eVoice^® Alert

June 18, 2010

Senate passes six-month SGR fix

The U.S. Senate passed an amended version of H.R. 3962, now called the “Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010,” by unanimous consent this afternoon. This legislation provides a 2.2 percent Medicare physician payment update for six months, from June 1 through Nov. 30, in lieu of the 21 percent cut scheduled for 2010.

Unfortunately, the U.S. House of Representatives is not scheduled to hold any floor votes until the evening of June 22. As a result, the Centers for Medicare and Medicaid Services (CMS) is instructing its carriers to lift the hold on processing claims for services provided on or after June 1, and to begin processing them under the law’s negative update requirement. In other words, claims will begin to be paid today at the 21 percent lower rate on a first-in/first-out flow basis.

Once H.R. 3962 is passed by the House and signed by President Obama, CMS will retroactively adjust any June claims that have been paid.

View an AMA news release about the Medicare physician payment crisis.

eVoice^® Alert

June 17, 2010

CMS will process claims tomorrow, June 18,
with 21 percent cut

As the clock continues to tick toward the June 18 final deadline for implementation of the 21.3 percent cut in Medicare physician payments produced by the sustainable growth rate (SGR) formula, U.S. Senate debate continued June 17 over H.R. 4213, the American Jobs and Closing Tax Loopholes Act. In addition to providing another short-term reprieve from the impending Medicare cut, the legislation would increase federal Medicaid funding and extend various expiring programs, such as disaster relief and long-term unemployment insurance benefits.

If legislation is not signed into law before the weekend, the Centers for Medicare and Medicaid Services (CMS) will have no option but to instruct its contractors to begin processing Medicare claims for physician services provided in June at rates that reflect the 21.3 percent cut.

Once the House and Senate act to avert the cut, claims will be processed as follows:

• If the submitted charge is higher than the new rate, the contractor will automatically reprocess the claim.
• If the submitted charge is lower than the new rate, the physician should call the contractor.

CMS says almost all physicians submit claims for more than the Medicare rates. No one is going to be reviewing the limiting charge for the period that the cut was in place because CMS assumes Congress will ultimately make the fix retroactive.

The Office of Inspector General and CMS are close to releasing a document to waive patient co-pay requirements for situations such as the retroactive increases that were made to the geographic practice cost index increases. CMS will share that document once it is available.

Congressional inaction is a dereliction of duty

Democrats and Republicans in Congress are responsible for the current Medicare payment debacle. Congress has missed three separate deadlines and is now allowing cuts to go into effect that they pledged they would not allow to occur.

We expect our elected officials to resolve budget issues without punishing physicians, seniors and military families. State medical societies and national specialty societies sent a joint statement to Congress on June 16 that emphasizes this point. Continue to let your representatives and senators know that their inaction is unacceptable, and that it is harming patients and physicians across the country.

Use the AMA Physicians’ Grassroots Network toll-free hotline at (800) 833-6354 to call your lawmakers and tell them to repeal Medicare’s SGR formula once and for all.

Details on Senate impasse over Medicare physician payment cuts

The debate and delay in the Senate centers on growing concerns about how much the legislation would add to the federal deficit. On June 16, a substitute amendment to the House-passed version of the bill, offered by Sen. Max Baucus, D-Mont., was defeated on a bipartisan vote of 45-52. That amendment would have afforded a 19-month reprieve from the scheduled Medicare payment cuts by providing a 2.2 percent update for the remainder of 2010 and an additional 1.0 percent update in 2011. In 2012, physician payments would have been reduced by 33 percent.

After the defeat of his first amendment, Baucus introduced a second substitute amendment late on June 16 with reduced spending and additional funding offsets. The SGR relief provision was scaled back to a six-month, 2.2 percent update that would expire Nov. 30, 2010, after which the 21.3 percent cut originally scheduled for 2010 would take effect. Reports from Capitol Hill on June 17 indicate that this package may still lack the bipartisan support needed to reach the 60-vote threshold that is required to end debate and pass a final bill.

On June 17, an amendment offered by Sen. John Thune, R-S.D., was defeated on a vote of 41-57. The amendment was far less costly than either Baucus proposal, and according to the Congressional Budget Office, would begin reducing the federal deficit. It also would have provided 2.0 percent Medicare physician payment updates for the remainder of 2010 and all of 2011 and 2012, followed by a steep payment cut of well over 30 percent and an additional statutory cut of 4 percent. The Thune amendment also included medical liability caps on non-economic damages and other traditional tort reforms.

Because the Senate is considering substantial revisions to H.R. 4213, the bill will have to be sent back to the U.S. House of Representatives for passage. While House leaders have indicated they are prepared to stay in session late tomorrow, June 18, so that a vote can be held on the bill, it is far from clear that the Senate will be able to complete its consideration before the weekend.

A 61-Year-Old Woman With Intermittent Worsening Abdominal Pain

http://cme.medscape.com/viewarticle/720078?src=emed_case_nl_0&uac=147602PZ

An Atypical Cause of Gastrointestinal Bleeding

http://cme.medscape.com/viewarticle/720456?src=emed_case_nl_0&uac=147602PZ

Medical Student Perspectives: Writing the Residency Application Personal Statement

The residency personal statement process may feel a bit like déjà vu from those days of finger-crossing about getting into medical school. While we all wrote personal statements compelling enough to get into medical school, these four years offer very few opportunities to produce reflective written work. As such, the personal statement may be a larger challenge than expected during the residency application process.

For internal medicine, the personal statement needs to explain why you are choosing a particular career path and what makes you unique. It goes without saying that it should be well written; it also needs to be succinct and direct. This is not the time to brush off your creative writing skills: we have all been warned that personal statements that use a SOAP note structure to be cute, or a yellow brick road theme to be creative are not well received by residency directors.

Keep in mind that the first paragraph and the last paragraph are what get read most often and by the most people. These two paragraphs get skimmed by the administrator to set you up with a good interviewer match, and then by your interviewer five minutes before the interview starts. Open the first paragraph with an interesting story about yourself. Readers are trying to get a sense of who you are and whether you would be a good fit for the culture and tone of the program. The temptation is high to talk about an experience with a patient. Resist the urge. Residency directors know about patients. They don’t know about you. Make yourself the subject of each sentence as often as possible.

In approaching the meat of the essay, use it as an opportunity to breathe life into your ERAS application. Use this part of the essay to explain why your activities during medical school will render you a strong, dynamic physician. Talk about your accomplishments and accolades, but remember that humility goes a long way in this profession. You may also want to talk about earlier experiences in high school or college that led to your decision to go into medicine that may not be apparent in your ERAS application.

The last paragraph is very important. It should act as a summary, but also talk about what you envision for your future. A good question to help you formulate this part of the essay is “Where do I see myself in 10 years?” You may have very specific ideas. You may not. That’s okay. The process of thinking about the future says a lot about your priorities and your goals, which ultimately are of interest to residency directors. Do not feel like this is set in stone either—if you say you want to be a cardiologist in your essay and then decide in a few years that you want to do GI instead, this essay is not going to hold you back.

Your letter should be no more than one page long. End of story.

Some other things to keep in mind:

Think twice about revealing a personal illness. This may bring about questions regarding your ability to perform.

If there is a blemish in your record, you may want to discuss whether or not to touch on it in your essay with a career advisor at your school. If you have a good explanation for the fact that you failed Step 1 (e.g., a serious death in the family), this essay is a good opportunity to explain. But if you didn’t get Honors in your first clerkship and you explain this with, “I had a hard time adjusting to third year,” residency directors are not going to feel very reassured with such an explanation.

Do not talk about the field of medicine. Your reader has been in the field a lot longer than you. Trying to sound authoritative on the subject will backfire on you.
Some tips on the writing process:
Start early. Perhaps the biggest hurdle is getting the first words on the page. Even though the whole application is not due for a few months, try to spend some time now getting your ideas on paper.

Read well written prose with attention to what makes the writing good. A professor I had in college said that to improve your writing, read good writing. So head out to your local newsstand, pick up a New Yorker or an Atlantic Monthly. As tempting as it might be to read a novel, reading non-fiction will probably be more fruitful. Pay attention to the structure and how the concepts are communicated.

Read your old personal statements. The potential for cringing is high, but remember that your essay was good enough to get you into medical school in the first place. Regardless of how much you have changed in the last four years, it is good to reflect on your reasons for entering the medical profession. Now that you have had years away from this piece of writing, note what sentences and paragraphs jump out at you both as strong and weak, and keep those in mind as you start the writing process.

Talk it through out loud. While you may not have been writing op-ed pieces during medical school, you have learned how to communicate information effectively for presentations and rounds. By talking through your ideas aloud, you may be able to make major progress in getting through that first draft.

Accept input from others. A non-medical reader may have good insight on the writing, the organization of the essay, and the content. But remember to trust your gut in terms of modifying anything. Another reader will also pick up typos and serve in a proofreading capacity—always a plus.

I would like to thank Vineet Arora, MD, MA, FACP, Associate Director of the Internal Medicine Residency Program at the University of Chicago, and James Woodruff, MD, FACP, Director of the Internal Medicine Residency Program at the University of Chicago, for their advice and assistance with this article.

The Application Process: A Timetable for Success

Written by Jeff González, M.D.,Resident, Department of Medicine, Hospital of the University of Pennsylvania; MAC Governing Council, Resident and Fellow Section Representative

The best advice I know about the application process is summed up in 2 words: “Apply Early”. Now is the time to start. With this in mind, the following is an outline of what you need to attend to, and when:

Please note: The following timetable is particular to INTERNAL MEDICINE only, and may be applicable to most other specialty programs. However, for those residencies that are considered “early match” -- e.g., Military, Neurology, Neurosurgery, ENT, Ophthalmology, Plastic Surgery, Urology -- the deadlines will begin much earlier. PLEASE REVISE YOUR OWN SCHEDULE ACCORDINGLY.

Spring/Summer:

In the spring of your 3rd year of medical school you should:

1. Do your sub-internship and medicine electives in the specialty you’re applying to, and consider an ICU month.
2. Get a letter from your sub-internship attending, if possible (If not, definitely do an ICU month), and ask for it during your month or shortly thereafter! The longer you wait to ask for a letter, the less they remember you, the less personal the letter, and the longer it seems to take them to send it to your medical school residency coordinator. I suggest providing a copy of your C.V. along with your personal statement at this time.
3. Arrange to obtain at least one more letter from an medicine attending with whom you have worked. Have the attending send the recommendation letter to your residency coordinator, to remain there, awaiting the rest of your application. Some will tell you that the bigger the name, or the higher the title, or the more prestigious the position, the more pull the letter will have. All will agree that whoever knows you the best will write the most personal letter. Remember that you can ask for multiple letters of recommendation and, when all have been received, you can then decide which ones to forward to programs. Usually your Dean will be able to tell you which letter is stronger or weaker.

Summer:

1. Work on C.V., personal statement, and paragraphs of extra curricular activities for the Dean’s Letter.
2. Meet with Dean of Students for an official meeting. However, if possible, you really should try and meet with them much earlier than this. Again, the more familiar they are with you and what you have done in medical school, the better the “Dean’s Letter will be.
3. Figure out where you want to be for your residency, and make a BIG list. This usually entails considerations of geography and academic intensity. If you are restricted geographically, go deep and apply to many programs in that area. Use your resources: fellow students, attendings, residents, and advisors.
4. Make a list of addresses, contact names and phone numbers for all your programs of interest. You can get this from the AMA’s FREIDA Web site here. This is an excellent site to compare programs and has excellent search tools.
5. Send self-addressed postcards requesting information or call the programs directly. A fancy letter is not needed -- no one will read it! Just request a brochure and application. Be sure to specify what you want, i.e., for “a 3 year residency in internal medicine. Remember most programs now provide all their program information on-line. Their URL’s can be found on FREIDA as well.
6. Plan your winter schedule so that December and/or January are light or free. Most people take one month off and then plan for the other month during a course that is known to be flexible like Radiology, Dermatology, etc.

August:

1. Call places whose information you want but have not received.
2. Consider designing a grid/sheet to compare programs.
3. Meet with your assigned advisor to discuss the appropriateness of your list.
4. Work on polishing your C.V. and personal statement.

September:

1. You can start putting information on ERAS; refer to their website at www.aamc.org/eras.
2. Read through all of your brochures and start to narrow list somewhat (you’ll do more of this when deciding on interviews).
3. Meet with your school’s program director to discuss your list and request a Department letter. You should bring to the meeting your C.V., personal statement, your list of programs, and all of your medicine grades including clerkships, consults, sub-internships, etc.

October:

1. Finish your ERAS application and send it off. Most programs will not send interview requests until they receive the Dean’s Letter.

Around November 1:

1. The Dean’s Letter, Department of Medicine Letter, and your transcript are sent out.
2. Now is a good time to send a thank-you letter to the attendings who wrote your letters of recommendation.
3. You can check ERAS applicant information on the web to see which things each of your programs has downloaded, and/or if anything is missing.

October/November:

1. Respond to your interview offers. This is tricky. You can try and wait a little to schedule things in one city together, but if you wait too long you might not get what day you want. So play it by ear.
2. Have the suit you wore for medical school interviews dry cleaned, or buy a new one now. You will not go wrong with either of two colors: black or navy blue. Remember that often the most prestigious programs are the most conservative for the interview process.

Late November through early February:

1. Interviews: There is a controversy over whether notes are necessary after these interviews. At some institutions, for instance, they are NOT EVEN READ and may even be thrown out. However, many of us have stories of letters being written back to us, referencing these notes and assuming a level of interest/enthusiasm based on them. While they may not help, everyone agrees that they can’t hurt. Most agree that form letters, however, are a waste of everyone’s time.
2. Keep those who have written letters of recommendations up-to date on how your interviews are going and your perceptions of the programs that you are interviewing. Gather their feelings and gestalt on different programs. Your goal is to engage them in your application process in order for them to call and make a strong push for the residency of your choice. However, you cannot expect to walk into an attending’s office and say: “Do you remember writing a letter of recommendation for me 5 months ago, can you call so-and-so for me?” Instead, make this an ongoing relationship.

Late January:

1. Many agree that a letter sent out now, goes further than a post-interview “obligatory” note. It is not appropriate to mention ranking, per se, but if a particular program is your top choice, then go ahead and tell them this. You have nothing to lose; just don’t change your mind!
2. Now is the time to have any phone calls made on your behalf. Most program directors offer “one phone call” per student. Many programs also encourage “second looks”. While a few programs use this as a sign of your interest, most programs offer this for the student’s benefit. A well placed phone call or letter can often help make the distinction. Remember, most programs will meet to finalize their match list by February 5th.

Other Considerations:

There are several other issues that are often of concern to students.

The Need for Research Experience: This is an issue that always comes up. The way to approach it is two-fold. First you need to figure out if you are going to apply to a high ranking academic program and what career you want to pursue. If you are interested in academic medicine, you will find that most applicants will have performed some kind of scholarly pursuit. Many will have taken a year out, are MD-PhD, or have done research in college. Scholarship may also include leadership positions or community service activities.

However, if you have decided to pursue primary care, research is much less important. If you feel that, academically, you would benefit from research, then consider it. But, remember to speak to a wide variety of individuals for their insights.

What counts most in your application?
First, it is difficult to assess one’s own competitiveness -- i.e., grades, boards, AOA, Dean’s Letter, etc.—and different programs place importance on different things. But most programs seem to place a lot of importance on letters of recommendation. Board scores are important, but do not compromise a large portion of the evaluation process. They will help/hurt you if you are on the edge of the match list at a particular institution. In evaluating your application, how well you do in your other core clerkships particularly (OBGYN, Pediatrics, and Family Medicine) is important. If you are looking to attend a top tier program, it is very important that you receive a grade of honors for your core/introductory medicine clerkship.

Should I do an ICU rotation?
Again, this pertains to how well you have performed during your clerkships and electives. If you did not receive honors in a medicine clerkship and would like to attend a top tier program, it is recommended you take an ICU rotation. If you want to do Primary Care, it is not.

I hope the above information has been helpful and informative. And remember: “Apply Early.”

Writing Your Personal Statement

Written by Jeff Gonzalez, MD Resident, Department of Medicine, Hospital of the University of Pennsylvania; MAC Governing Council, Resident and Fellow Section Representative

Why is the personal statement so important? It is important because it is the only part of your application that is not based on test scores or other people’s perceptions of you. For this reason committees place a heavy emphasis on the personal statement. It is the one part of your application that you have complete control of and allows you to make a personal case for yourself. Because of these reasons, however, it is so very difficult to write.

There are some basic questions that you need to address in your personal statement. These are usually divided into three paragraphs that address: 1) what got you interested in the field that you have chosen; 2) what are you looking for in a residency program; and 3) what are your expected goals in the field you have chosen. You are always free to add other commentary that is relevant to the above topics. But, make sure you discuss these 3 topics in your essay.

Your personal statement should fit onto one page when it is printed from the ERAS system. You can test this prior to submitting your statement to residency programs.

Some helpful suggestions in getting started:
1.Go back to your medical school application essay. Some students find it useful to look at that as a basis for their residency statement. Specifically the introductory and final paragraphs.

2. Find out if your school has a writing office, which can help you with your statement.

3. Use a theme to structure your essay. This helps unite all aspects of your statement.

4. Provide concrete examples that pertain to your life, goals and experiences.

5. Be concise. Refrain from using a lot of unnecessary words.

6. Begin your essay with an attention grabber: a quote, a story, an anecdote, or a riddle.

7. Finish your essay with a conclusion that refers back to the beginning of your statement and restates the theme.

8. Have your departmental program director evaluate/critique your statement. Remember they have probably seen thousands of essays and is most likely the best authority at your institution to evaluate your work.

9. Don’t be afraid to start from scratch if your essay is not working.

10. Do write about what interests you, excites you. Your reader wants to hear a positive essay not a negative one about the profession.

Mistakes to avoid in a personal statement:
1. Underestimating the importance of the personal statement.

2. Underestimating the time and difficulty involved in developing the personal statement.

3. Lack of “flow”. You read the essay and have no idea what the applicant is trying to say. They jump from one tangent to another. When reading a statement like this I would rather not read the essay at all. To prevent this error you need not one, not two, but at least three people to read your essay and give you feedback. You need to revise your essay several times. Therefore, you cannot start working on the essay one week before it is due. I recommend starting to work on your personal statement in July. Remember that most attendings will ask for a copy of your personal statement in order to write a letter of recommendation. You therefore need to start early.

4. Spelling and Grammar mistakes. These can kill you. It says a lot about an applicant if they have not taken the time to carefully proof read their essay. Is this someone who pays attention to detail and will spend time taking care of patients in my hospital? No!

5. Avoid clichés.

6. Making the writing process a group effort. This does not work.

7. Being too cute. This is not an essay for college admissions where originality/strangeness is applauded. Keep it simple to the point and address the issues I have brought up before.

8. Procrastinating until the very end to begin your statement. You need to start months in advance.

9. Failing to let yourself come through. This goes back to trying to make your statement too cute. You do not want to show up to an interview and have the interviewer thinking: Am I speaking to the same person that wrote this statement?

10. Including topics in the statement that if asked to discuss you would not be able to answer, such as particular research points, volunteer activities, etc…

Sample Personal Statement

Early in medical school, I suspected I would chose a field in medicine based on a long-standing fascination with the complexity and varied nature of disease processes. With an open eye, I embarked on a rigorous year of clinical clerkships. However, while rotating through medicine, my initial interests were solidified. I found the ability to connect with patients and the development of strong emotional ties all encompassing. When taking care of patients I was focusing not on one, but multiple body systems.

The marriage in medicine between pathophysiology and man is best exemplified by MP. I had begun my month in hematology when I was first consulted on his case. Recently transferred from an OSH for management of “the worst case” of ERCP induced pancreatitis anyone had seen, his diminished platelet count of 30,000, PT of 16, and numerous schistocytes led me to believe it was disseminated intravascular coagulation(DIC). As his underlying pancreatitis was controlled his DIC resolved. The following week, now as part of the infectious disease team, I was seeing him again, this time for continual spiking fevers to 103 degrees despite negative cultures and a trial of antibiotics. Since cultures of his pancreatic cysts had been negative, we went ahead and stopped all antibiotics, and waited, believing this to be a drug fever. The days passed and MP remained in the hospital, with out much change. I moved on the the liver service, which had been his primary team, and eventually left him still fighting for his life – and me wondering if there was anything different that we could have done. Although fractured at time, I found the relationship which I developed with him and his family to be the most rewarding experience I have had as a medical student.

During medical school I have used the opportunities afforded me to broaden my networking and educational experiences in pursuit of a more well rounded medical education. During the summer after my first year I spent a month in one of the university hospitals in Madrid, Spain, gaining insight into the differences and similarities inherent in our health care systems. I found that medicine abroad is much more holistic and spiritual when compared to our system. My goal when I returned was to share these findings with my classmates. I began acting on this interest by revitalizing the William Pepper Medical Society under the guidance of the Department Chairman, Dr. Peter Traber. My responsibilities include recruiting medicine faculty to lecture students interested in internal medicine on topics that are not covered by the traditional medical curriculum, such as medical futility and alternative medicine. For many students in their pre-clinical years, this forum serves as an introduction to the field of medicine, and hence is of enormous import in medical education at the University of Pennsylvania. Another of the intriguing challenges that I have faced at Penn includes living with nine other medical students at Nu Sigma Nu, a medical school co-op. Being able to work as a team with many diverse personalities had been a formidable task, but, one that has shown me that many times you need to step back, let go of your ego and think of the broader picture. Only then can you proceed. For the next three years, I hope to join a program that will impart a solid foundation in the science and technical practice of medicine while maintaining a personal connection with the patients I see. Eventually I aspire to a career in academic medicine, which will allow me to increase my effectiveness as an educator and researcher. Academia allows for a continuous exchange of ideas as well as interaction among colleagues enabling me to contribute and keep up to date with new advances in medicine. The training and rigors of an academic institution will also strengthen my interests in combining clinical research with that o patient care. By partaking in such activities I will also be acting as an educator passing my insights to rising residents and medical students.

As someone who has always been very goal-oriented, I am looking forward to beginning my residency. My life to date has prepared me to deal with many obstacles and also has shown me the determination, resilience, strength, and caring that are a part of my character. As I look toward my future in medicine, I believe these characteristics will enable me to succeed and be a valuable asset to the profession. My experiences have been very rewarding because I have identified with patients and admired their courage in the face of an uncertain prognosis. I anticipate that working in internal medicine will be equally rewarding and look forward with enthusiasm.