The American College of Physicians (ACP) continues to call for “common sense” gun reform even after they were targeted by the National Rifle Association (NRA) that resulted in a social media firestorm last year.

“It’s an important topic for our patients,” said Ana Maria Lopez, MD, the ACP’s president, during a news conference at the college’s annual conference in Philadelphia. “There are very few people who have not been touched by gun violence.”

In November, the NRA responded to ACP’s latest call for gun control and further gun violence research by tweeting that “someone should tell self-important anti-gun doctors to stay in their lane.”

The ACP has for years called gun violence a public health issue, and has pushed for bans on assault weapons, more stringent background checks and increased funding for research into gun violence. ACP officials also threw their support behind a new state law in Colorado that created “extreme risk protective orders” that allow police to temporarily seize a person’s guns if they are deemed a threat to themselves or others.

Many physicians took umbrage on social media, responding under the hashtag “this is my lane.” Some posted photos of themselves splashed in blood after they said they were operating on gun violence victims.

The back-and-forth between physicians and the NRA received national media coverage.

“It really brought medicine together, and brought together healthcare professionals to say that this is our lane and we have a voice here,” Lopez said.

In December, Medical Economics conducted a 

 asking for their thoughts on gun violence. Two-thirds of respondents said physicians should be involved in the gun violence debate, and another 70 percent said physicians should ask patients about guns in their home during appointments. An additional 59 percent supported increased funding for gun research.

“I don’t have a problem with people having guns,” one physician respondent said in the Medical Economics survey. “I have a problem with dangerous people having guns and with people using/storing guns in an unsafe manner. This affects the health and safety of my patients. As a physician, I am involved, whether I want to be or not.”

Lopez said discussions with patients about guns in the home should be handled in a “straight-forward and honest” way. Questions she encouraged physicians to ask include whether patients have guns in their home, and if so, how they secure them.

Lopez said that new regulations and these conversations with patients can turn the tide on gun violence.

“Taken together these could really make substantial difference in public health,” Lopez said.

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The ACP has for years called gun violence a public health issue, and has pushed for bans on assault weapons, more stringent background checks and increased funding for research into gun violence.

ACP 2019: Despite NRA uproar, internists not backing down on gun violence

More than half of internal medicine physicians (and subspecialists) are working in practices that implemented telehealth, according to new survey results from the American College of Physicians (ACP).

The survey of ACP members, released at its Internal Medicine Meeting 2019 on April 11 in Philadelphia, showed that 51 percent have adopted at least one of these telehealth services:
	• e-consults (33 percent implemented, 10 percent considering)
	• remote care management/coaching (24 percent implemented, 11 percent considering)
	• video visits (18 percent implemented, 17 percent considering)
	• remote patient monitoring (14 percent implemented, 11 percent considering)
	• integration of data from patient wearables (9 percent implemented, 9 percent considering)

The survey, ACP reports, sought to better understand adoption of telehealth services by its members. ACP sampled 1,449 members in October 2018 and January 2019. Completed responses were received from 233 members (16 percent response rate). Of the respondent base, 72 percent were general internal medicine specialists and 28 percent subspecialists. All of the respondents were providing outpatient care.

Other notable findings:
	• About 63 percent of those respondents with e-consult technology use it every week
	• Having the technology does not equate to adoption and usage of telehealth services, the survey reports. Among those with the technology, only 19 percent use video visits every week, while 50 percent use remote care management every week.
	• Physician respondents were typically not making decisions to implement the technology
	• Many physicians are interested in learning more about available technology solutions (55 percent of those with no technologies implemented, and 51 percent of those with some implementations)
	Barriers to adoption:
	• 42 percent: Challenging to integrate virtual care into practice workflow
	• 36 percent: Patients do have access to the technology to support virtual care
	• 29 percent: Concern about potential medical errors
	• 23 percent: Security and privacy of patient information
	• 18 percent: No barriers identified
	Reimbursement, licensing, and regulatory issues were also recognized as barriers to telehealth applications.

Andrew Dunn, MD, FACP, chief, Division of Hospital Medicine of Mount Sanai Health System in Montebello, N.Y. and incoming chair of ACP, explains, “As telehealth payment and regulatory burdens are removed, physicians are more likely to use these services for the care of their patients. ACP believes very strongly that telehealth can be a valuable tool to improve access, quality, and decrease cost especially in used in the context of a valid physician-patient relationship.”
	
	Dunn cited recent policy changes that will facilitate adoption of telehealth applications, including:

• Medicare’s new payment codes for virtual check-ins, e-consults, and remote evaluation of patient images

• The Centers for Medicare and Medicaid Services (CMS) plan (slated for July) to remove the geographical requirements for the originating site of care (e.g. not limiting the use of telehealth to rural settings)

• CMS will add a patient’s home as the originating site for services for treatment of substance abuse disorders or mental health disorders

• Easing of geographic restrictions in the patient setting for conditions like stroke, home dialysis for end-stage renal disease

• On April 5, CMS eliminated geographic restrictions on telehealth services for patients with Medicare Advantage (slated to take effect in 2020)

 
	The results of the survey underscored the need for additional physician resources, ACP notes, and the college is developing practical resources for members covering virtual visits, including appropriate use cases, practice workflow changes, the current state of reimbursement and regulation, and equipment and vendor selection. Other telehealth applications will be explored as telehealth technology matures.
	
	"We hope these resources can help close the gap between physician use of telehealth and patients' desire for flexibility and access to their physicians," explains Tabassum Salam, MD, FACP, ACP's vice president for medical education.
	
	In a prepared statement, the college states: “ACP supports the expanded role of telemedicine in the primary care setting when used as a component of a patient's longitudinal care, but recommends that physicians should use their professional judgement about whether the use of telemedicine is appropriate for a patient and the situation. ACP also supports reimbursement for appropriately structured telemedicine communications.” A 

 on the use of telemedicine in primary care offers additional information the subject. 

"ACP recognizes that telehealth technologies have the potential to improve access for patients, enhance patient-physician collaboration, improve health outcomes, increase patient satisfaction, and reduce medical costs," adds ACP President Ana MarÃ­a LÃ³pez, MD, MPH, MACP, in a prepared statement.

Policy changes, physician adoption of telehealth technologies to help advance patient care options, survey reports

ACP 2019: Internist use of telehealth on the rise

Not only are disagreements between physicians and patients uncomfortable, they also can negatively impact health outcomes and patient satisfaction. It’s no surprise, therefore, that most physicians would rather avoid conflict than engage with patients to overcome it.  

But being able to navigate conflict is an important skill for physicians. When handled correctly, conflict can lead to positive change, says Rebecca A. Andrews, MD, FACP, general medicine clinic director and associate program director for categorical internal medicine at UConn Health in Farmington, Conn. The key, she adds, is knowing how to communicate effectively when emotions run high. 

Equipping physicians with the knowledge and communication tools to do so is the goal of the session Andrews and Auguste H. Fortin, VI, MD, MPH, MACP, professor of general medicine at Yale School of Medicine in New Haven, Conn., will present at this year’s ACP Internal Medicine Meeting in Philadelphia.

They will begin the session with a discussion about implicit bias, or the unconscious attitudes and beliefs about an individual or group that impact decisions and actions. “You might have thoughts or opinions developed by your experiences, your gender, your culture growing up that might affect how you approach a different situation,” Andrew says. 

Andrew emphasizes that having implicit bias does not mean that an individual is bad or has done anything wrong, but it can compromise patient care. So it’s crucial that physicians identify the issues they are overly sensitive about and make a conscious effort to check those views or feelings at the exam room door. 

Once they are in the exam room, Andrew says there are three communication models that physicians can use when conflict and strong emotions arise. 

1. NURS = Name > Understand > Respect > Support 

The NURS model illustrates how to empathetically address emotion. The physician will 

the emotion that the patient is expressing (“You’re worried.”), convey 

of why that emotion is present (“I can see why you’re feeling this way. Many people in your situation would feel like this too.”), demonstrate 

for the patient’s experience (You’ve been through a lot.”), and offer 

(Let’s see what we can do to get to the bottom of this.”).  

2. ADOBE = Acknowledge the difficulty > Discover meaning > Opportunity for empathy > Boundary-setting > Extend the system 

The ADOBE model delineates how to effectively communicate when there are a lot of strong emotions present. The physician will 

the emotion out loud (“You seem angry.”), request more information to 

the cause (“Help me understand why you’re angry.”), find an 

to display empathy (by using the NURS model), set 

to the conversation (“I’ll work with you as long as you exhibit the same respect towards me that I am giving you.”), and 

the care if the patient has needs that the physician cannot address (refer the patient to a specialist).  

3. Non-violent communication = Observe > State > Connect > Make

The non-violent communication model demonstrates how to express and receive emotions with empathy. A physician will 

objectively (“I see that you’re frustrated because your current medication is not alleviating your pain.”), 

that the situation is causing (“I understand how difficult this is, but I am uncomfortable prescribing medication that is not recommended for your condition.”), 

(“I need to balance helping you feel better and prescribing a safe treatment.”), and 

(“Why don’t we look into approved treatments and create a plan?”).  

These models are effective when used alone or in conjunction. “A doctor might find that one approach might work better for them than another approach. Another might find that they like to do the different approaches depending on what they’re talking about,” Andrew says. “But as long as you’re using empathy and [patients] can understand that you’re caring, you can’t help but get to a good place.” 

Andrews’ ACP 2019 session, “Communicating Effectively When You Don’t Want To,” will take place on Saturday, April 13 at 9:30 a.m.

Communication tools physicians can use to manage conflict during patient encounters.

ACP 2019: How to overcome conflict with patients 

As more physicians become employed, learning how to successfully negotiate an employment contract becomes a crucial skill to learn. 

A common issue is that many physicians simply don’t negotiate, and just sign what’s put in front of them, says Michael S. Sinha, MD, JD, a Regulatory Science Fellow at the Harvard-MIT Center for Regulatory Science.

Sinha, who is presenting a session on negotiation basics at the American College of Physicians annual conference in Philadelphia, talked with Medical Economics via email to discuss some of the key aspects of negotiation vital for physicians to learn.

 What is a common mistake physicians make when negotiating contracts?

: Often, physicians will eagerly sign a binding letter of intent or agree to terms of a contract with little or no negotiation-in some cases, they aren’t even aware of what can be negotiated!

The key is to consult a healthcare lawyer early in the process. Find someone who specializes in physician employment contracts in that state. They will have a lot more insight as to what can, and should, be negotiated.

Ultimately, if you don’t negotiate, you’re only cheating yourself.

 What areas in an employment contract are most important to focus on?

 The first thing to do, before any financial compensation is discussed, is to clearly define the duties and responsibilities in the contract. Get any promises that are important to you in writing. Only when those details have been hammered out can you get an estimate of your true market value.

It will also affect the salary structure that works best for you. Perhaps you have a lot of administrative responsibilities that would cut into meeting pre-defined relative value unit (RVU) thresholds-this may mean you’ll miss out on bonuses under an incentive-based contract, and a fixed salary would make more sense.

Flexibility and vacation time may also be up for negotiation, but at the expense of your base pay. Here, an incentive-based contract may mean that, as long as you’ve hit appropriate metrics, you’ll have more time off with no salary repercussions.

That said, be sure that you have access to the performance reviews or quality metrics that are being used to determine bonuses. Get it in writing!

 One area we regularly hear about from physicians is restrictive covenants/non-compete clauses. What do physicians need to know before signing a contract containing one of these? Is there anything they can do to protect their post-employment career opportunities if they sign a contract containing a restrictive covenant?

 State-level legal expertise is particularly important here. Some states, like Massachusetts, ban restrictive covenants in physician contracts. Others have limits on what these clauses can entail. The lawyer you hire should know the standard for a particular area and can push for compromises in duration and geographic distance.

That distance can be very important. For instance, a 20-mile restrictive covenant may be reasonable in rural Tennessee but would be unreasonable in New York City. Negotiate favorable terms for a restrictive covenant prior to signing the contract; if you don’t, disputes over restrictive covenants could take a few years and several thousand dollars in litigation fees to resolve. Don’t ignore the clauses just because you think you’ve found your “dream job.” And don’t be afraid to ask around. Other physicians in your practice group may have a covenant of shorter duration or distance-or may not have one in their contract at all.

 What are some items physicians can/should negotiate for that many physicians tend to overlook?

 I would start with student loan repayment. Some newly-minted physicians are coming out of residency with $200,000 to $300,000 in student loan debt. There are usually ways to get the hospital to pay some of it off. They may be reluctant to pay a lump sum directly to you, but may be happy to write a check straight to the lender. They’re also less likely to pay any of it up front, but may agree to annual installments, payable after each year of service.

As more physicians become employed, learning how to successfully negotiate an employment contract becomes a crucial skill to learn.

ACP 2019: Contract negotiation: What physicians need to know

Loneliness: It is a growing societal challenge that can dramatically influence patient and physician health.

In a keynote presentation April 11 at the American College of Physicians (ACP) Internal Medicine Meeting 2019, former Surgeon General Vivek H. Murthy, MD, MBA, told about 4,000 attendees that the country’s state of emotional health remains an important driver of health.

“If you told me five years ago that I would be talking to physicians about the subject of loneliness, I would have been surprised,” Murthy said. As he travelled the country as the 19th Surgeon General of the United States, he began to hear more patient stories related to addiction, violence, mental illness and other behavioral-based health conditions. There was an undercurrent, Murthy says, that connected many of these prevalent social issues to loneliness. “Many patients are struggling with it,” he adds.

Healthcare professionals are starting to recognize its impact on adherence to physician treatments and recommendations, lack of exercise, smoking, and other unhealthy lifestyle behaviors and other social determinants.

It is estimated that as much as 20 percent of the population struggles with loneliness, and additional research in this area is starting to offer stronger linkages to health consequences associated with loneliness including depression, dementia, cardiovascular disease, and anxiety.

“It affects physicians too. We talk about burnout in our profession,” Murthy says, but healthcare is not a profession that often promotes self-care.

Physicians work long hours, which can definitely contribute to feelings of isolation and a kind of physical and emotional barrier to making stronger connections with friends and family.

When your professional lives take over, Murtha says, you need to adopt strategies that can help you stay connected with your love of medicine and maintain a healthy balance outside of busy schedules.

During long shifts, try to add a micro-dose of self-appreciation, Murthy says. For example: Take five extra seconds when you are washing your hands to reflect on the ways you have helped patients that day. Do that three times a day.

“We are not designed to work alone,” he says. “We need each other, and we need to support each other.”

Murthy called on attendees to imagine a time in healthcare where physicians have built a culture that supports each other. “The lives of the people in this room matters.”

“Our country is in this struggle between love and fear,” he says. “People are worried about the kind of environment their children are growing up in. They see the polarization of politics. They look at the meanness on social media. People are worried. How are we going to create a better world for ourselves? Where will that leadership come from? Our profession has to lead.”

Loneliness is a quiet epidemic causing loud health impacts on patients and physicians. 

ACP 2019: How loneliness affects patients-and their physicians 

As the prevalence of physician burnout rises, so too might the occurrence of medical errors. A recent 

 by researchers at Stanford University School of Medicine found that physicians with burnout were more than twice as likely to commit medical errors, even after adjusting for specialty, work hours, fatigue, and workplace safety. 

But the relationship between physician burnout and medical errors may be more cyclical than linear. “We value our relationships [with patients], so when someone dies or an error occurs … not only does it hurt the patient and the family, but we are upset as well,” says Tracey L. Henry, MD, MPH, FACP, assistant professor of medicine at Emory University in Atlanta. When left unaddressed, this emotional or psychological stress can further contribute to burnout.

Despite this issue, Henry says most institutions do not have a system in place to support physicians and other healthcare professionals in the event of a medical error or adverse patient outcome. As a result, many physicians avoid disclosing errors and end up internalizing their emotions because “there’s this machismo culture in medicine, and so a lot of times we are ashamed to ask for help,” she explains, noting that early career physicians tend to struggle the most with error-related stress because their clinical self-confidence is still developing.

At this year’s ACP Internal Medicine Meeting in Philadelphia, Henry will moderate an interactive panel discussion focused on helping physicians recover and grow from medical errors. The panelists will use programs currently in place, such as 

, to provide physicians with resources and best practices for coping with medical errors that they can take back to their organization or practice. 

Specifically, leaders should create awareness that medical errors happen and can happen to any physician, and then ensure that physicians are able to process their emotions in a healthy way. Henry recommends developing a protocol that includes nonpunitive teams debriefs following an error or adverse event and a peer-to-peer support network. She notes that it’s important for the individuals leading the debriefs and peer support groups to receive training in order to ensure they understand how to discuss the error without pointing blame or re-traumatizing the physician.  

“We’re all human. Everyone makes medical errors at some point in their career,” Henry says. “This is how you deal with it. This is how you move forward.”

Henry’s ACP 2019 session, “Medical Errors and How to Grow From Them,” will take place on Saturday, April 13 at 11:15 a.m.

When medical errors occur, patients suffer-but so do physicians.

ACP 2019: Caring for the caregiver after a medical error

Doctors have long known that patients’ health depends as much on life circumstances, such as being able to afford healthy food and decent housing, as any treatments doctors themselves can provide. Even so, many physicians are, for a variety of reasons, reluctant to ask patients whether they face such challenges in their lives. 

But that situation may be changing, thanks to a growing focus on the importance of social determinants of health (SDOH) says Elaine Waxman, PhD, a senior fellow at the Urban Institute, a Washington, D.C.-based think tank, and former vice president for nutrition issues at Feeding America, a nationwide network of food banks.

Waxman is among a panel of experts who will discuss ways doctors and healthcare policymakers can address SDOH at the 2019 ACP Internal Medicine Meeting in Philadelphia.

Waxman notes that among the challenges to incorporating SDOH into medical care is recognizing when it is an issue, then knowing how to discuss it with patients. “Most doctors don’t mean to be insensitive to the challenges their patients face, they just don’t understand the extent of them because they haven’t experienced significant hardship in their own lives,” she says. 

Moreover, it can be difficult to identify patients experiencing SDOH-related health issues by outward appearances alone. “When we see a homeless person we make assumptions about how they’re doing. But if someone has housing and is working, even if it’s a low-wage job, it’s easy to think things are better for that person than they really are.”

The solution, Waxman says, is for doctors to routinely screen for SDOH issues such as food insecurity, and get trained in how to talk about them so they feel less awkward in doing so. “Give them resources they can tap to address issues they may feel are outside their wheelhouse,” she says. 

Similarly, doctors need information on how to help patients deal with the high cost of many prescription medications, another important SDOH, either through programs that can make the drugs more affordable, or managing the patient’s disease around the problems resulting from low incomes.

She cites the example of diabetic patients who skip meals at the end of the month when their Supplemental Nutrition Assistance Program (SNAP) benefits run out, but continue taking insulin, thereby risking hypoglycemia. “Some physicians will tell their patients, ‘if you know you can’t eat, that’s a time not to take that medication,’” she says. “It’s a matter of partnering with patients to address these problems, instead of patients feeling they have to manage on their own.”

When it comes to advocating for policy changes that can improve health-another topic the panel will discuss-Waxman says physicians can, and should, make their voices heard among elected officials and other policymakers. 

“Doctors can speak up on issues where they feel comfortable, like helping policymakers understand that adequate food is a type of medicine or that poor-quality housing has a direct health impact,” she says. She points out that it was a physician who discovered and publicized the elevated lead levels in Flint, Michigan’s drinking water. “That proves physicians can make a huge difference in elevating the importance of a public health issue to a community,” she says.

Doctors around the country are starting to understand they need to think of themselves as just one part of a community-wide care team, Waxman adds. “You can’t just refer a patient out and hope that works,” she says. “If you really want to make headway in health improvements you’ve got to be actively engaged.” 

This ACP 2019 panel, “Improving Individual and Community Health,” will take place on Friday, April 12 at 4:30 p.m.

Doctors understand that social determinants of health have a major impact on patients' wellbeing, yet they often are reluctant to address such issues with their patients.

ACP 2019: Panel looks at how doctors can address social determinants of health

When Matthew Taylor, MD, PhD, began the process of choosing a medical specialty, he made a list of the disciplines he thought would evolve significantly during his career. Of the various areas he considered, the one he kept coming back to was genetics. 

Clearly, he was right. The breadth of genetic knowledge and its applicability to patient care is expanding rapidly. “We have many, many more [genetic] tests, and often those tests lead to confirming a diagnosis, providing some prognostic information, accessing a clinical trial, and in some cases, actually accessing some disease-specific therapies,” says Taylor, who is double boarded in internal medicine and clinical genetics and is the director of the adult medical genetics program at the University of Colorado Denver. 

Patients’ interest in their genetic information has increased as well, and the growth of the direct-to-consumer genetic test industry means a physician is no longer required. Patients do, however, expect their physicians to help interpret the results and determine appropriate treatment.  

The problem is that there are far too few geneticists to meet this demand, which means that primary care physicians must be prepared to integrate genetics and genomics into their daily practice. But many primary care physicians are not fully confident in their abilities to have genetic conversations with their patients, Taylor says.

“It’s quite frequent for us to see patients come in who have read a lot about what has been suggested they have, and they want to talk about what their mutation will or won’t be,” he says. “That can be daunting for the physician who realizes that the patient may know more about [a genetic condition] than they do, and you can’t always assess whether the patient has it right or not when you don’t really know what they’re talking about.”

At this year’s ACP Internal Medicine Meeting in Philadelphia, Taylor will lead a session focused on what internists need to know about genetics. 

He acknowledges that genetic diseases tend to be rare and unfamiliar to internists, so it’s difficult to have a comprehensive discussion about genetics without a disconnect from clinical practice. However, he will cover areas that most internists should expect to encounter, including what to do if a patient requests interpretation of genetic test results, how to determine if a patient might have a condition for which genetic testing is available, and how to assess if testing would have any utility for a patient and/or the patient’s relatives. 

Beyond attending this session, practicing internists looking to strengthen their competency in genetics may have to turn to a self-study approach, unless they want to go back to medical school. Taylor recommends guiding CME to focus more on genetics, attending genetics conferences, and reading the literature. 

And while it’s understandably difficult for internists in busy practices to devote additional time to learning more about genetics, Taylor believes it’s imperative. “If you’re an internist who is looking at retirement in the next couple of years, no problem. But if you’re just starting out or you’re in the midst of it … genetic and genomic medicine has arrived,” Taylor says. “And internists have a really critical role to play.” 

Taylor’s ACP 2019 session, “Genetics: What the Internist Needs to Know,” will take place on Thursday, April 11 at 7:00 a.m.

Internists have a major role in helping patients understand and manage their genetic conditions.

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