Internal Medicine Chairperson

The University of Nevada School ofMedicine Department of InternalMedicine is seeking qualified candi-dates for Associate/Full Professor,Chairperson, Department of InternalMedicine. The successful candidate willhave a strong academic and admin-istrative background in medical edu-cation, excellence in teaching medicalstudents and residents in a ACGMEaccredited residency or medical school.For more information, please contact:

Recruitment Manager, Anita Prince at 702-671-2208 oraprince@medicine.nevada.edu. To apply, please visit https://www.unrsearch.com/postings/6660. AA/EEO. Women andunderrepresented groups areencouraged to apply.

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Senior Faculty Member forCenter for Promotion of Healthy

CommunitiesThe UC Riverside School of Medicine isrecruiting a senior faculty member tolaunch and direct the Center forPromotion of Healthy Communities.This center will be a catalyst forresearch in population-based assess-ment of health and wellness, healthinterventions, healthcare disparities,and access. Of particular interest arecandidates experienced in comparableeffectiveness research and approachesto quantifying behaviors, services andtools leading to superior patient out-comes and lowered cost.

Inquiries: ameae.walker@ucr.edu. Full advertisement:www.medschool.ucr.edu/employment/.The University of California, Riverside isan affirmative action/equal opportunityemployer committed to a campusclimate that embraces diversity.

Position Type: Faculty/ResearchThe Division of General InternalMedicine, University of Pittsburgh, isseeking a clinical investigator withfellowship training or a PhD for a newfull-time academic position in theSection of Chronic Disease Epidem-iology. We are particularly interested incandidates with interests in cardi-ovascular disease, HIV, and or alcoholepidemiology. Academic rank will beAssistant or Associate Professor Levelin the tenure stream. Salary andappointment commensurate withqualifications. Please forward letter ofinterest and CV to:

Matthew Freiberg, MD, MSc,University of Pittsburgh, 230 McKee Place, Suite 600.23,Pittsburgh, PA 15213 (Fax 412 692-4838) or emailfreibergms@upmc.edu. The University of Pittsburgh is anAffirmative Action, Equal OpportunityEmployer.

Physician BC/BE in Internal Medicine

Santa Barbara, California. Busy privatepractice with five locations throughoutSouthern California, specializing in spinesurgery, general orthopedic surgery, andinterventional pain management iscurrently seeking a physician BC/BE inInternal Medicine with experience inevaluating worker’s comp patients.Physician will help evaluate/treat ail-ments such as GI problems and otherinternal medicine issues, as well asassist with pre-op histories/physicalsand pain management. Our goal is toprovide both surgical and nonsurgicalspine and orthopedic care by utilizing amulti-disciplinary approach. You will bepart of a growing and successfulpractice with locations throughoutSouthern California. Attractive compen-sation package available.

Please fax CV to 805-563-0998 or email tolilly@spineandorthocenter.com.

Applications for Tufts’s AHRQ-sponsored fellowship

Tufts Medical Center’s Institute forClinical Research and Health PolicyStudies is accepting applications for itsAHRQ-sponsored fellowship (T32) inHealth Services / Clinical CareResearch. Primarily intended for physi-cians who have completed their resi-dency training, all participants willcomplete an independent researchproject in an environment whereexcellence and innovation are expectedand opportunities are plentiful, and willearn a masters degree or PhD in Clinicaland Translational Science at TuftsUniversity Sackler School of BiomedicalSciences, which also has a CertificateProgram. Contact: NBonnoyer@tuftsmedicalcenter.org.

General Internal MedicineFellowship—Harvard Medical

SchoolA joint program of Harvard MedicalSchool teaching hospitals invites appli-cants for two-year research-orientedfellowships beginning 7/1/12. Fellowsreceive an appointment at HarvardMedical School and one of its affiliatedhospitals. Most Fellows complete anMPH degree at the Harvard School ofPublic Health. Research areas of specialinterest include primary care, preventivemedicine, vulnerable populations andhealthcare disparities, and patient safetyand quality of care. Applicants must beBC/BE in internal medicine by July 1 oftheir first fellowship year. For infor-mation, contact:

Rachel Quaden, HMS Fellowship in General Medicineand Primary Care, Beth Israel Deaconess MedicalCenter, 1309 Beacon Street,Brookline, MA 02446, 617-754-1434,rquaden@bidmc.harvard.edu,www.hms.harvard.edu/hfdfp. The 2012 application deadline is3/1/11. The participating institutions areequal opportunity employers. Weencourage underrepresented minoritiesto apply.

Attend SGIM Hill Day March 2, 2011 in Washington, DC

Visit your representatives on Capitol Hill and advocate for issues important to GIM

For more information – visitwww.sgim.org/go/healthpolicy

Register NOW for the SGIM 34th Annual Meeting“The Many Faces of Generalism”

May 4-7, 2011Sheraton Phoenix Downtown

Phoenix, Arizona

Register NOW for the SGIM 34th Annual Meeting

“The Many Faces of Generalism”May 4-7, 2011

Sheraton Phoenix DowntownPhoenix, Arizona

Opening Plenary Speaker: H. Jack GeigerFriday Plenary Speaker: Ed H. Wagner

Saturday Plenary Peterson Lecture:Professor Sir Michael G. MarmotRegister online at www.sgim.org to avoid paper processing fees.

Register early and avoid late fees.

Society of General Internal Medicine2501 M Street, NWSuite 575 Washington, DC 20037www.sgim.org

SGIMFORUM

Academic Hospitalists/Clinician-Educator

Tulane University School of Medicine, Section of General InternalMedicine is seeking BE/BC general internists to join our academichospitalist program. Rank will be commensurate with experience.

These faculty provide inpatient and medical consultative care atUniversity affiliated hospitals in concert with housestaff. Applicants willjoin a robust academic hospitalist group active in scholarly activitiesincluding quality improvement and medical education. Those withexperience and interest in student and resident education desired.

Physicians enjoy competitive salaries and benefits package.Candidates from underrepresented minorities are encouraged toapply. No J-1, O-1 or H1-B visas please.

Interested applicants should submit a CV and cover letter to: Alys Alper, MD, MPH, Associate Chief, Section of General Internal Medicine and Geriatrics, Tulane University Medical School, 1430 Tulane Avenue, SL-16, New Orleans, LA 70112aalper1@tulane.edu or 504-988-7518. Applications will be accepted until qualified candidates are identified.AA/EOE.