Section of General Internal Medicine 2007/08 Annual Report
GENERAL INTERNAL MEDICINE
The Section of General Internal Medicine (GIM) has had an active year under the leadership of Jeffrey Samet, M.D., M.A., M.P.H., Vice Chairman of Medicine for Public Health, and Professor of Medicine and Public Health. With its >100 faculty members, the Section continues to be highly productive in clinical, educational, and research realms.
Over the past year, GIM’s research activities have grown. Direct research support to GIM faculty during the 2006-2007 academic year increased by 14% and exceeded $10.7 million, with the vast majority of funding coming from the National Institutes of Health (NIH). The Section’s active research and training grants account for direct costs totaling more than $47.5 million. In addition, faculty members have submitted research proposals with total direct costs of $22.6 million. GIM faculty coauthored 54 medical articles in peer-reviewed journals in 2006, an increase from 46 and 31 in 2005 and 2004, respectively.
The Women’s Health Unit (WHU) is under the direction of Karen Freund, M.D., M.P.H., Associate Director of Boston University School of Medicine’s (BUSM) Women’s Health Interdisciplinary Research Center, and Professor of Medicine. The WHU’s research activities continue to provide new insight through interventions to address health outcomes disparities in minority and underserved women. The WHU is one of nine sites nationwide funded through the National Cancer Institute’s Patient Navigation Research Program, which studies the potential benefit of patient navigators as an intervention to address health disparities. Co-Principal Investigator Dr. Tracy Battaglia, Assistant Professor of Medicine, has secured 2 additional research grants through the Avon Foundation to investigate work design, social network, and outcome effectiveness of patient navigation. WHU researchers Dr. Frank Perna, Associate Professor of Medicine and Dr. Bonnie Sherman, Instructor of Medicine, have focused on exercise and physical activity interventions within the primary care setting, publishing research on the benefit of exercise during active breast cancer treatment, and addressing exercise for rural women.
The WHU continues to expand its focus on research training. In the past year, the WHU supported the training of four women’s health fellows as part of the combined general internal medicine/family medicine fellowship program. The WHU was successful in its competitive renewal of the K-12 institutional junior faculty Scholar award, BIRCWH (Building Interdisciplinary Research Careers in Women’s Health), which provides resources to 4 junior faculty yearly in a mentored career development program.
The WHU has increased its role in health policy within women’s health. Dr. Michele David, Assistant Professor of Medicine, secured a Health Policy Fellowship through the Soros Foundation and with additional support from the Johnson and Johnson Foundation, as developed collaboration with Massachusetts Health Care for All in policy initiatives for the health of minority women. The WHU has sponsored a Health Policy Grand Rounds series to increase interest and participation in health policy on campus.
Another GIM unit is the Health Care Research Unit (HCRU), under the direction of Arlene Ash, Ph.D., Research Professor of Medicine. The HCRU is involved in a variety of projects and frequently uses large claims-based databases, especially from Medicare, to understand differences in healthcare utilization and outcomes by gender and race or ethnicity. A key tool in facilitating these studies is the Diagnostic Cost Group (DCG) method for summarizing the illness burden of individual patients and facilitating risk-adjusted comparisons of healthcare outcomes. These methods, developed by Dr. Ash and her colleagues, are used to facilitate equitable payments to HMOs in the Medicare program.
Major HCRU projects include a multi-year NIH study focusing on racial differences in healthcare utilization and costs for Medicare beneficiaries at the end-of-life. HCRU investigators have worked on several contracts with the Department of Defense (DoD) to examine the power of models to predict future healthcare costs in the TRICARE health system, to explore the implications of a prospective payment system, and to assist the DoD in understanding and addressing small-area variations in its healthcare delivery. The HCRU also provides support to the Building Interdisciplinary Research Careers in Women’s Health (BIRCWH) Program, an NIH-funded K-12 faculty program that supports an interdisciplinary group of junior faculty, and provides mentorship to departmental fellows and assistance to the Graduate Program in Molecular Medicine. Drs. Ash and Amresh Hanchate PhD, Research Associate, work with multiple BU Medical Center researchers on projects funded by the Centers for Disease Control and Prevention (CDC) (“Examining Quality of Epilepsy Care”); the Food and Drug Administration (glucose-monitoring study); the National Cancer Institute (“Impact of Breast Cancer on Older Survivors” and “Patient Navigation in the SafetyNet,”); and the National Institute on Aging (“Exceptional Survival and Longevity in New England” and the “Long Life Family Study”).
Dr. Hanchate is also pursuing the following projects: “Surgery Volume and Mortality:,” funded by the Agency for Healthcare Research and Quality (AHRQ), “Examining the Validity of Community Based Screening Questions for Assessing Epilepsy” funded by the CDC, “The Demographic Assessment of Health Literacy, A New Independent Covariate of Health Status in the Elderly”, and “Patient Safety Indicators in the VA”, funded by AHRQ. Dr. Andrea Kronman, M.D., M.Sc., is a BIRCWH faculty scholar pursuing the following projects: “The Role of Primary Care at the End of Life” and “Improving Risk Adjustment Methods for Illness Burden.”
The Clinical Addiction Research and Education (CARE) Unit is an academic unit addressing the clinical, educational, and research aspects of alcohol and other drug use. CARE is under the direction of Richard Saitz, M.D., M.P.H., Professor of Medicine and Epidemiology and Associate Director of the BUMC Office of Clinical Research. Faculty members include Dr. Samet; Daniel Alford, M.D., M.P.H., Associate Professor of Medicine; Sheila Chapman, M.D., Medical Director, Pregnant Women’s Program, Methadone Maintenance Treatment Program at the Boston Public Health Commission (BPHC), and Assistant Professor of Medicine; Debbie Cheng, Sc.D., Associate Professor of Biostatistics and Medicine; Theresa Kim, M.D., Assistant Professor of Medicine, Medical Director of CAB Detoxification Unit; Colleen LaBelle, R.N.; Jane Liebschutz, M.D., M.P.H., Associate Professor of Medicine; and Christopher Shanahan, M.D., M.P.H., Director of the Community Medicine Unit at BMC, and Assistant Professor of Medicine. This year the Unit will add a new research faculty member, Dr. Alexander Walley, former BU General Internal Medicine and CARE research fellow. CARE Unit projects directly employ approximately fifteen staff and several college and medical students, and provide research experiences for medical students, residents, and fellows.
The CARE Unit collaborates with a number of other Boston University departments, other universities, and outside agencies. Dr. Saitz is Associate Director of a P60 NIH Center grant to address alcohol problems among young people, awarded to the BU School of Public Health. In addition, the CARE Unit is collaborating with faculty in Boston University’s Departments of Psychology, Gastroenterology and Psychiatry and in the Schools of Social Work and Public Health, as well as eight other American universities, and Pavlov State Medical University in St. Petersburg, Russia.
In 2006-2007, the NIH, the Health Resources and Services Administration (HRSA), and the Robert Wood Johnson Foundation provided support for nine randomized controlled trials and observational studies conducted by CARE Unit faculty. These studies address hazardous drinking in college freshmen via a web intervention; unhealthy alcohol use in hospitalized medical patients; the role of alcohol in hepatitis C and HIV outcomes; post-traumatic stress disorder (PTSD) and substance use in primary care; a study of the interaction between PTSD and substance use in people with chronic pain; drinking and health across the lifespan (in collaboration with the Framingham Heart Study); HIV prevention in risky drinkers with HIV and in uninfected narcology hospital patients (in Russia); and quality of care for people with addictions. The Unit also addressed studies of screening tests for alcohol and other drug use disorders.
In this past year the National Institute on Drug Abuse (NIDA) awarded the Unit a $3.4 million award for which Dr. Samet is the Principal Investigator; this is a complementary study to the National Institute on Alcohol Abuse and Alcoholism (NIAAA) grant to the CARE Unit in 2005, a $4.4 million award for which Dr. Saitz is the Principal Investigator. Both of these grants fund the test of a disease management/chronic care model for people with alcohol and/or drug dependence in the primary care setting. Three additional NIH proposals (K24, R25, and R01) were funded this past year (Dr. Samet PI), and a $14 million proposal was funded by Substance Abuse and Mental Health Services Administration (SAMHSA). This proposal to disseminate screening and brief intervention was spearheaded by Governor Mitt Romney’s office, and the CARE Unit was the lead agency, with Boston Medical Center receiving the majority of the funds as a subcontract to the state. Dr. Alford is the Principal Investigator for this proposal, and most CARE Unit faculty are working on this project in some capacity.
To support its research dissemination and educational activities, the CARE Unit has two NIH R-25 grants for drug abuse and alcoholism training for physicians and other health providers, including a well-established and popular Chief Resident Immersion Training (CRIT) Program. Generalist chief residents from around the United States are trained at this annual four-day immersion course on addictions. These projects have visible web sites and produce a highly regarded alcohol and health electronic research summary newsletter. This year the newsletter was expanded to address alcohol and other drugs. A web-based curriculum for physicians is being disseminated in collaboration with the American College of Physicians. These R-25 awards support an Addiction Medicine research track in the GIM fellowship program. Drs. Alford and Saitz contribute to a national mentoring program for physicians prescribing buprenorphine for the American Society of Addiction Medicine. Dr. Samet was a member of the Institute of Medicine committee that released the 2005 report Improving the Quality of Health
Care for Mental and Substance Use Conditions. Dr. Saitz has served on a SAMHSA advisory committee and on the Washington Circle Group to implement the report’s recommendations.
In addition, Dr. Liebschutz continued her work on an NIH K23 career development award to study the intersection between drug abuse, PTSD, and primary care. BUSM residents have access to addiction clinical experiences with Unit faculty during primary care block time (spots also sought by trainees elsewhere such as the Brigham and Women’s Hospital), and the CARE Unit has a longstanding Summer Medical Student Research Program. Dr. Alford has led national efforts to train physicians in the use of buprenorphine in collaboration with the American Society of Addiction Medicine. Two Unit members play active roles in a Center for Substance Abuse Treatment-supported residential facility for homeless adults with addictions.
CARE Unit faculty members provide the major physician leadership of the BPHC Substance Abuse Prevention and Treatment Services (SAPTS). Dr. Samet serves as SAPTS Medical Director, Dr. Alford has been Medical Director of the Methadone Clinic and is turning this position over to Dr. Walley this coming year, and Ms. LaBelle provides clinical leadership for the Office Based Opioid Treatment (OBOT) Program, recently funded to expand its efforts to include statewide training for the delivery of buprenorphine for opioid dependence in primary care settings, by the state Department of Public Health. Drs. Shanahan, S. Chapman also provide clinical services to SAPTS: Dr. Shanahan oversees the Transitional Opioid Program (TOP), which helps hospitalized, opioid-dependent patients engage in substance abuse treatment, and Dr. Chapman works with pregnant methadone-treated patients.
Robert Friedman, M.D., Director of the Medical Information Systems Unit (MISU), and Professor of Medicine, continues to lead research and education in medical informatics (computer applications in biology and medicine). The MISU has a staff of 43 including five full-time faculty members and four post-doctoral fellows. During 2006-2007, the MISU had sixteen federally funded research projects and one foundation funded research project, including one new NIH K07 training award.
The MISU is internationally known as the first research laboratory to demonstrate that a totally automated, computer-controlled telephonic intervention program helps patients and consumers modify their lifestyle behaviors that significantly contribute to the prevalence of chronic disease, morbidity, and premature mortality. These programs also promote self-care in patients with chronic disease, and facilitate disease monitoring and alerting of responsible health professionals for patients with chronic disease. The MISU is a leader in integrating these automated systems into traditional healthcare delivery systems to improve control of important chronic health conditions such as hypertension.
Currently, the MISU research laboratory is focusing on developing and evaluating totally automated primary prevention programs directed to people who have multiple health behavior risks: smoking, unhealthy eating habits, and sedentary lifestyles. In the area of disease management, Dr. Friedman directs a research project that is developing an innovative, multi-component, computer-assisted chronic disease management system. The MISU is evaluating this system, which uses both automated telephone communications and patient monitoring using automated home measurement devices in patients’ homes.
Dr. Friedman is completing a research project that compares automated telephone calls to motivate women to have a routine screening mammogram with the traditional approach of mailed reminders. In addition, he is completing a study in which an automated telephonic intervention for patients with hypertension has been culturally adapted for African-Americans. Finally, Dr. Friedman is leading research teams that are applying computer technology to the management of patients with spinal cord injury and disease and in facilitating the transition between hospital inpatient care and post-discharge primary care.
Julie Wright, Ph.D., Assistant Professor of Medicine, is a co-investigator on five studies related to computer-assisted interventions that target cancer prevention behaviors (e.g., healthy diet, regular physical activity, weight management). Three of these studies are delivered in primary care settings. Two of her projects involve the development and evaluation of behavioral informatics systems that use electronic health records (EHR) and telephony systems to increase healthy behaviors in pediatric patient populations. Dr. Wright is also a recipient of a Cancer Career Development Award (NCI K07).
Ramesh Farzanfar, Ph.D., Assistant Professor of Medicine, has designed and developed two automated mental health systems. One, funded by the National Institute of Mental Health (NIMH), is a disease management system intervention for patients with unipolar depression. The second, funded by the CDC, is designed to detect mental health problems, particularly those that affect productivity, in the workplace. Dr. Farzanfar is also the site PI of a multi-institutional research project to improve the management of depression in medical illness through the use of computer-assisted programs. She completed this year a Robert Wood Johnson Foundation-funded research project in which she developed new research methods to measure factors that affect the utilization of computer-based behavioral change programs.
Julien Dedier, M.D., M.P.H., is an Assistant Professor of Medicine. He is conducting an NIH-funded study on the relation of ethnic identity to the prevalence of behavior-related risk factors for cancer in African Americans. He is also evaluating the influence of ethnic identity on the use and effectiveness of culturally-adapted behavior change interventions in this population. Dr. Dedier has recently obtained a career development award from the American Cancer Society to develop and evaluate culturally-tailored messages to promote physical activity among urban African-Americans.
Amy Rubin, Ph.D., Research Associate, is a psychologist whose interests include early intervention and treatment research for alcohol problems and investigating technology-based treatment intervention and dissemination. Dr. Rubin has joined her interest in substance abuse research and technology-based treatment dissemination in a number of studies evaluating computer telephony. She has collaborating roles in the NIAAA funded (R01 AA014258) study titled “Telecom & Bibliotherapy Programs for Problem Drinkers”, and the SAMHSA-funded project to bring screening, brief intervention and referral to treatment to medical care. Dr. Rubin is also collaborating with colleagues at the Boston VA Healthcare System on a web-based treatment program for returning veterans with alcohol problems and PTSD symptoms.
The MISU leads the Boston University Biomedical Informatics Training Program that provides 2 – 3 years of post-doctoral training in biomedical informatics to physicians, psychologists, and other scientists. During 2006 – 2007, the Program combined existing programs at BUMC and the Boston VA Healthcare System.
Other active GIM researchers include Elaine Hylek, M.D., M.P.H., Associate Professor of Medicine, and Michael Paasche-Orlow M.D., M.P.H., Assistant Professor of Medicine. Dr. Hylek’s research has focused on cardiovascular epidemiology issues, specifically the risks and benefits of anticoagulation for atrial fibrillation. Dr. Paasche-Orlow is a national leader in health literacy. His publications include a special issue of the Journal of General Internal Medicine for which he was a Co-Editor.
CLINICAL ACTIVITIES
Clinical activities within the Section of General Internal Medicine have been active. Guided by Peter Davidson, M.D., Associate Chief of Clinical Affairs, and Associate Professor of Medicine, ambulatory visits handled by GIM faculty exceeded 73,000 and GIM faculty were the attendings on 69% of all medicine inpatient blocks on non-subspecialty services. Total outpatient visits have decreased over the past year by 13% from 2006 largely due to the attrition of GIM outpatient faculty in BMC’s Yawkey Ambulatory Care Clinic (YACC) and Doctors Office Building (DOB). A clinical incentive program has evolved in its fourth year of existence and measures work-RVUs (relative value units). Outpatient clinical activity in primary care practices in the YACC is under the direction of Jason Worcester, M.D., Assistant Professor of Medicine. The leadership of the DOB’s primary care practice was assumed by a newly recruited physician, Peggy Chou, MD, Assistant Professor of Medicine. The Women’s Health Group primary care practice and the Boston University Medical Group at Quincy Medical Center is lead by Elizabeth Dupuis, M.D., Assistant Professor of Medicine. The WHG, under the clinical directorship of Dr. Elizabeth Dupuis, Assistant Professor of Medicine provides primary care and mental health services to address women’s health comprehensively. During this time of primary care shortage nationwide, the WHG has continued to increase its panel, with 16% of all visits in the past year from new patients. The WHG is part of the multidisciplinary Breast Health Group, and this year moved this aspect of the clinical practice into the new Moakley Building. The Group provides consultation to patients with breast problems or abnormal screening results, or increased cancer risk.
The Commonwealth Medical Group practice continues under the leadership of Steven Abreu, M.D., Clinical Assistant Professor of Medicine. The Medicine Consult Service at BMC, lead by David Halle, M.D., Assistant Professor of Medicine, has undergone extensive transformation and growth this past year with development of a newly constituted pre-operative evaluation center in collaboration with other hospital departments.
The Hospital Medicine Unit (HMU) within GIM has been transformed with the addition of six new faculty members this year. The HMU with Jeffrey Greenwald, M.D., Associate Professor of Medicine, as its Director, will increase its provision of inpatient care for the Department of Medicine from 15% in 2006 to nearly 50% in 2008. HMU faculty members have been consistently ranked very highly for their teaching skills by both residents and medical students. They made substantive contributions to BMC’s quality improvement efforts including medication reconciliation and inpatient influenza vaccinations.
Under the direction of Dr. Christopher Shanahan, the Community Medicine Unit (CMU) pursues its mission is to support the development and management of community-focused clinical, educational, and research programs. The Joint Hire Program (JHP), overseen by the CMU, is a collaboration between BMC and the DOM to support physician effort for integration of general internists at BMC and the neighborhood health centers. This past year 15 physicians provided 30 clinical sessions each week with JHP support. The JHP attracts highly qualified primary care clinicians into academic clinical positions with creative teaching arrangements. This past year, Elizabeth Rourke, MD (South Boston CHC) and Alexandra Molnar, MD (Upham’s Corner NHC) were recruited into the JHP. CMU faculty can also provide inpatient attending supervision. This year the CMU worked actively with East Boston Neighborhood Health Center, South Boston Neighborhood Health Center and Upham’s Corner Health Center to coordinate recruitment efforts and facilitate JHP arrangements for highly qualified community-based clinician educators. Dr. Shanahan maintains an open dialog and supportive working relationship with the leadership of the Boston HealthNet facilitating collaborative activities. The CMU director maintains an ongoing dialogue with Medical Directors, key staff physicians and administrators at over 15 community-based sites.
GIM contributes to BMC Information Technology (IT) activities. Dr. Shanahan is the IT Medical Director. Two other general internists are supported by this hospital department to develop a clinically user-friendly electronic medical record and utilize the electronic health record to assess and improve the quality of medical care delivery.
The clinical practice recruited new faculty members in 2006-2007. Leila Obeid, M.D., joined the YACC primary care practice. Carol Bravo, M.D., joined the Latino Health Clinic practice located on YACC in addition to Peggy Chou, M.D., Medical Director of the DOB practice. Nicolette Fontaine, M.D joined the practice at QMC.
Several GIM units also perform clinical functions. The Women’s Health Unit plays an active role in patient outreach and policy advocacy in addressing health disparities for minority women. The Women’s Health Network, under the direction of Chava Chapman, M.D., M.P.H., Clinical Associate Professor of Medicine, provides uninsured women with comprehensive cancer screening. Michele David, M.D., M.P.H., M.B.A., Assistant Professor of Medicine, leads the public policy and advocacy activities within the Unit.
EDUCATION
All program directors at BMC within the Department of Medicine continue to be GIM faculty. Leadership was provided by David Battinelli, M.D., Professor of Medicine and Vice Chairman of Medicine for Education, until his departure at the end of the academic year. Angela Jackson, M.D., Associate Professor of Medicine, continues in the role of Director of the Primary Care Training Program. Medical student education within the Department of Medicine is headed up by Warren Hershman, M.D., M.P.H., Associate Professor of Medicine. Robert Dawson Evans Educators were appointed this year and GIM faculty, Drs. Peter Davidson and Elaine Hylek will serve in these roles.
Medical students receive extensive clinical exposure in the primary care clinics, with GIM faculty providing one-on-one precepting in 399 clinic sessions this past academic year. GIM faculty and fellows provide a substantial portion of the Department’s teaching contribution to the “Introductory to Clinical Medicine” course offered to BUSM students. Twelve GIM faculty members attend at the Department’s traditional resident morning report, and nine attend at the ambulatory morning report.
GIM faculty plays a leading role in resident and student education on diversity through the activities of the BUSM Diversity Curriculum Task Force. In addition to the Department’s Grand Rounds, GIM faculty continues their medical education at the weekly General Internal Medicine Grand Rounds lecture series organized by Bernard Kreger, M.D., M.P.H., Professor of Medicine. The latter conferences included lectures by Bill Ghali, M.D., M.P.H., Professor of Medicine at the University of Calgary, who was the 2007 Mark Moskowitz Memorial Visiting Professor.
Under the direction of Drs. Friedman and Liebschutz, the General Internal Medicine Fellowship Program and Preventive Medicine Residency Program provide a collaborative two- or three-year fellowship experience with the Department of Family Medicine. Assistant Program Directors Michael Paasche-Orlow, M.D., M.P.H., Assistant Professor of Medicine, and Dr. Tracy Battaglia make significant contributions to this program. Specialized areas of training covered within these fellowship experiences include concentrations in women’s health, substance abuse, cancer prevention, and informatics. Five fellows completed the program in 2007. This fellowship program continues to enjoy broad support from HRSA, National Research Service Awards, Department of Veterans Affairs, National Institute on Drug Abuse, and the American Cancer Society.
The Core Curriculum in Adult Primary Care Medicine, a Continuing Medical Education course sponsored by the Section of General Internal Medicine, transitioned its leadership this year to Beth Manning, M.D., M.P.H., Assistant Professor of Medicine. It reviews the spectrum of general internal medicine in half-day monthly presentations attended by more than 180 generalist clinicians in suburban Boston.
In addition, individual units with the Section of General Internal Medicine contribute to the Section’s educational activities. The WHU serves as a training resource for BUSM students and internal medicine and family medicine residents; Renee McKinney, M.D., Instructor of Medicine, directs training activities. The Unit supports a nationally recognized women’s health fellowship, which is embedded in the GIM fellowship program. The fellowship provides training for future leaders in academic women’s health across the nation. The Unit also administers BIRCWH, Boston University’s only NIH-funded K-12 faculty program.
CMU faculty Julie Crosson, MD, leads the Medical Interviewing Course for internal medicine residents. The CMU also continues to support the efforts of the Residency Training Program and specifically with the Primary Care Training Program to recruit excellent residents after graduation from the program.
MAJOR ACCOMPLISHMENTS
Geoffrey Modest, M.D., Clinical Professor of Medicine, was honored with the inaugural 2007 Robert Witzburg Outpatient Teaching Award from the Section of General Internal Medicine.
Jay Orlander, MD was appointed Associate Chief of Medicine, VA Boston
David Halle, M.D., Assistant Professor was appointed the Director, Internal Medicine Pre-Operative Assessment Center
Christine Phillips, MD, Assistant Professor, received the Dean’s Recognition Award for Teaching
Daniel Alford, MD, was selected for the national Nyswander Dole Award given by the American Association for the Treatment of Opioid Dependence
Nancy Kressin, PhD, Associate Professor, received a VA Research Career Scientist award
Jeffrey Samet, MD, Professor, received an NIAAA career development award (K-24)
Drs. David Battinelli, Sondra Crosby, Julien Dedier, Angela Jackson, Jane Liebschutz, James O’Connell and Suzanne Sarfaty were inducted to the BUSM Humanism Honor Society
Frank Perna, PhD, received the Walter Peach Award from the Association of Applied Sport Psychology
David Halle, MD received the 2007 Section of General Internal Medicine Most Valuable Player Award
Dr. Peter Davidson, Associate Professor of Medicine has been awarded a quality grant award from Harvard Pilgrim Health Care. This project focuses on improving health care of Latinos with diabetes using the internet.
