SAFE Opioid Prescribing: Strategies. Assessment. Fundamentals. Education
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The Texas Internist is a publication of the Texas Chapter of the ACP. Articles from the chapter membership are welcome. Send to the Newsletter Editor, Texas Chapter of the ACP Business Office, 401 W. 15th St., Austin, TX 78701, or fax to (512) 370-1635.
The mission of the Texas Academy of Internal Medicine is to promote quality health care for all Texans by strengthening the practice of internal medicine.
Steve Urban, MD, FACP
Like many of you, I have recently started using an EHR (or, as one of my colleagues wryly terms it, the electronic billing record). I like many things about my new system. I like how easy it is to access my records, day or night. I like how it informs me about drug-drug interactions. Sure, it constantly reminds me that I have the typing skills of a three-toed sloth, but I'm getting better. I'm not discouraged!
What my shiny new EHR has not done, however, is to make me a better doctor. As a matter of fact, it is trying its hardest every day to make me worse. And, if I judge from the quality of their medical records (a criterion I have long used to determine if my consultants are paying attention), it has already made many of my colleagues worse doctors.
It's not just because the EHR makes it easy for practitioners to fool payors into thinking they're doing a complete exam (payors invited this by their insistence on all those bullet points). And it's not just because the EHR leads into such a proliferation of useless and repetitive verbiage that you search high and low to find one sentence of original human thought. It's because computers don't know how to think diagnostically.
The time honored method of arriving at an efficient diagnosis has been termed the iterative method. The history of present illness (HPI) is the cornerstone of this process. If you want to be efficient, you listen attentively to the patient. Each new piece of information changes your next question, and so on. The patient leads the informed practitioner down the path to the diagnosis. This is the iterative method.
The template-driven HPI, where a number of boxes are checked and the results dumped into the EHR, although lending itself to the scoring of bullet points, is a completely different process. Perhaps this is why those computer aids for differential diagnosis are so useless—they don't encourage the patient to lead you to the diagnosis.
Computers are great at storing information, okay at prioritizing, and poor at creating. You can't have a conversation with a computer. Historians and creative writers don't let the computer write for them. And diagnosis (in all but the simplest cases) is a creative act. Making a diagnosis is like writing a story that makes sense.
We've all read H&Ps by new third year medical students that are a jumble of facts leading nowhere. The physical exam doesn't flow out of information in the HPI, and the diagnostic studies are shotgunned because the student hasn't followed clues from the H&P. A poor medical student practices template-driven medicine.
How does a good internist do it? He or she sits down with the patient and, through attentive listening, creates the diagnosis. The medical record is not just a method of recording facts; properly done, it facilitates the diagnostic process. Lab tests, imaging studies or (usually) time just provide confirmation.
Maybe template-driven medical care is better than the old-fashioned iterative method. I could be wrong! (I speak from experience). But we in medicine like to think that we are evidence-based. And there are no prospective, controlled studies to prove that EHR-generated, template-driven medicine is better than the iterative method.
Maybe Osler was misguided and Wikipedia is right. I'd like, however, to have a single shred of evidence before I turn my diagnostic thinking over to my EHR. For the time being, I plan to follow the iterative method for a few more years, trying to focus more on the patient than on my computer screen, even though this will make it harder to code up to a level 4!
Andrew K. Diehl, MD, MSc, FACP, San Antonio
Texas Southern Region
On March 23rd, President Barack Obama signed the Patient Protection and Affordable Care Act of 2010 into law. No one was happy with the process by which the bill was finally passed. No one is entirely satisfied with the final product. No one knows for certain how the law's provisions will be implemented, or what its effects will ultimately be. But many believe that this legislation, which (with reservations) was supported by the ACP and the AMA among others, represents an important and necessary step forward for the health of the American people and the U.S. economy.
All So, you may be wondering, what's really in the legislation? And when will it be implemented? Working from information provided by the College's health policy leadership, I'll attempt to provide an overview.
First, the law is intended to expand health insurance coverage to the public. Beginning immediately, private insurance companies are barred from dropping coverage for insured patients should they become seriously ill. Later this year, purchasing pools will be established to allow high-risk individuals to have better rates and choices of private insurance plans. Those in traditional Medicare plans will have better benefits, including waived co-payments for preventive services endorsed by the U.S. Preventive Services Task Force. By 2014, the Medicaid program will expand to cover families with incomes up to 133% of the federal poverty level, with the incremental costs paid by the federal government. Tax credits will be provided to individuals and families to help them afford private coverage.
These measures are expected to increase the number of insured Americans by 32 million. Some 95% of legal residents will be covered, most by employment-based private insurance. Still, 25 million residents will remain uninsured, many of these being undocumented immigrants.
The law also strengthens primary care. On January 1, 2011, office visits to qualifying primary care physicians will increase by 10%. By 2013-14, Medicaid payments to primary care doctors will rise to the level of Medicare, the increase fully paid by the federal government. A workforce commission will begin work this year to identify ways to attract and retain physicians in primary care, and there will be improvements to student loan programs and scholarships for disadvantaged students who commit to primary care practice in medically underserved areas.
Next year, the legislation provides for accelerated testing and implementation of new practice models, including the Patient Centered Medical Home, that focus on quality and value rather than the quantity of services provided. Funding begins this year for outcomes research in the comparative effectiveness of competing treatment approaches. Simplification of insurance plan administration will be phased in, beginning in 2013.
Unfortunately, the law does not provide for caps on non-economic damages resulting from malpractice litigation, unlike the system successfully introduced in Texas. Instead, competitive grants will be awarded to states next year to test alternatives to current medical liability tort systems. The College is disappointed with the weakness of this part of the legislation, and will continue to push Congress for improvements.
All of these changes will cost money, and how it will be paid for is a universal concern. Some savings will be achieved through the reduction in payments to Medicare Advantage programs. Higher wage persons will pay more Medicare taxes, and Disproportionate Share payments to hospitals that currently serve the uninsured will be reduced. There will even be a new tax on tanning salons, as well as on medical devices. New taxes on so-called "Cadillac" health insurance plans will be delayed until 2018. If all goes according to plan, the Congressional Budget Office estimates that the new law will reduce the federal deficit by $143 billion over 10 years. But no one really dares to predict what will actually happen, and many remain concerned.
Overall, the PPACA can, and probably will, do much good for Americans with no or inadequate insurance. It will help primary care physicians in their struggle to survive in the current fee-for-service environment, and will seek ways to attract more students to the field. But more needs to be done to bring health care expenditures under control, and new models of care are desperately needed. The ACP will continue to be involved in the legislative process, working from sound principles to advocate for additional reforms. I'm proud to be part of that process. I hope you are as well.
My eyes grow wide as I hear of the patient en route. Adventure finds me this month in the MICU, especially on call at 0100. "Young man in his thirties, nearly drowned, swimming in the ocean. He's intubated, hypoxic." He rolls past me with an oxygen saturation on the vent of 30%. Cold, motionless he lies as forced breaths jolt his chest by the enthusiastically bagging respiratory therapist. Per my quick eyeball assessment from the doorway he appears quite nearly dead to me; brisk heart sounds would prove me wrong. We play with the ventilator. Hypoxic he remains. I stand helplessly, thinking, What do you do for hypoxia when a patient is intubated and his lungs are filled with sea water? They didn't teach me this in ACLS. I stare at him and avoid meeting my student's questioning eyes. As I examine him, I note that my patient has a gold cap on his front tooth. Chest X-ray confirms bilateral near complete white-out. Pensively I tug with both arms on the stethoscope draped around my shoulders as the fellow tries a plethora of vent settings.
Blood pressure drops; activity flurries. I snatch the triple-lumen catheter kit and prep his groin for central access. A stick later I have good blood return. It's dark red. I grab the scalpel to nick the skin and, in the chaos of the moment, slice it into my finger. I stop for a split second to suck in a breath, uncertain if I stabbed flesh or only glove. My own catecholamines distract. I shove the catheter into the vessel, tie it in, and dash away to scrub my hands before the arterial line. My blood or my patient's? I wonder. I feel a twinge, wipe away a drop of my blood, and throw on another pair of gloves.
I stare at the monitor—SpO2 of 70% now. He's stabilizing, but it has been three hours of hypoxia. The family arrives from out of town. I sniff away tears when I see his wife gazing at him tremulously. She slides into a chair thrust behind her just in time. My fellow has told me there's essentially no way his brain function could be preserved with such a length of hypoxia. We discuss code status, and even withdrawal of care that night. I pull up my knees to my chest and sigh. You shall not die but live. The scripture keeps coming to my mind.
The nurse hands me an ABG. "It's from your central line. We were afraid the blood flow was a little too brisk for venous." We exchange smiles, and I chuckle that it really was dark red blood. The SpO2 and PaO2 are consistent with arterial blood, though unfortunately we cannot get the saturation above 80%. Oops. Not only did I manage to stab myself, but I also stuck the line in the wrong vessel. My laceration is dressed with a stylish plastic piece of adherent tegederm. I gown up to fix the problem, praying for my patient to pull through, somehow.
Six hours later morning rounds begin at my patient's bedside. As I tell the tale, my attending changes the ventilator settings with a few swift dials of the knobs. Like magic, the saturation rises before our eyes to the 90's. Pressing my lips together to hide a grin, I ask what we did wrong the night before. "PEEP takes time! Pick a pressure-control setting and give it an hour. The alveoli need time to be recruited!" What was so hard overnight is somehow so simple in the light of day—the attending sign.
I struggle to leave post-call. "You can't let him die today," I adjure my colleague. As if it is entirely in our control, or in our control at all. After I hear my fellow resident's appropriate reassurances, with an admonishment to get some rest, I depart. I hate to leave my sick patients, even with good care, yet in the uncertainty of my absence.
Days pass, and my patient perseveres. Daily on rounds the team expresses doubt at the likelihood of return of meaningful brain function. I shake my head at them; somehow, I still believe. I go to his bedside and call his name, squeeze his hand, lift his eyelids, searching for life. Now that I have learned from him more about mechanical ventilation, I guard my patient's settings doggedly, keeping his oxygenation up with careful weaning, tenaciously checking every blood gas.
The month ended, and I had to leave the MICU. But my patient stayed on my mind, and I continued to visit frequently, asking the nurses and residents for updates. My patient progressed. He very gradually woke up, becoming agitated and delirious. Eventually, he was extubated, much to the surprise of many. He made it out of the MICU one day, transferred to the floor. I went by one day to visit, but he was out of the room at that moment. I chatted with the physical therapist, inquiring of his brain function. "Why, he's doing great!" She exclaimed, "He reminds me of a very mild traumatic brain injury patient. But he's walking and talking. No one can believe it!"
A few days later, I sat at a computer at the nurse's station perusing labs for my current team's many patients. I felt an abrupt jolt. I turned, and noted a rolling walker that had collided with my chair. "Excuse me, miss."
I leaped up and gushed at my patient. "Did you know that you almost died? We really thought you were going to die! You are a miracle!" His wife at his side, my patient beamed. He knew. I shook his hand and recognized the gold-capped tooth as he broke into a broad grin. I am incredulous that patients live, sometimes with the help of medical care, sometimes in spite of us—mistakes, intentions, and all.
Associates and medical students are invited to submit new entries that have never been submitted in the past for several competitions during the Texas Chapter of the ACP Annual Meeting Nov. 13-14 in Houston.
Medical Student Poster Competition: Medical students are invited to submit abstracts of clinical vignettes that have clinical relevance to internal medicine to the 2010 Texas Chapter of the ACP medical students' poster competition via the medical student abstract submission form on the Texas chapter's web site. Research abstracts will not be considered for this year's meeting. On the submission form, students can indicate whether they want their abstract considered for the poster competition only or for the poster and/or clinical vignette competition. In order to submit an abstract for either competition, you must be a member of the American College of Physicians. Submission deadline for medical students is Tuesday, August 31, 2010. Abstracts will be reviewed and submitters will be notified of the status of their abstract via e-mail by Friday, October 1, 2010. Those who are accepted to the competition will be invited to present their abstract in poster format at the 2010 Annual Meeting, November 13-14, 2010 at the JW Marriott in Houston, TX.
Associate Poster Competition: Associates are invited to submit abstracts of clinical vignettes and clinical research (not basic science research) that have clinical relevance to internal medicine to the 2010 Texas Chapter of the ACP associates' poster competition via the associate abstract submission form on the Texas Chapter's web site. In order to submit an abstract for either competition, you must be a member of the American College of Physicians. Submission deadline for associates is Friday, August 6, 2010. Abstracts will be reviewed and submitters will be notified of the status of their abstract via e-mail by Friday, October 1, 2010. Those who are accepted to the competition will be invited to present their abstract in poster format at the 2010 Annual Meeting, November 13-14, 2010 at the JW Marriott in Houston, TX.
Residents and medical students are invited to submit abstracts of clinical vignettes and research projects that have clinical relevance to internal medicine to the 2010 TexasACP Associates and medical students poster competitions via the abstract submission form (link).
On Being a Doctor creative writing competition: Associates and medical students are invited to submit original prose or poetry dedicated to the theme, "Medicine as a Calling". Submissions are limited to 1,000 words or less and must be submitted via the submission form on the Texas Chapter of the ACP web site. Contestants must reside in Texas and be members of the ACP.
A panel of physicians will review the submissions, and the winner will be announced no later than October 1, 2010. The winning author will be invited to present his or her work in a 10-minute oral reading during the general session at the Annual Meeting. The author will win an all expense paid trip to attend the Texas Chapter of the ACP Annual Meeting.
Residents and medical students are invited to send your stories (prose or poetry) about the joys or distress of medical practice, which remind us what is most special about our profession. Send your stories in using the 2010 On Being a Doctor submission form (link).
Submissions are limited to 1,000 words or less and must be submitted via the submission form on the Texas Chapter of the ACP web site by Friday, August 27, 2010.
All across the state of Texas, internal medicine residents are hard at work learning, practicing, and teaching medicine. The Texas Chapter of the ACP has the honor of allowing these young physicians to showcase their hard work locally at one of our five Associates regional competitions.
This year's meetings followed in the successful tradition of those of the past. Competition was stiff, participation was high and all of the work was exceptional quality. An enormous amount of time and energy went into the planning of each event. Recognition for the extensive meeting preparation goes to Drs. Alejandro Moreno for the Southwest region, Richard Hamill for the Southeast region, Steve Urban for the Northwest region, Clark Gregg for the Northeast region, and Pedro Blandon for the Far Northwest region. Thank you all for your diligence and hard work. A special thank you goes out to Dr. Suma Pokala for all of her involvement with these regional events as the Texas Chapter of the ACP Associates Committee Chair.
The Texas Chapter supports the regional Associates' councils with annual grants of up to $1,000 per Council to help fund their programming. Each regional clinical vignette competition winner will receive Chapter support to allow them to travel to Houston, November 13-14, 2010, to represent their region at the Annual Meeting.
Congratulations go to the following regional competition winners!
Oral Vignette Presenters:
Sandra Barrow, MD (Methodist), "Myocardial infarction with normal coronary arteries"
Fardina Malik, MD (BCM), "An Uncommon Cause of a Common Compliant"
Sukhdeep Basra, MD (BCM), "Extrapontine Mylelinolysis"
Sukhdeep Basra, MD (BCM), "Hypertrophic Pulmonary Osteoarthropathy: A rare and often missed cause of joint pain in cancer patients"
Amit Zachariah, MD (BCM), "Progressive Persistent Polyneuropathy? POEMS is a possibility"
Valentina Hoyos, MD (BCM), "Co-expression of a Chimeric Antigen Receptor targeting CD19 (CAR19), Optimized Human IL-15 and iCaspase9 to enhance the activity and safety of Cytotoxic T Lymphocytes"
Rene Celis, MD (UTMB), "Magnetic resonance assessment of LV hypertrophy and function in aortic constricted mice"
J. Daniel Kelly, MD (BCM), "Stopping AIDS means more social support before diagnosis"
UT-Houston: Rajeev Fernando,MD; Lilit Sargsyan, MD; and Jose Tafur-Soto, MD
Oral Vignette Presenters:
Sameer Islam, MD (TTUHSC-Lubbock), "My eyes are bouncing"
Pradeep Selvaraj, MD (TTUHSC-Amarillo), "Graves' Disease Associated with Curable Pulmonary Arterial Hypertension"
Amr Mohamed, MD (TTUHSC-Permian Basin), "Recurrent Leg DVT in an Elderly Patient"
Oral Vignette Presenters:
Amy Kalina, MD (Methodist), "Mastocytosis"
Lorraine Pelosof, MD (UT Southwestern), "Salmonella montivideo Meningitis"
Adam Falcone, MD (Baylor-Dallas), "Here Fat, There Fat, Everywhere Fat, Fat"
Karen Steffer, MD (Baylor-Dallas), "Primary Coccidioidal Meningitis in Texas"
Amy Kalina, MD (Methodist), "Metabolic Alkalosis in ESRD"
Farah Masood, MD (Methodist), "Hereditary Angioedema Presenting as Acute Abdomen"
Oral Vignette Presenters:
Jinyi Ling, MD (TTUHSC-PLFSOM), "The Great 'Air' Space"
Karla Quevedo, MD (TTUHSC-PLFSOM), "An Unusual Case of Abdominal Pain—Not everything that shines is Gold"
Clinical Oral Vignette Presenters:
Tedmond Szeto, Capt, USAF, MC (SAUSHEC), "Ulcerative Colitis in a patient who presented with Leukocytoclastic Vasculitis (LV) and not Gastrointestinal Symptom"
Nabanita Basu, MD (Seton/UTSW Austin), "Loa Loa: The Elusive Worm"
Research Oral Vignette Presenters:
Chris Calcagno, CPT, MC, USAF (SAUSHEC), "Association of Caffeine Consumption with Fatty Liver Disease and Hepatic Fibrosis"
Rushit Kanakia, MD (UTHSCSA), CCR5 "Deletion Impairs the Post-Myocardial Infarction Inflammatory Response"
Austin Metting, MD (TAMUHSC-S&W), "Waiting to Exhale: An Unusual Case of Pulmonary Hypertension"
Timothy Ori, Capt, USAF, MC (SAUSHEC), "Inflammatory Myofibroblastic Tumor of the Lung in Active Duty Patient"
Tyson Sjulin, CPT, MC, USA (SAUSHEC) "Characterization of Inhalation Injury with CT of the chest"
B.C. Barnett, MD (TAMHSC-S&W), "The Sleeping Heart Study: A Comparison of Polysomnographic Parameters and Hemodynamics obtained via right heart catheterization"
UTHSCSA: Rashit Kanakia,MD; Tony Ho, MD; and Tejas Patel, MD
The GIMSPP received 260 student applications this year, up from 212 in 2009. Even with an alert of scarce funding shared at each of the ten preceptorship recruitment meetings, the program received the largest number of applications since 2003. That year saw a record number of 369 applications and 240 preceptorships. By contrast, the program was only able to match 90 students in 2010 with eight of them agreeing to forego the stipend.
The Internal Medicine Preceptorship Program continues to attract more applications than the Family Medicine and Pediatric Programs combined.
Ironically, as student applications were flooding the Web site, the GIMSPP learned that its state funding for the current biennium, 2009/2011, would be cut by 5%. Because the funds for 2009/2010 had already been disbursed, the total 10% cut of $13,844 will come out of the 2010/2011 funding.
The 82nd Legislative Session will be a contentious one, with redistricting and a projected $18 billion budget shortfall being top priorities. It will be imperative that advocates of the statewide preceptorship programs contact their legislators to emphasize the importance of these early rotations for the future of our primary care physician workforce in Texas.
Robert E. Jackson MD, FACP, Houston, was elected Governor for the Texas Southern Region through a member vote by mail.
Following a year as Governor-elect, he will begin his four-year term in April 2011. As Governor, Dr. Jackson will serve as the official representative of the Texas Southern region at the College, providing a link between members at the local level and leadership at the national level. To learn more about Dr. Jackson's background and experience, please see his biography and vision statement (link).
ACP Services Inc. holds an annual advocacy day on Capitol Hill. This event provides an opportunity for ACP and our members to increase our presence in Washington and bring visibility to issues of common concern. Participants receive a comprehensive orientation and briefing on ACP's top legislative priorities and then have an opportunity to meet with legislators and the staff on Capitol Hill.
|Roger Khetan, MD, FACP; Hua Chen, MD; Erin Dunnigan, MD; Gene Stokes, MD, FACP; Pete Yunyongying, MD; Sue Bornstein, MD, FACP; Clark Gregg, MD, FACP and Gates Colbert at Leadership Day 2010 in Washington D.C.|
We would like to thank the following physicians for taking time out of their busy schedules to attend ACP Leadership Day 2010.
Nearly 230 Texas Chapter members enjoyed the outstanding medical education in Toronto at this year's ACP Internal Medicine 2010.
The Texas Chapter governors; Andrew K. Diehl, MD, FACP, TXACP Southern Governor, San Antonio and Clark R. Gregg, MD, FACP, TXACP Northern Governor, Fort Worth escorted nineteen new Fellows of the College during the convocation grand procession, along with three new Masters of the College: Frank C. Arnett, MD, MACP, Houston; Matthew J. Dolan (Military), San Antonio; and Daniel M. Goodenberger, MD, MACP, Dallas.
|Vanessa Gray, medical student abstract winner at IM 2010 in Toronto.|
|TXACP newly elected fellows and TXACP Governors preparing for the Convocation ceremony at IM 2010 in Toronto.|
|Daniel M. Goodenberger, MD, MACP and Clark R. Gregg, MD, FACP, TXACP Northern Governor at the TXACP Chapter Alumni Reception at IM 2010 in Toronto.|
|Clark R. Gregg, MD, FACP, TXACP Northern Governor and Andrew K. Diehl, MD, FACP, TXACP Southern Governor at the TXACP Chapter Alumni Reception at IM 2010 in Toronto.|
|Newly elected fellows, Paul Ogden, MD, FACP, Christian Cable, MD, FACP, Curtis Mirkes, DO, FACP, and John ‘Jack’ Myers, MD, FACP|
Fred C. Campbell, Jr. MD, FACP, San Antonio was honored with the prestigious Oscar E. Edwards Memorial Award for Volunteerism and Community Service.
Two outstanding medical students were recognized for their winning abstracts at the Internal Medicine 2010 in Toronto. Priti Dangayach, Baylor College of Medicine, Houston; A Benign Cause of Neck Swelling in the HIV Patient and Vanessa Gray, Texas A&M University, College Station; An Aberrant Right Subclavian Artery and Duct of Kommerell Aneurysm Complicated by Dissection.
Saba Radhi, MD, Texas Tech Lubbock, competed in the Associate's abstract competition during the ACP Internal Medicine 2010.
Drs. Stacey Rose, Dannis Siddiq and Fawad Aslam, Baylor College of Medicine, represented the Texas chapter in the Doctor's Dilemma competition.
A Texas ACP Chapter and Alumni reception was held on Friday evening, April 23 to honor our award winners, new Masters of the College, and to celebrate Robert E. Jackson, MD, FACP as Governor – elect for the Texas Southern Region.
Jane E. O'Rorke, MD, FACP, San Antonio, was voted President-elect of the Southern Society of General Internal Medicine.
Andrew K. Diehl, MD, FACP, San Antonio, received the Southern SGIM Leader and Mentor in General Internal Medicine Award.
Frank C. Arnett, MD, MACP, Houston, was awarded Mastership in the ACP.
Matthew J. Dolan, MD, MACP, San Antonio, was awarded Mastership in the ACP.
Daniel M. Goodenberger, MD, MACP, Dallas, was awarded Mastership in the ACP.
Fred C. Campbell, Jr., MD, FACP, San Antonio, received the Oscar E. Edwards Memorial Award for Volunteerism and Community Service.
Lynne M. Kirk, MD, MACP, Dallas, served as the 13th O. Roger Hollan Professor and gave Medicine Grand Rounds at the University of Texas Health Science Center at San Antonio.
Stacey Rose, MD, Baylor College of Medicine Associate member, competed in the national Doctor's Dilemma competition at the ACP Internal Medicine 2010 (IM10) in Toronto, as a member of the winning team from the statewide competition hosted by TXACP in November.
Fawad Aslam Baylor College of Medicine Associate member, competed in the national Doctor's Dilemma competition at the ACP Internal Medicine 2010 (IM10) in Toronto, as a member of the winning team from the statewide competition hosted by TXACP in November.
Vanessa Gray, Texas A&M Health Science Center College of Medicine student, was invited to present a poster at the ACP IM10 in Toronto, as the winner of the statewide competition hosted by TXACP in November. At the national level, Vanessa was chosen as one of the top 5 winners out of all the posters submitted.
Saba Radhi, MD, Texas Tech – Lubbock Associate member, was invited to present a poster at the ACP IM10 in Toronto, as a finalist in the statewide competition hosted by TXACP in November.
Send news of your accomplishments, or that of a colleague, to: Gena Girardeau, TAIM Executive Director, 401 W. 15th St., Austin, TX 78701; fax to (512) 370-1635; or e-mail to Gena-dot-Girardeau-at-texmed.org.
Fellowship recognizes personal integrity, superior competence in internal medicine, professional accomplishment, and demonstrated scholarship.
Oladimeji S Akiode, MBBS, FACP, Tyler
Loganayaki Anandasivam, MBBS, FACP, Brownsville
Garth A Beinart, MD, FACP, Houston
Kathryn H Dao, MD, FACP, Dallas
P Gopalakrishnan, MBBS, FACP, Irving
Steven E Haber, MD, FACP, Houston
Kim T Hovanky, MD, FACP, Georgetown
Daniel Y Kim, MD, FACP, League City
Scott Kopetz, MD, FACP, Houston
Sumit Kumar, MBBS, FACP, Richardson
Sarah E Lapey, MD, FACP, San Antonio
Michael J Lichtenstein, MD, FACP, San Antonio
Curtis R Mirkes, DO, FACP, Temple
William H Pieratt, III DO, FACP, College Station
Darush Rahmani, DO, FACP, Abilene
Maria C Rodriguez-Barradas, MD, FACP, Houston
Elizabeth A Walter, MD, FACP, San Antonio
Michael K Williams, MD, FACP, Lakeway
Randall M Wooley, MD, FACP, Dallas
Pete Yunyongying, MD, FACP, Dallas
Advancement to Fellowship applications are available:
Texas Chapter Annual Scientific Meeting
November 17-18, 2018, JW Marriott Austin
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