News

Huge step toward health care payment reform

By now I'm sure you've heard the groundbreaking news that broke last week regarding the nation's health care payment system: As a result of an industry-wide investigation by New York Attorney General Andrew Cuomo, UnitedHealth Group and Aetna will pay a combined $70 million to settle accusations that they used a rigged database to manipulate out-of-network reimbursement rates, overcharge millions of people and increase their own profits at the expense of patients and physicians. We're told another insurer is expected to sign onto the settlement next week.

Through the investigation, which is ongoing, Cuomo alleged that the database had been channeling manipulated data to health insurers, which used this information to reimburse patients at less than the "usual, customary and reasonable" (UCR) rates for physician services.

The database is operated by Ingenix Inc., a subsidiary of United that is the nation's largest provider of health care billing information. Under the agreements, United will close Ingenix's database and the $70 million will go to a qualified nonprofit organization, to be selected by Cuomo's office, that will establish an independent database to help determine fair out-of-network reimbursement rates.

These agreements about the database helped resolve a long-standing lawsuit against United by the AMA and others that challenged the validity of the Ingenix database. Through the lawsuit, which had been pending since 2000, the Litigation Center of the AMA and State Medical Societies, the Medical Society of the State of New York (MSSNY), the Missouri State Medical Association, a number of individual physicians and patients, and several New York unions, alleged that Ingenix's database to determine UCR charges used unreliable or insufficient data. The suit further alleged that the UCR charges for certain procedures are substantially higher than the insurance companies used.

The $350 million settlement of the lawsuit, which is subject to preliminary approval by a federal district court in New York, marks the largest monetary settlement of a class-action lawsuit against a single health insurer in the United States. And it supports the separate agreements between Cuomo's office, United and Aetna.

All this combines to be a monumental victory for patients and physicians. Cuomo's investigation, which the AMA had urged, discovered and confirmed what we've been saying for years—that Ingenix has been operating a defective database that corrupted the system for paying out-of-network medical bills.

Ingenix's reimbursement method worked like this: Customers of a health insurer would pay a higher premium for the right to use out-of-network physicians, and in exchange, the insurer would promise to cover up to 80 percent of either the physician's full bill or the UCR rate, whichever was less. Cuomo's investigation found that by distorting the UCR rate, United and other insurers using the Ingenix database kept their reimbursements artificially low and forced patients to take on a higher share of the costs.

In some cases, this ploy has instigated acrimony between physicians and their patients, creating a false perception that any unexpected balance on a patient's bill is the fault of the doctor. When a low payment rate is reimbursed to a patient, a physician simply trying to collect payment for the cost of delivering care sometimes gets accused by the patient of overcharging—a scenario that can impair or even destroy a patient-physician relationship.

This scheme has touched every state, many doctors and many millions of patients—and it has gone on for far too long. In the wake of these agreements with United and Aetna, the AMA calls on all health insurers to act immediately to create an industry-wide commitment to Cuomo's health insurance payment reform effort. An independent and transparent database will keep private interests from tarnishing the data used to set reimbursement rates for out-of-network care.

As I noted, Cuomo will select the nonprofit academic organization that will own and operate the new database. The AMA fully supports his efforts in choosing such an organization to create a new, reliable database that is fair to patients and physicians.

According to the settlements between the attorney general's office, United and Aetna, the nonprofit organization will be the sole arbiter and decision-maker with respect to all data contribution protocols and all other methodologies used in connection with the database. It will use a Web site to inform consumers in advance how much they may be reimbursed for common out-of-network medical services in their area. And it will make rate information from the database available to health insurers and use that to conduct academic research to help improve the nation's health care system.

In addition, United has agreed to fund a new institute that will focus not on fees but on ways insurers and physicians can constructively engage for the benefit of patients. We hope this will be a turning of the page by this health plan behemoth and the beginning of building bridges between insurers and the clinicians who provide care for their members.

I applaud Attorney General Cuomo for his leadership in reforming the nation's health care reimbursement system, but this isn't the first time his office's health care industry task force has made positive news for physicians. You might remember that in 2007, with significant input from the AMA and the MSSNY, Cuomo announced groundbreaking agreements with several large health insurers regarding physician profiling (or "economic credentialing") programs.

Patients and physicians have a right to expect fair and accurate payment for services promised to them by health insurers. The events of the past week have brought us one step closer—a colossal one at that—to ensuring transparency, accuracy and integrity in the way health insurers determine out-of-network reimbursement rates, which will make certain that patients' and physicians' expectations are realized.

It was a long time in coming, but our work has resulted in a huge victory for doctors and patients.

E-mail comments, questions and replies to Dr. Nielsen

1) Coming next week: A new AMA Web site that has more for you

A more engaging and interactive AMA Web site has been designed around its most important audience—you! Offering a fresh look and expanded content, the AMA's newly redesigned Web site will launch Jan. 29 and present a wealth of information and resources in a more dynamic and timely fashion.

The new Web site will feature:

• More content and resources accessible directly from the home page, which means fewer clicks to get to the information you need
• Dedicated sections—for physicians, residents and fellows, students, and patients—that give you quick and easy access to the content most important to you
• News pages updated daily so you know what's happening
• Related links that direct you to other information and resources that may be of interest

Because of the transition to the new site, the current AMA Web site will be unavailable from 8 p.m. CST Jan. 28 to 8 a.m. CST Jan. 29, when the new site will go live. We appreciate your loyalty and thank you in advance for your patience as we transition to newer and more engaging technologies to serve you better.

If you have questions or comments, please contact the AMA Member Relations Center at (800) 621-8335. And on Jan. 29, visit www.ama-assn.org to view and use the new site.

2) Implementation of ICD-10 and HIPAA 5010 regulations delayed

Following strong advocacy by the AMA and several other organizations, the U.S. Department of Health and Human Services decided to set far more reasonable adoption dates for the new International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) codes and Health Insurance Portability and Accountability Act (HIPAA) electronic claim standard.

The adoption date for the new HIPAA electronic claim standard, the 5010 rule, will be Jan. 1, 2012, and one year later for small health plans. The adoption date for the ICD-10 codes will be Oct. 1, 2013, two years later than originally proposed.

The AMA will continue to closely monitor the move to the 5010 standards and stress that the new standards be adopted successfully before requiring adoption of the ICD-10 code sets.

3) Study shows liability concerns may harm public health emergency response

Public health emergency relief efforts can be hindered because the United States lacks clear liability protection laws for all medical emergency responders. Concerns about liability exposure and a lack of guidance on the scope of liability that medical emergency responders could face may make doctors, nurses and other health care professionals wary of responding to emergencies, according to a study in the AMA's Disaster Medicine and Public Health Preparedness journal.

The study found that the U.S. liability law is a patchwork with many gaps and inconsistencies that do not always protect health care providers during emergencies. Hospitals or clinics that donate their time, space, supplies and resources to emergency response efforts and individual responders who continue to receive a salary from their employer are at the greatest risk.

View the study, which was released early online and will be published in the March issue of Disaster Medicine and Public Health Preparedness.

View past issues of Disaster Medicine and Public Health Preparedness.

View the AMA's news release about the study.

4) Physicians speak out on Medicare

After attending several health care community discussions that convened across the nation last month, U.S. Department of Health and Human Services (HHS) Secretary Tom Daschle compiled a video highlighting remarks made at meetings he attended in Indiana and Washington, D.C.

The video shows physicians and senior citizens describing the roadblocks to care that they experience under Medicare and other health insurance plans. Daschle acknowledged physicians' frustrations with Medicare and other insurers and underscored the need for reforms.

Also online, the AMA posted a new resource to help physicians better understand the changes in this year's Medicare payment rates and policies. "2009 Medicare physician payment rates: What to expect in your practice" includes an explanation of the many factors affecting the net payment rate changes, a specialty impact table reprinted from the 2009 final rule, and links to detailed information about the 2009 incentive payment programs for electronic prescribing and quality reporting.

5) In JAMA: Abnormal heart function associated with reduced capacity for exercise

Patients with abnormal diastolic function—when the heart is relaxed and expanded in the left ventricle of the heart—have a substantially lower maximum capacity for exercise, according to a study in the Jan. 21 issue of the Journal of the American Medical Association (JAMA).

View the JAMA Report video about this study.

1) In The Boston Globe: Blue Cross, Tufts Medical Center reach fee negotiation
A deadlock between Tufts Medical Center and Blue Cross Blue Shield (BCBS)—Massachusetts' largest health care insurer—ended in an agreement that allowed both sides to claim success, according to a Jan. 18 story in The Boston Globe.

In the story, Tufts Medical Center and its affiliated doctors said they will join BCBS's "alternative quality contract," which the insurer had been advocating as a way to slow the spiraling cost of health care while improving treatment. The medical center warned 60,000 patients that its doctors would no longer accept BCBS health maintenance organization (HMO) insurance after Jan. 31, charging that BCBS was not paying a "reasonable rate" for the medical care of its HMO members.

Although Tufts Medical Center is the major teaching hospital of Tufts University as well as Boston's sixth largest employer, the hospital has struggled financially for years, in part because the hospital loses money on major insurance contracts, according to the Globe.

Tufts officials estimated that their 750 physicians are typically paid 20 to 40 percent less for each procedure than doctors at other Boston teaching hospitals even though quality measures are comparable, the Globe reports.

1) In AMNews: Court orders Medicaid coverage for low-income HIV patients
A recent California trial court ruling could help extend Medicaid coverage to hundreds of HIV-positive patients in the state, according to a Jan. 12 American Medical News (AMNews) article.

The court is following up on a rule implemented in 2002 that was intended to close a gap in the state's Medicaid regulations for those HIV-positive patients who met federal income requirements that would qualify them for benefits until they developed AIDS.

In a November 2008 decision, the judge in the case found that health officials had not carried out the necessary steps required to institute the program. The state has responded that actions were not made because of a lack of funding and confidentiality issues.

1) In The New York Times: Middle-class consumers increasingly turn to health clinics for the poor
Some medical clinics in the New York area are seeing a trend of middle-class professionals, small-scale businesspersons, artisans or young people just out of college—all without health insurance—seeking care in clinics designed for the poor.

According to a Jan. 8 story in The New York Times, the staff at Open Door Family Medical Centers in New York believes this trend is a sign of a breakdown in the nation's health care system and testimony to the strain placed on many middle-class people. The clinic's middle-class patients are not poor enough to qualify for Medicaid, and while many work, they do not have employer-based health insurance or the means to afford private health insurance.

To qualify for free care at the centers, patients can earn no more than 200 percent of the poverty level for a family of four, or roughly $40,000, the Times reports. For remaining patients, Open Door Family Medical Center has a sliding fee scale from $25 to $150 per visit.

1) Participate in new AMA-IMG Section virtual congress
Resolutions submitted by April 3 for consideration at the AMA-IMG Section annual congress will be placed on the AMA-IMG Section Web site for review and online testimony submissions. This new virtual congress format allows for increased participation of AMA-IMG Section members and allows the section's resolutions to be included in the AMA House of Delegates handbook.

The AMA-IMG Section Governing Council and resolutions committee will serve as the reference committee by reviewing all submitted testimony and finalizing resolutions by April 27. AMA-IMG Section members will vote between April 30 and May 7 to approve or not approve each resolution in its final form.

E-mail resolutions for consideration. Resolutions are due no later than April 3.

Visit the AMA-IMG Web site to view the resolution writing guidelines. Call (312) 464-5397 with questions.

1) AMA GME e-Letter: Rediscovering real patients
The electronic medical record (EMR) is a much-needed tool in modern medicine but has an unfortunate side effect—the "iPatient"—which is an abstraction of the real patient resulting from the availability and demands of the EMR.

In the January issue of the AMA GME e-Letter, the iPatient concern is featured noting that in such cases the intimate doctor-patient relationship is at risk.

Read more on this and other issues in graduate medical education in the AMA GME e-Letter.

Subscribe to this free monthly e-mail newsletter.

2) Check out AMA learning tools
The AMA provides practical, certified educational programs to help physicians apply new knowledge and strategies to improve patient outcomes.

AMAprimarycare.org delivers a variety of multimedia educational programs designed to improve physician competency and performance by providing new evidence-based strategies and by assisting physicians on approaches to modify their practice. These programs are eligible for AMA PRA Category 1 Credit™.

AMA Therapeutic Insights is a quarterly online continuing medical education activity designed to assist physicians in clinical practice by giving them unprecedented access to state and national prescribing patterns for self-assessment. Each newsletter is eligible for AMA PRA Category 1 Credit™.

Pain is one of the most common reasons patients seek medical attention and is a symptom that is encountered by every physician, crossing all medical specialties. The AMA's pain management series features online modules eligible for AMA PRA Category 1 Credit™.

Accreditation statement
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Designation statement
The American Medical Association designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

3) AMA Health Care Trends report available online and on CD
Changes in medicine influence the delivery of patient care. Keep current on the latest developments in delivery of care with 2008 Health Care Trends, a newly updated publication from the AMA that details the issues and trends shaping medicine today and how they affect physicians and their patients. The report includes information on health status and demographics of the U.S. population, factors affecting health care spending, and changes in the physician work force. It also covers patient expectations and perceptions, the public health system, trends in technology, and changes in medical education and physician continuing professional development.

Visit the Web site for more information or to download this resource. Health Care Trends is updated every two years by the AMA Council on Long Range Planning and Development.

E-mail Don Zeigler, the AMA's director of long range health care trends, for more information.

E-mail Carrie Domangue for a free copy of the 2008 Health Care Trends CD.

Brought to you by the AMA Minority Affairs Consortium

1) Order your national "Wear red day" toolkit
Help raise awareness of women's health and heart disease Feb. 6 on National Wear Red Day. This lifesaving awareness movement encourages everyone to participate by wearing a favorite red dress, shirt or tie and the red dress pin—introduced by the campaign in 2002 as its national symbol.

As part of "The heart truth" campaign aimed at recognizing heart disease in women, National Wear Red Day offers a toolkit with useful information and resources to help celebrate the day in your office or community. The National Wear Red toolkit materials can be used in a wide variety of settings, whether you work in a health care facility, business, non-profit organization, government agency or community group.

2) Study: Access to healthy foods vary by neighborhood
Neighborhood differences in access to food may have an important influence on relationships and health disparities in the Unites States, according to a study in the January 2009 issue of the American Journal of Preventive Medicine.

The study showed that poor dietary patterns and obesity, which are established risk factors for chronic disease, have been linked to neighborhood deprivation, minority composition and low area population density. Additional research is needed to identify policy actions and design intervention strategies to help promote equitable access to healthy foods.

1) View AMA-OMSS Interim Assembly Meeting materials
The AMA-OMSS is pleased with the positive and supportive outcomes of its assembly resolutions and other items of business discussed during the 2008 Interim Meeting of the AMA House of Delegates (HOD). The AMA-OMSS submitted a resolution on behaviors that undermine safety, which was adopted by the AMA-HOD as policy.

Visit the AMA-OMSS Web site to view the full 2008 AMA-OMSS Interim Assembly Meeting summary and PowerPoint presentation, as well as its disposition of actions.

2) Download free copy of AMA-OMSS presentation for medical staffs, hospital boards
The AMA-OMSS developed two PowerPoint presentations—one for medical staffs and another for hospital boards—to provide information on the section and its mission, duties and past actions.

AMA members can visit Web site to download these presentations free of charge.

3) AMA Annual Meeting webcasts added to archives
The AMA-OMSS is offering four 90-minute educational webcasts, including "Transitioning to an improved hospital discharge," "Keys to the successful implementation of the revised Joint Commission Medical Staff Bylaws Standard MS.1.20," "Creating a new future for a new day with a revamped organized medical staff structure" and "Physician hospitals of America: Reclaiming quality patient care through physician leadership."

Three of the webcasts provide AMA PRA Category 1 Credit™. Access these webcasts and learn more about each one.

Accreditation statement
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Designation statement
The American Medical Association designates this educational activity for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

4) Align your bylaws with Joint Commission standards
Because medical staff bylaws are considered a contract and are legally binding in most states, it is extremely important that they are well-designed and well-written. The fourth edition of the "Physician's guide to medical staff organization bylaws" contains practical guidance on bylaws development, model bylaw language, information on emerging issues and recent trends in medical staff re-engineering. The guide will be especially helpful to medical staffs as they update their bylaws to align with Joint Commission standards.

AMA members can visit download the guide (PDF) at no charge.

5) Resource helps strengthen physician-hospital relationship
A printable version of the "Principles for strengthening the physician-hospital relationship," developed by the AMA-OMSS and adopted by the AMA House of Delegates, is available online (PDF). These principles are designed to improve the working relationship between physicians and hospitals and ultimately foster better patient care and improve patient safety.

Send an e-mail to order a poster of the principles for your medical staff lounge.

1) Apply for resident spot on AMA-GLBT Advisory Committee
An AMA-RFS position on the AMA Advisory Committee on Gay, Lesbian, Bisexual and Transgender (GLBT) Issues will be available this spring. The AMA-RFS has slotted seats on three AMA special group governing councils: the AMA-GLBT Advisory Committee, the AMA Minority Affairs Consortium and the AMA Women Physicians Congress.

If interested, complete the application materials and forward them to the AMA-RFS Governing Council no later than Feb. 6.

Visit the Web site to apply for the AMA-GLBT Advisory Committee position or to learn more.

Send an e-mail with questions about the AMA-GLBT Advisory Committee.

Send an e-mail with your application materials.

2) Become a leader on the AMA Council of Ethical and Judicial Affairs
The AMA-RFS is seeking applicants for a resident position on the AMA Council of Ethical and Judicial Affairs (CEJA). CEJA has original jurisdiction in all questions involving the principles of medical ethics of the AMA, as well as the constitution, bylaws and rules of the association.

The council investigates unethical behavior, conflicts or complaints from the AMA and specialty and state societies. The term of the resident position, appointed by the AMA president, is three years with a two-term maximum.

Visit the AMA-RFS Web site for more information and to apply. Applications are due Feb. 6.

3) Apply for legislative awareness internship in Washington, D.C.
The AMA-RFS, in conjunction with the AMA's Washington, D.C., office, is sponsoring a two-week legislative internship program in the spring. The program provides residents and fellows an opportunity to participate in the political process of organized medicine at the national level.

Visit the AMA-RFS Web site for more information and to apply. Applications are due Feb. 27.

4) AMA GME e-Letter: Rediscovering real patients
The electronic medical record (EMR) is a much-needed tool in modern medicine but has an unfortunate side effect—the "iPatient"—according to the January issue of the AMA GME e-Letter. The iPatient is an abstraction of the real patient resulting from the availability and demands of the EMR.

In this issue, Paul Rockey, MD, notes that over the past few decades, teaching physicians have seen the emergence of iPatients and house staff's increasing dedication to their care and upkeep at the expense of knowing and nurturing their real patients. "Much is lost in this ubiquitous practice," said Dr. Rockey. "Bedside skills are not taught or learned. Emotions are not felt. Clinical findings are missed. And ultimately, the intimate doctor-patient relationship is threatened."

Other articles highlighted in this issue, include:

• "Reader feedback: IOM duty hours report well-intentioned but flawed"
• "Plans underway to examine, improve the Match 'scramble'"
• "ACGME creates new office to assist residents"
• "IOM makes recommendations for improving health care work force"

1) Sign up for daily AMA Morning Rounds
AMA Morning Rounds, an e-mail news service produced exclusively for AMA members, is a tightly written weekday briefing of news and studies that affect members of the medical profession and their patients. Each daily briefing's content is distilled from more than 3,000 major newspapers, magazines, Web sites and broadcast media sources around the country.

Sign up for AMA Morning Rounds. You may receive periodic e-mails about AMA initiatives and members-only surveys, but your e-mail address will not be used for commercial use.

2) In AMNews: 150 Years of Gray's
Gray's Anatomy is no longer a medical textbook for beginners. The clinical reference book has evolved from a textbook to a clinical reference book for physicians, according to a Jan. 12 American Medical News (AMNews) article.

The famous book celebrated its 150th anniversary with the September 2008 release of its 40th edition. Henry Gray, MD, who wrote the text, was only 30 years old when the book was first published. The original intent of the book was to be a textbook for students in England. The book now has many offshoot publications, including the television series Grey's Anatomy.

Brought to you by the AMA Women Physicians Congress

1) Get a copy of the national birth defects prevention packet
The National Birth Defects Prevention Network's Education and Outreach Committee compiled an educational packet focusing on obesity prevention and weight management for use before, during and after pregnancy.

The materials come from a variety of sources and provide information on obesity and how excessive weight gain can affect pregnant women and their fetuses. They also identify opportunities for prevention. Included in the materials are pamphlets, posters, fact sheets, sample proclamations, news releases, letters and lists of resources.

Many of the materials are available in both English and Spanish. Visit the Web site to receive a copy of the packet.

2) Order the new health care careers directory from the AMA Bookstore
An updated Health Care Careers Directory for 2009–2010 will soon be available online through the AMA Bookstore. Order this newly expanded edition, which includes 8,000 educational programs in more than 80 different health care fields.

New professions listed for this year include acupuncture/oriental medicine, anesthesia technologist/technician, cancer registrar, health advocate, health educator, horticultural therapist, medical coder, medical transcriptionist and naturopathic medicine.

The book includes occupational descriptions, employment characteristics and information on educational programs, such as length, curriculum and prerequisites.

Call (800) 621-8335 to order a copy.

View the AMA's chart of health care career income ranges.

1) Sign up for AMA-YPS policymaking committee
As a follow up to the town hall discussion at the 2008 AMA-YPS Interim Assembly Meeting, the AMA-YPS Governing Council would like to invite you to participate in one of three short-term policymaking committees.

The purpose of these committees is to study priority issues of the AMA-YPS with the goal of developing resolutions on one or more of the following topics:

• Scope-of-practice issues
• Medical student loan debt
• Competition between nonprofit and for-profit hospitals.

Committees for each of these topics will operate between mid-February and the end of April. The AMA-YPS anticipates two to three conference calls for each committee as well as electronic communications between calls.

E-mail Jane Ascroft by Jan. 30 with questions or to sign up for a committee.

2) Deadline extended to Jan. 30 for AMA-YPS Young at Heart Award nominations
Nominations for the 2009 AMA-YPS Young at Heart Award will be accepted through Jan. 30. If you are an AMA-YPS Assembly member, submit your nomination via e-mail, mail or fax by this date.

Nominees should be AMA members who are not eligible for AMA-YPS membership and whose support and guidance have strengthened the AMA-YPS through organizational aid, support of AMA-YPS issues in reference committees and causes (and on the floor of the AMA House of Delegates), or support of AMA-YPS leadership development.

Nominators must be members of the AMA-YPS Assembly.

E-mail your nomination; mail it to 515 N. State St., Chicago, IL, 60654; or fax it to (312) 464-5845.

Visit the Web site for more information or to submit a nomination.

3) Applications for the AMA-GLBT Advisory Committee and AMA-MAC Governing Council due Feb. 6
AMA-YPS positions on both the AMA Minority Affairs Consortium (MAC) Governing Council and the AMA Advisory Committee on Gay, Lesbian, Bisexual and Transgender (GLBT) Issues will be available this spring. The AMA-YPS has slotted seats on three AMA special group governing councils: the AMA-GLBT Advisory Committee, the AMA-MAC and the AMA Women Physicians Congress.

Complete the respective application materials and forward them to the AMA-YPS Governing Council no later than Feb. 6 to be considered for one of these positions.

Visit the AMA-GLBT Web site to apply for the AMA-GLBT Governing Council position.

Visit the AMA-MAC Web site to apply for the AMA-MAC Governing Council position.

Send an e-mail with your application materials as well as any related questions.

4) Apply by Feb. 15 for Joan F. Giambalvo Memorial Scholarship
Researchers interested in exploring issues concerning women physicians are encouraged to apply for a 2009 Joan F. Giambalvo Memorial Scholarship by Feb. 15. Established by the AMA Foundation in conjunction with the AMA Women Physicians Congress, the scholarship provides funding to help researchers advance the progress of women in the medical profession and identify and address the needs of women physicians and medical students.

Visit the AMA-MAC Web site to learn more and apply for up to $10,000 in funding.

5) In AMA GME e-Letter: Rediscovering real patients
The electronic medical record (EMR) is a much-needed tool in modern medicine but has an unfortunate side effect—the "iPatient"—according to the January issue of the AMA GME e-Letter. The iPatient is an abstraction of the real patient resulting from the availability and demands of the EMR.

In this issue, Paul Rockey, MD, notes that over the last few decades, teaching physicians have seen the emergence of iPatients and house staff's increasing dedication to their care and upkeep at the expense of knowing and nurturing their real patients. "Much is lost in this ubiquitous practice," said Dr. Rockey. "Bedside skills are not taught or learned. Emotions are not felt. Clinical findings are missed. And ultimately, the intimate doctor-patient relationship is threatened."

Other articles highlighted in this issue, include:

• "Reader feedback: IOM duty hours report well-intentioned but flawed"
• "Plans underway to examine, improve the Match 'scramble'"
• "ACGME creates new office to assist residents"
• "IOM makes recommendations for improving health care work force"