Winter 2012

Mission Statement

The mission of the Texas Chapter of the American College of Physicians is to promote quality health care for all Texans by strengthening the practice of internal medicine.

President's Message

Felicia Austin-Tolliver, MD, FACP
TXACP President

It is with sincere pleasure and gratitude that I greet you in the first edition of the year of The Texas Internist as your President. I assume this role during a time of much excitement and trepidation about the state and future of the practice of medicine. We are in the midst of another election year that will undoubtedly play a role in how we are able to care for our patients.

The 82nd Legislative Session was a trying one due to budgetary shortfalls. Although our successes included defeating any threats to tort reform, fending off scope of practice expansions, and eliminating the anonymous complaint to the Texas Medical Board, primary care took a staggering hit. With any available monies being poured into public education it left the practice of medicine with deep budget cuts in funding for internal medicine, family practice, and pediatric residency training through the Texas Higher Education Coordinating Board, reduction in graduate medical education formula funding by 31%, decrease in loan repayment programs, and complete elimination of funding in FY 2012-2013 for the Texas Statewide Preceptorship Program. I can not say with certainty that all of these cuts could have been adverted had we been more aggressive from the onset but I do feel that physicians as a group have become too comfortable practicing “defensive lobbying”. We must began to act proactively instead of reflexively and voice our views, concerns, and expertise well before a decision is to be made on our behalf. Our voices are an integral part of policy making, we must ensure and be responsible that they will be heard.

Having the foresight of things to come, your Board began establishing a Foundation that could support and address the issues and needs that are important to the practice of Internal Medicine. I am elated to report that The TXACP Foundation is now functional and ready to start its work. The Foundation is a 501(c) (3) corporation that operates exclusively for education and charitable purposes that enhance health care in Texas. The time has come to start “mattering” and investing in ourselves. Please refer to the Chapter website on more information concerning the Foundation.

It has been said many times throughout history that there is strength in numbers. We have approximately 6500 members in the organization but still need to expand our numbers and more importantly increase active participation. Our members have such a rich, diverse background with a plethora of skill sets and interests. It is my intent to tap into these under-utilized wells. The Board of Directors strives to be your voice but we must hear from you in order to accurately reflect the message. We have formed the Council of Young Physicians to help those transitioning out of residency moving forward into different career paths and to foster involvement within the college. There are also a variety of committees with concerns ranging from public policy, quality, Medicare, IT, and medical student and resident education. Our strategic planning session last fall was quite robust with many new projects and adjustments to old. However as you are aware any plan is only as successful as the ability to implement and follow-up on it. Your involvement is the key to success.

I am excited about the possibilities of this upcoming year and am committed to executing and supporting the goals and objectives of the Chapter. There will be some challenges but I am confident that by coming together and presenting a united front we will be able to strengthen this great organization and become the leaders of healthcare. Please do not hesitate to contact me or any of your Board members for questions, concerns, or recommendations. I wish you the best in 2012.

Governor’s Message

Clark R. Gregg, MD, FACP
Governor, TX Northern Region

PCMH on the Move

The Patient Centered Medical Home (PCMH) movement, led by the American College of Physicians (ACP), is gaining increasing traction in how health care is provided in the United States. I want to highlight two major initiatives that are relevant to internal medicine and other primary care practice in Texas and to the future of health care for a broad cross section of Texans. Your Texas Chapter of ACP (TXACP) is a national leader in this movement, whose goals focus on reinvigorating primary care practice through both access to patient-centered primary care and increasing patient and provider satisfaction.

The Texas Medical Home Initiative (TMHI) is a multi-stakeholder, non-profit, practitioner-led project of which TXACP is the convening body. TMHI was formed in 2008 as the brainchild of Robert Jackson, MD, FACP, current Texas Southern Governor of ACP, and Sue Bornstein, MD, FACP, Immediate Past President of TXACP and Governor Elect Designee for the Texas Northern Region of ACP. A kickoff summit was held in 2008 that gathered representatives from eighteen key stakeholder entities, including physician organizations and practices, nurse practitioners, payers, government agencies, and major businesses. Agreed goals were to improve health outcomes while managing costs, to invest in sustainable infrastructure, and to improve both patient and provider experience and satisfaction. The unity that emerged from that summit led to TXACP’s granting $10,000 for a pilot of 7-10 internal medicine practices of various sizes (2-30 internists) in North Texas that has been leveraged into TMHI’s becoming a 501(c)3 organization and attracting $520,000 in grants and donations to sustain and expand this effort. Two more summits have been held and strongly attended, and an array of tools for PCMH practice transformation are now in place, including intensive professional coaching, technology support, and shared best practices using timely and actionable clinical quality data. TMHI promises to markedly enhance the value of TXACP membership for practicing internists and is a nominee for a 2012 ACP John Tooker Evergreen Award.

The Veterans Health Administration (VA), the largest fully integrated health care system in the United States, has fully embraced Patient Aligned Care Teams (PACT) as its version of PCMH. VA is fully utilizing the ACP Medical Home Builder tool with added features and since 2010 has seriously funded patient-centered care transformation simultaneously across all its health care venues. The foundation of PACT is primary care but is being expanded to embrace specialty care, women’s health care, geriatrics, and academic training programs. Key components of PACT goals include timely access to care (including alternatives to face-to-face care), seamless coordination within VA and with non-VA providers, and redesign of primary care practices and team roles to facilitate a patient-centered culture. Technological supports are universally applied, such as VA’s iconic Computerized Patient Record System as well as newer modalities including secure e-mail messaging, telehealth systems, and enhanced use of creditable telephonic and group encounters. Expansion to specialty care embraces e-consultation and other leading edge virtual medicine telehealth tools. The PACT program is not a pilot study; it is a dedicated and well-funded transformation of VA primary care in the PCMH model. Texas is home to a large and growing population of eligible military veterans, and VA’s PACT program serves as the most ambitious and widespread laboratory for the PCMH concept currently in play.

A recent publication (Arch Intern Med 2012; 172(1): 23-31) on the subjective perceptions of staff and providers of the effects of PCMH in a selected group of clinics found that though morale was higher, providers still may be vulnerable to burnout. An accompanying commentary noted that practices and providers less adaptable to change might be at risk of not completing a medical home transition. Keys to success of PCMH include adequate financial resources and realistic expectations from providers’ time and effort.

Investment of resources in the patient-centered medical home model and the products of these investments, exemplified by TMHI and VA’s PACT initiative, will provide visible and accountable evidence of the value and sustainability of this health care delivery model for private sector and public sector health care of many Texans.
 

On Being a Doctor

Evan Ross
"No One Dies Alone"

The pager rang at 7:02 in the afternoon. It was the first time it had done so in my presence and for a moment I couldn’t believe it was ringing. Surely it was someone’s phone here by the pool, one of my friends by the grill. Surely this wasn’t my pager. I reached down, popped it out of its holder and lifted it up, squinting to see the numbers on the screen through the glare of the Texas sun. Five digits glowed back at me. I picked up my phone, hand not entirely as steady as I would have liked, and I punched in the phone number for the hospital’s Medical ICU.

This was happening.

A nurse’s voice came on the other end of the line. I told her who I was and why I was calling. She put me on hold. All I could hear was poolside revelry, splashes and laughter. Then another nurse’s voice on the line: “We have a patient,” she said, “we’ve withdrawn care, but his mother won’t come to see him. He has a friend in town, but he won’t come either.” “You called the right guy,” I said, hoping that was the truth. 23 minutes later I walked into the MICU, the smell of disinfectant and plastic sounding a sharp contrast to the grilling and chlorine and freshly cut grass I had left behind. In the room I saw a man sitting up in bed, eyes wide open. I had not expected him to be awake and it took me a split second to wrap my mind around it. He was going to die, but he wasn’t dead yet; he was going to die, but for now he was wide-awake.

I spoke briefly with his nurse, the woman who had called me. She gave me the most brief of back-stories: a mass in his neck was constricting his airway. He had declined surgery and wanted no more interventions. What little comfort we could bring him was all we had to offer. I nodded, as if to show that I understood, as if I could possibly understand.

The man was sitting up in bed, his body rocking back and forth as if he was in a trance, his eyes fixed on the middle distance, an oxygen mask tight to his face. He did not seem to see me come in, so I took his hand and introduced myself. I told him I was there if he needed anything. A few seconds later he stopped rocking, his head swiveled towards me, his eyes found mine, and for a moment I knew that he saw me. Then his gaze slipped past me, his focus somewhere beyond. I felt him squeeze my hand as he resumed his back and forth, back and forth, back and forth. That was the last time he showed any sign of being aware of what was happening in the room.

All through the night as he fought to breathe I could see the skin tighten against his neck and chest. He may have decided against surgery and declined further interventions, but this was not a man who was going out without a struggle. At one point he grimaced at the wall and reached for his oxygen mask. His hands were not strong but he succeeded in pulling the mask off of his face. He shook his head as if to clear out the cobwebs, never once ceasing his slow oscillation. Moments later he took my hand and pulled himself forward, making as if to get out of the bed and walk away. Then he stopped and lay back, putting his hands behind his head as if he didn’t have a care in the world. I couldn’t help but smile.

His condition predictably deteriorated as the night wore on, but it didn’t strike me as a particularly violent process. His vital signs didn’t seem to be falling so much as gliding slowly downwards like a bird tracing a lazy circle above the earth. He was dying, yes, but it was clear that he had decided it would be on his terms.

My partner in the program had agreed to arrive at midnight to take over the vigil and maintain it until 6 AM, so I darted home for a few hours of sleep. When I came back I found the man on his back, fatigue having robbed him of his rhythm. His eyes now watched the ceiling, and his mouth was open wider than it was when I had left. His breathing was louder now, more difficult and less steady. He’d seem to forget to breathe for seconds at a time then pant to make up the difference.
    
As the sun began to rise outside, I noticed that his breathing had become much quieter. I somehow knew that it was time. I squeezed his hand as I listened to his last breath. I waited for him to gasp, to remember to breathe once more as he had a thousand times before, but he never did. I watched his pulse flutter in his neck, the beats of his heart arrive further and further apart until another beat didn’t come. The monitor beeped. It was over.

I don’t know what he was seeing when he stared at the wall, and I’m not certain he was completely aware of my presence. I can’t explain what his rocking motion was about or why his family couldn’t come to attend his final moments. I don’t know the etiology of the mass in his neck, and I can’t say why he refused further care. I don’t know much about that night, but I do know that this was why I decided to come to medical school in the first place. I know that this vigil’s end is where me being a doctor begins.

Associates, Students Energize Chapter Annual Meeting

The Associates clinical vignette competition featured five residents who were selected in their regional competitions to compete at the statewide meeting. Outstanding presentations were made by Aries Gavino, MD; Samantha Goodman, MD; CPT Meridith Hays, DO; Ben Kahn, MD; and Mike McNeal, MD. Mike McNeal won first place in the competition with his vignette, “Gastric Bypass: Lowering More than Weight”.  Mike will automatically advance to New Orleans to compete at the national level during the ACP Annual Session in April.

In a dramatic conclusion to the annual Doctor’s Dilemma, the team from Baylor College emerged as champions.  Congratulations to team members: Prathit Kulkarni, Premal Lulla and Salman Bandeali. The team will represent the Texas Chapter in the Doctor’s Dilemma competition at the ACP Annual Session in New Orleans this April.

Congratulations to the William Beaumont Army Medical Center team that took second place.  This competition would not have been possible without the help of Drs. Suma Pokala, FACP, Temple and George Crawford, FACP, San Antonio, for organizing this event.  A special thank you to Drs. Jose Perez, Jr., FACP, Hari Raja, and Ray Lazarus, for their assistance with the competition.

Of the 64 abstracts that were submitted for the competition, 15 were chosen to participate in the Associates’ Poster Competition. The submissions came from 9 residency programs.

Thanks to the work of dedicated TXACP volunteers who judges the posters.  The competition would not be possible without your help.  The following winners were announced during Saturday evening’s reception:

Associate Clinical Poster Winners:
1st place: Linh Lu,Plaza Medical Center of Fort Worth Medical Association
2nd place: Shannon Ward, Scott & White

Associate Clinical Research Poster Winners:
1st place: Farshad Forouzandeh, Methodist
2nd place: Elizabeth Bowhay, UTHSCSA  
 

Sponsorships for GIMSPP

Thank You to all of the GIMSPP 2011 Sponsors

Internal Medicine departments at various Texas medical schools as well as foundations within the state have provided sponsorships so that more students were matched for preceptorships through the GIMSPP.

Alejandro C. Arroliga, MD, FACP, Chair of Internal Medicine at the Texas A&M University System Health Science Center, has again provided a sponsorship of $2,100 that allowed additional students to be matched in GIMSPP this past year.

Marc Boom, MD, MBA, FACHE, Executive Vice President of The Methodist Hospital, has again provided a sponsorship of $1,000 that allowed additional students to be matched in GIMSPP this past year.

Cynthia Jumper, MD, MPH, FACP, Chair of Internal Medicine at Texas Tech University Health Sciences Center, has given $2,000 so that more students were matched in GIMSPP this past year.

Randall J. Urban, MD, FACP, Chair of Internal Medicine at the University of Texas Medical Branch, funded the James C. Guckian, MD internist-in-training sponsorship with $1,300 that allowed additional students to be matched in GIMSPP this past year.

Thank you to the Baylor Healthcare System Foundation for providing $10,000 in funds so that more students were matched in GIMSPP this past year.

A special thank you goes out to the Texas Chapter of the ACP for contributing $2,700 towards matching more students for this past year's program.

These vital sponsorships demonstrate the importance the chairs place on academic Internal Medicine departments taking the lead in supporting students’ introduction to this exciting field of medicine.

Drs. Eugene W. Stokes and Karen Szauter, Co-Chairs of the Medical Students Committee, Govs. Robert E. Jackson and Clark R. Gregg and the GIMSPP staff thank all of our sponsors for their continued support of this crucial program.
 

Thank You to 2011 Supporters

The annual meeting would not be possible without the help of the companies that continue to support our organization. The Texas Chapter of the ACP would like to thank the Harris Methodist Health Foundation for their generous educational grant at this year’s meeting.
The following companies provided financial support as well for the meeting. Our chapter is extremely grateful for all of their assistance and for every company that contributed to this year’s meetings success!

Abilene Regional Medical Center
Allscripts
Amgen
American College of Physicians
American Express
Baylor Health System
Bristol-Myers Squibb
Boehringer Ingelheim
CaridianBCT
Chase Bank
Community Health Systems
Eisai Inc
EmCare
GIMSPP
GL Advisor
IPC-The Hospitalist Company
Kelsey-Seybold Clinic
Lippincott, Williams & Wilkins
Masimo
Merck
Otsuka Pharm
Pulse Systems Inc.
Sanofi Pasteur
Scott & White
Sigmatu
TeamHealth
Texas Department of State Health Services
Texas Health Resources
Texas Medical Association
TMLT (Texas Medical Liability Trust)
Texas Medicaid Wellness Program
US Army

Thank You to the 2011 Preceptor Participants

To all of the physicians that participated in GIMSPP this past summer, thank you for your dedication to the future of medicine in Texas by being a preceptor and mentor to our medical students.  Without your service, the program would not be possible!  TXACP would like to thank the following preceptors:
 
Thwe Htay MD
Sarah Smiley, MD
Ellen Manzullo, MD
Randlow Smith, Jr., MD
Carmen Escalante, MD
Alan Kaye MD
KoKo Aung, MD
Susan Andrew, MD
Jeffrey Y. Lee, MD
Edward Sargent, MD
Donna Sue Dolle, MD
Wenli Liu, MD
Philip C. Johnson, MD
Mark L. Ginnings, MD
Julie C. Nguyen, MD
Mark A. Johnston, MD
Robert Thompson, MD
Paraic Mulgrew, MD
James Michael Neff, MD
Ildefonzo Flores, MD
Lynn Lester, MD
Allan Kelly, MD
Uyen Thi Cao, MD
Suresh Antony, MD
Gordon B Strom, Jr., MD
Felicia Austin-Tolliver, MD
Alan Keister, MD
Patrice Alves, MD
Errol B. Bryce, MD
Enrique Rodriguez, MD
Roxana Rhodes, MD
William Robinson, Jr., MD
Joel Walker, MD
Mark A. Farnie, MD
Michelle Mercatante, MD
Ali Bagheri, MD
Fay Simon, MD
Zafer Haydar, MD
Craig Berent, MD
Joel Kneitz, MD
William E. Mitch, MD
Ben Barnett, MD
George Burnazian, MD
Gopinath Chandrahasan, MD
Khanh Vu, MD
John Crommett, MD
Patricia D. Salvato, MD
Hafiza Docrat, MD
Pedro Arrazola, MD
Raymon Aggarwal, MD
M. Keith Schrader, MD
Alejandro Moreno, MD, MPH, JD
Michelle M Ho, MD
Stephanie Mundy, MD
Steve Rosenbaum, MD
Oladayo Sanusi, MD
Mark Armstrong, MD
Scott Yates, MD, MBA
Thomas Baxter, MD
Kathleen A Smalky, MD
Brook T. Jimma MD
John Dickson, MD
William Mania, MD
 

Chapter Elects Officers, Directors

Officers and board members for Texas Chapter of the ACP and Texas Chapter of the ACP Services, the Texas Chapter’s advocacy arm, were elected during the annual awards and business meeting luncheon November 12, 2011, in Austin.

TXACP President
Felicia Austin-Tolliver, MD, FACP, Sugar Land

TXACP President-elect
Jose A. Perez, Jr. MD, FACP, Houston

TXACP Secretary-Treasurer
Stephen J. Sibbitt, MD, FACP, Temple

TXACP Services President
Alejandro Moreno, MD, MPH, JD, FACP, Austin

TXACP Services President-Elect
John D. ‘Jack’ Myers, MD, FACP, Temple

TXACP Services Secretary-Treasurer
Temple Howell-Stampley, MD, FACP, Dallas

Directors

Daniel M. Goodenberger, MD, MACP, Dallas– Northeast Director

Jose D. Burgos, MD, El Paso – Northwest Director

Julie C. Nguyen, MD, Houston – Southeast Director

KoKo Aung, MD, MPH, CPH, FACP, San Antonio – Southwest Director

Randy A. Fuentes, MD, Corpus Christi – At-Large Director

If you are interested in serving on the TXACP or TXACP Services board of directors in the future, e-mail Gena Girardeau, TXACP Executive Director. Be sure to include your curriculum vitae.

Chapter Honors Members

Four distinguished members were honored with the Texas Chapter highest awards during the November 2011 Annual Chapter Scientific Meeting in Austin.

Texas Chapter Laureates for 2011 are:

Harry ‘Pete’ E. Davis II, MD, FACP, El Paso            

John C. McKechnie, MD, FACP, Houston             

Randall L. Rosenblatt, MD, FACP, Dallas           

William ‘Bill” Winters Jr., MD, MACC, FACP, Houston

The Laureate Award honors those Fellows and Masters of the College who have demonstrated a life of commitment to excellence in medical care, education, or research and in service to their community, the Chapter, and the ACP.

Ruth E. Berggren, MD, San Antonio was honored with the Chapter Volunteerism and Community Service Award.
The Volunteerism and Community Service Award honors Texas Chapter members who have demonstrated an abiding commitment to excellence in medical care, education, research, and dedicated service to their community, the Chapter, and the ACP.

Scott W. Yates, MD, FACP             Howard R. Marcus, MD, FACP

The Texas Chapter of the ACP Services Chumley/Synder Advocate of the Year 2011 award was presented to Scott W. Yates, MD, FACP, MBA, MS, Plano for his outstanding leadership in legislative advocacy and grassroots activism on behalf of medicine and the patients of Texas. Howard R. Marcus, MD, FACP, Austin received his Chumley/Synder Advocate of the Year award for 2010 as he was unable to accept his award in last year due to unforeseen circumstances.

The Awards committee welcomes and accepts nominations from the membership year round. Nominations from the chapter should include a detailed letter of recommendations and curriculum vitae (CV). Additional letters of support are welcome and may strengthen the nomination.

Send nominations, CVs, and letters of support to: Texas Chapter of the American College of Physicians, Awards and Recognitions Committee, 401 W. 15th St., Austin, Texas 78701; or email.

Member Kudos

Roger S. Khetan, MD, FACP, FHM, Dallas, will receive the ACP LEAD Program’s certificate at Internal Medicine 2012 in New Orleans.

Sue S. Bornstein, MD, FACP, Dallas has been elected as the TXACP, Texas Northern Governor-elect designee.

Send news of your accomplishments, or that of a colleague, to: Gena Girardeau, TXACP Executive Director, 401 W. 15th St., Austin, TX 78701; fax to (512) 370-1635; or e-mail.

Congratulations to Our Newest Fellows

Fellowship recognizes personal integrity, superior competence in internal medicine, professional accomplishment, and demonstrated scholarship.

Mandeep Bajaj, MBBS, FACP, League City
Matt Jeremiah T Chua, MD, FACP, Amarillo
Cristie Columbus, MD, FACP, Dallas
Sumit Mamun, MBBS, FACP, San Antonio
Biykem Bozkurt, MD, FACP, Houston
Cynthia L Clagett, MD, FACP, San Antonio
Georgie A Eapen, MD, FACP, Houston
Jinping Fan, MD, FACP, Houston
Bruno P Granwehr, MD, MS, FACP, Houston
Mary T McGarry, MD, FACP, Plano
Julie C Nguyen, MD, FACP, Houston
Paul Knight Piper, MD, FACP, The Woodlands
Thomas J Purgason, MD, FACP, Arlington
Chijioke David Ukoha, MD, FACP, Coppell

Advancement to Fellowship applications are available:
•    At the ACP Web site
•    From the ACP Customer Service Department at (800) 523-1546, ext. 2600
•    By e-mail