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Emergency Physicians Emerge as Healthcare’s Management Specialists

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History’s great achievers—Napoleon, da Vinci, Mozart—have always managed themselves. That, in large measure, is what made them great, according to Peter F. Drucker, father of modern management theory. This principle is especially relevant to emergency medicine today. The founders of our specialty and the wave of emergency physicians that followed them have carved us a unique position in the house of medicine. We have reached a stage where managing our specialty and its next steps carefully are critical to great achievement.

It is hard to imagine that less than 35 years ago we did not have primary board status with the American Board of Medical Specialties. At that time, other specialties questioned whether emergency physicians offered truly unique skills. They suggested that our skill set was merely a partial collection of those of several different specialties. However, the skills to intubate a patient in respiratory failure, resuscitate a neonate, diagnose and treat a heart attack, and deliver a baby do not by themselves an emergency physician make. It is the ability to lead a team successfully through simultaneous medical, surgical, psychiatric, and social emergencies while managing the clinical and administrative activities of the ED as a whole. In other words, leadership and management define the core of the specialty of emergency medicine.

We are clinicians. What separates us from other specialties is that we are also managers. We need not redefine ourselves. We need only to embrace that which we already are. We have embraced our clinical prowess – gaining primary board status, growing in numbers, establishing strong research credentials, and becoming a popular specialty. Let us also embrace the core that ties our clinical work together. Let us embrace management – its theory, practice, and application to emergency medicine. Doing so will unleash the full potential of our
specialty.

In what seems to be an uncanny coincidence, not only are emergency physicians natural leaders and managers, but we are also afforded a view of health care that equips us to wield our core expertise beyond the emergency department. Each day at work, we take 10 hour-long swigs from the fire hydrant of the U.S. health and social system, MacGyver-ing our way through a shift to fashion the best possible result for each patient. Is there anything in patient care we don’t see? Is there any perspective we don’t understand? This torrent of information that we receive from our patients about their health, illnesses, and troubles with the health system is invaluable knowledge that needs to be put to use. We must develop a system to harness this knowledge.

Namely, we must formally recognize and develop leadership and management as the core of our specialty. Currently, emergency medicine residents undergo pseudo-management training by virtue of working in the ED – on-the-job management training. Thus, most emergency physicians today are at least adequate managers. But as a specialty, we must raise the bar from adequacy to specialization by focusing the provision of emergent care through the lens of formal training.

Management is a widely researched topic that is studied and applied in every sector. This repository of theoretical and practical knowledge belongs in every emergency medicine curriculum. Every emergency medicine resident today is training to become a clinician and a manager. In most cases, the former is acknowledged and developed while the latter is largely ignored, despite a wealth of available resources.

Secondly, a wider range of educational options should be made available to enable emergency physicians to develop innovative health care solutions. Some programs already offer combined EM-Master’s degree opportunities. These opportunities must be promoted heavily. We should develop more EM-MBA programs to promote leadership in the corporate sector and EM-MPA/MPP programs (Masters in Public Administration/Masters in Public Policy) to promote political leadership. As management takes root and unleashes our specialty, the demand for such programs will increase. We should develop professional relationships and management experiences with local business schools and industries that demand the highest standards of management to ensure success.

Emergency medicine must follow its natural tendencies and reach out beyond the health sector to glean the best from the best and bring it home to the bedside.

Today, the political and corporate worlds are converging at the health sector. This movement was reflected in the 2010 Adelaide Statement on Health in All Policies, a World Health Organization (WHO) publication.

To advance Health in All Policies the health sector must learn to work in partnership with other sectors. Jointly exploring policy innovation, novel mechanisms and instruments, as well as better regulatory frameworks will be imperative. This requires a health sector that is outward oriented, open to others, and equipped with the necessary knowledge, skills and mandate. This also means improving coordination and supporting champions within the health sector itself.3

Taken together, the steps of formally developing leadership and management as the core of our specialty and promoting new educational options encouraging emergency medicine leadership will uniquely qualify us to be the champions that WHO describes. It will undoubtedly fortify the position of emergency medicine as a powerhouse, cutting edge specialty and attract highly motivated, superior talent to our ranks. These steps are not only important, they are also necessary to accelerate the momentum our specialty has developed over the past several decades. Fully matured, emergency medicine will be a specialty representing highly trained, trans-sectoral, transformative clinician-leaders who provide superior clinical care in the emergency department and are dedicated to a healthy society through the advancement of health care on all fronts. By working toward this goal, the modern emergency physician stays true to the spirit of service in which emergency medicine was founded and guides the trajectory of our specialty toward health sector leadership.

References
1. “Managing Oneself.” Drucker, Peter F. Harvard Business Review. v. 83, no. 1 (Jan. 2005), pp. 100-109
2. “Anyone, Anything, Anytime: A History of Emergency Medicine.” Zink, Brian J. 2006
3. Adelaide Statement on Health in All Policies. World Health Organization, 2010. http://www.who.int/social_determinants/hiap_statement_who_sa_final.pdf

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What Emergency Medicine Can Learn from the Teamsters

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If emergency physicians are going to have a chance at influencing healthcare policy in Washington, they’re going to need to get serious about organizing and fundraising.

The power of unions is legendary. The Teamsters, formed in 1903, now boast more than 1.3 million members and are the 11th largest campaign contributor in the United States. Fortune magazine consistently ranks the National Education Association in the top 15 of its Washington Power 25 list for influence in the nation’s capital. In the words of Terry Moe, author of Special Interest: Teachers Unions and America’s Public Schools, “the power of the unions to block change is the single most important thing that anyone needs to know about the politics of American education.”

How did a group of teachers and teamsters become so powerful? It started when a critical number decided to collectively contribute significant funds to political campaigns. If 330,000 union members in Sacramento, for example, agree to contribute $1000 per year to political campaigning, that’s $330 million a year that can be spent influencing and/or controlling California’s legislative process. With this kind of influence, nearly every piece of legislature would need union approval before it has a chance of surviving a vote. Extend this across the country and the same logic­—and influence—holds true.

Now I am not suggesting that it is good for the political process to bend to the will of a single group purely because they’ve got the most money. As a matter of fact, I find it unethical and ultimately destructive of our system of government. However, it is a stark reminder of emergency medicine’s need to engage actively in the political process. It is absolutely critical – even to our survival – that physicians take an active role in health reform at a legislative level.

In the 70s, a few of us tramped around the halls of Sacramento trying to influence legislation. Although we thought we were wearing the white hat and our cause was critical and everyone should do what we ask, we did not find ourselves to be very influential. And then along came Jim Randlett who became the Cal/ACEP legislative advocate for many years. Early in my Cal/ACEP government affairs activity, it became apparent that we needed a Political Action Committee, and EMPAC was born. About that time, upon the request of then ACEP President, John McDade, I accepted leadership of the Government Affairs Committee for ACEP and marched on Washington with our first part-time lobbyist, Terry Schmidt. In an effort to influence policy on a national level, the National Emergency Medicine Political Action Committee (NEMPAC) was born. ACEP opened and grew a substantial Washington office, all in recognition of the fact that if you want to make something happen – or prevent something from happening – you need to be influential where decisions are being made and where the money is doled out.

Emergency medicine now enjoys wide respect and influence at state levels throughout the land, and at the Federal level with very well placed and effective legislative advocates working full time on our behalf. But what we are doing is not enough when the “pie” is limited and powerful players are doing the slicing. Imagine if half of the physicians in the USA each contributed $1000 each year to political campaigning. We would match at least one union in California. Trial attorneys in California are trying to kill MICRA. Without some $2000/year that they each contribute to campaigning, they would not have a chance. Our AMA and state and county medical associations have worked hard to look out for physicians in America, but with physicians giving around $60 per year to the political process, their position is severely compromised.

We in medicine are looking at increased competition for declining dollars in the face of soaring demand for services. California is cutting MediCal payments to physicians by 10% and may even take some back that they have paid in the past. Medicare is scheduled for cuts and the legendary fight over the SGR continues. Do you think that this would be happening if physicians were spending $2000/year on the political process?

Why are physicians flocking to hospital employment? It’s not because fee for service is working well for most physicians. It is more likely because hospitals are community resources employing a lot of people who vote, supported by politicians who want their voters to have a hospital in their community.  Physicians, by drinking plenty of the water but not adequately helping to carry it, have not counted – and I submit will not be counted – for much unless they start participating in the process.

Participation in the process means joining and supporting your specialty society and, as I’ve extolled before, joining the AMA. Most physicians may not have the time nor interest in being a councillor or committee member or delegate to the AMA. That is perfectly fine. What physicians need to do is pay dues and belong to their speciality organizations and the big house of medicine represented by the American Medical Association. It might seem basic, but these organizations grow in influence and effectiveness with sheer member numbers. The next essential step is generous participation in our Political Action Committees, EMPAC in California, NEMPAC nationally and AMPAC as well. The cost might seem painful at first, but it’s a minor discomfort relative to the pain of declining reimbursement that is on the way and sure to get worse if we don’t step up to the plate.

Emergency medicine organizations have done an outstanding job of educating EPs and they advanced the specialty from unrecognized to being a highly respected, appreciated, and critical specialty logistically and academically. But there is still much work to be done. If just 900 emergency physicians were to give $1000 each, ACEP’s PAC would eclipse both the orthopedists (who have an average annual contribution of $106 per 18,318 members) and the AMA (who average $12 per 157,000 members). ACEP currently averages $47 per eligible member (22,000). The added influx could not only make ACEP the largest PAC in the beltway, but more importantly, allow it to be a whole lot more effective in promoting, preserving and protecting our specialty.

Finally, the number of delegates and alternates that ACEP is entitled to at the AMA House of Delegates is determined by how many ACEP members there are who are also AMA members and have designated ACEP as the organization to represent them. AAEM is represented at the AMA EM Section Council, usually in the person of Joe Wood.  Based on our 3007 AMA members at the last count, ACEP has five delegates and five alternates, up from the single one when I started in the 80s. We would like to raise that number to over 4000 members and gain another delegate as we work to potentially elect the first emergency physician as the 170th President of the AMA in June 2015 in the person of Steve Stack.

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Expanding Medicaid Will Hurt Emergency Departments

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“[P]eople are no longer going to the emergency room and they now have good health care, they’re now getting preventive care.”President Barack Obama, September 24, 2013

Read the counterpoint by Seth Trueger here

The optimism of those emergency physicians who have supported the expansion of Medicaid through the Affordable Care Act is built on the assumption that ‘some pay’ is better than ‘no pay’. And, of course, if it were that simple, they would be correct. But I would humbly submit that we need to take the problem apart a little more to see the details before drawing such conclusions.

When the ACA was proposed in Congress, the promise was that having insurance of any kind, either mandated private insurance or government provided Medicaid, would allow more patients to go to their family doctor and ignore the ED. And to the extent that some patients who have availed themselves of that service, hospitalizations and unneeded ED visits have been avoided. But the legislators failed to recognize the primary reason anyone, insured or otherwise, goes to the ED – to get care in a time frame acceptable to them. And with fewer primary care providers accepting Medicaid, office visits are simply not available in the time frame sick or injured people generally have. We are the medical home for everyone after office hours and for everyone when the office schedule is full. So if you can get into a primary care office with your Medicaid card then you are likely to stay out of the ED. But if you don’t choose to wait for an office appointment or can’t get one, then you will still go to the ED. And that’s what happened in Oregon where newly insured patients (through an expanded Medicaid program) visited the ED 40% more than their uninsured comparison group.

This study was particularly important because when Massachusetts instituted mandatory private insurance they also experienced a spike in ED visits. But the spike was actually lower than the increase seen in surrounding states without mandatory private insurance, which was presumably due to the natural expansion of ED demand for timely medical care. And this is where, I believe, supporters of the ACA have seen the same facts, but drawn the wrong conclusions.

The first assumption is that uninsured patients don’t pay anything (i.e. ‘no pay’). As Dr. Trueger correctly notes, the uninsured category is not a homogeneous group. There is a subset of uninsured – particularly newly uninsured or the young uninsured – who are not ‘dead beats’, who will pay a portion of their bills given time. So the basic ‘no pay’ assumption is incorrect. In fact, as Renee Hsia, MD, noted in her landmark study published in the Annals in 2007, uninsured patients actually paid a larger percentage of their ED bills than was paid by Medicaid. Although Dr. Hsia’s study did not address subspecialty availability, I suspect that it would have had similar results. Patients who were required to have money to see a specialist, and who really needed it, begged, borrowed, or saved the money to get the care they desired. Dr. Hsia’s study alone debunks the basic assumption that a simple expansion of Medicaid will improve EM reimbursement. But I believe that there is even more to the story.

We all know the chronically uninsured patient. He comes to the ED knowing, even telling you, that he came because he had no money for a private doctor. He’s also not on Medicaid, even though he might qualify. Why should he? He won’t pay either way. Why should he waste his time. He will ignore the bills if they can find him. Expansion of Medicaid will have no impact on him. Even getting temporary coverage in the ED, as some departments provide, has to have follow up by the patient. And this has very low compliance without a substantial costly bureaucracy chasing the patient down.

The other subset are the recently uninsured or working poor or young patients who didn’t think it necessary to have insurance. This is the group who used to pay part of their bills over time, but now will have Medicaid. And this, I believe, is the group that has chosen to come to the ED with more frequency now that they are “insured”. The impact on their bottom line is better, no doubt. But if the Hsia’s study is still true in 2014, it will not be better for those who treat them. The combined effect is that the percentage of patients who are chronically uninsured stays roughly the same and they will continue to come to the ED with roughly the same frequency. The newly uninsured or underinsured, however, shift to paying a lower percent of their bills and show up in higher frequency. This requires increased staffing and support that is not likely to be offset with the modest increase in compensation. Even worse, since many EDs actually lose money on a per capita basis treating Medicaid patients, treating a larger number will only mean larger losses that must be covered by cost shifting to insured patients.

And that is where, I think, the Massachusetts experience might be instructive. Newly insured patients will only avail themselves of medical care in higher numbers if there is a real financial incentive, such as a low or no co-pay and/or low deductibles. Free Medicaid is just such an incentive. Your old insurance (you know, the policy you were promised you could keep) if it was provided by an employer probably had a low co-pay and low deductibles. But the new policies with expanded coverages, in order to keep premiums within reach, have huge deductibles, some upward of $10,000. The effect of that is that the previously insured patients who now have new policies will likely behave like self pay and avoid medical care, especially expensive emergency care, whenever possible.

The bottom line is that medical reimbursement is all about payor mix. Like insurance companies who are threatened with a ‘death spiral’ if their payor mix is too heavily weighted with older, sicker patients, EDs will be threatened by the new shift in payor mix. Previously uninsured patients will shift into Medicaid and use the ED more, while better insured patients will become ‘pseudo self pay’ due to high deductibles and start to decline their discretionary use of the ED. The effect will be a double whammy, more patients who pay less and fewer patients who would have paid more. And that math just doesn’t work.

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Opening Wide the Door to Non-Certified Docs is a Step in the Wrong Direction

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Last month, Rick Bukata suggested that ACEP open its gates to non-boarded EPs. 
This would be an insult to EM residencies, and would set our specialty back decades.

Last month’s editorial by Dr. Rick Bukata re-ignited the debate over the role of board certification in emergency medicine. The American Academy of Emergency Medicine’s (AAEM) position has not changed in our 21 years of existence — you must be board certified to become a full-voting member and fellow of AAEM — period. AAEM has no control over how other EM organizations classify their members. However, we feel a call for other organizations to open their membership up to non-board-certified physicians is a step in the wrong direction. Since AAEM’s inception, supporting the value of board certification has always be a core part of our mission.

The first emergency medicine (EM) residency began 44 years ago. It has now been 38 years since the American Board of Emergency Medicine (ABEM) was incorporated. Progress in EM, as well as any other specialty, demands rising standards that evolve into formal training being the only legitimate route to certification. By the time ABEM closed the practice track in 1988, after a 10 year grace period, there were enough excellent training programs that a practice track no longer made sense for our evolving specialty. We are now at the point that the practice track was closed before many of our EM residents had even been born. We have had more than 100 EM residency programs for twenty years now. Today, there are at least 209 EM residencies (allopathic and osteopathic), graduating in excess of 2,000 residents a year. It has been 24 years since Dr. Gregory Daniel sued the American Board of Emergency Medicine (ABEM) for restraint of trade, seeking to re-open the practice track — the suit was dismissed in 2005 after 15 years of litigation. At a certain point, a specialty needs to move on — I feel we are well past this point.

Twenty-six years after the practice track has closed, it doesn’t make sense to look for ways to offer additional legitimacy to non-boarded emergency physicians. In 2014, it is not fair to patients when unsupervised physicians “learn on the job.” I’ve worked with and trained physicians from other specialties who took the difficult step of completing a second residency in emergency medicine, and ultimately becoming ABEM or AOBEM board certified. Each expressed how surprised they were about how much they didn’t know and how much of a better physician they became.

We realize it is highly inappropriate for an emergency physician to perform outside their scope of practice, such as by performing a cardiac catheterization or a hip replacement. Why should we encourage physicians trained in other specialties, who had not completed the board certification pathway while it was open, to be emergency physicians? By doing so, we would essentially say that emergency medicine residency training does not have any value, and that the more than 2,000 physicians who enter emergency medicine residency training each year are wasting their time. This undermines the entire construct of specialty-specific residency training that has clearly become the standard across all specialties. Becoming an emergency medicine specialist is a lifelong process, and emergency medicine residency training under the supervision of board certified emergency medicine faculty is the cornerstone of that process. If it is acceptable to learn unsupervised on the job, why have residencies in any medical or surgical specialty at all? AAEM’ s White Paper on The Value of Board Certification and Residency Training in Emergency Medicine concluded that “there is clear evidence in the literature that supports that board certification and residency training in EM improves the quality of care provided to patients in the nation’s EDs.” (The White Paper can be viewed at aaem.org.)

Proponents of non-board certified physicians in emergency medicine often argue that these physicians have significantly more training than a PA or NP. I certainly agree with this assessment; however, that ignores the supervision aspect (although supervision of physician extenders is subpar in many EDs and should be improved). On the other hand, it would be highly unusual for a non-boarded physician to be practicing under the supervision of another physician.

For years, I’ve repeatedly heard that we have a critical need for non-certified physicians in our EDs, as the demand far outweighs the supply of board-certified emergency physicians, and this imbalance may never be resolved during our careers. I’ve heard this argument countless times to justify the expansion of opportunities for non-board certified emergency physicians. In 2014, this simply isn’t true anymore. As of November 2012, there were 41,479 emergency physicians in the U.S. (source: Kaiser Family Foundation). Between 2000 and 2010, the number of emergency physicians increased by 44.6%, more than any other specialty (source: AAMC 2012 Physician Specialty Data Book). As of December 31, 2013, there were 31,154 emergency physicians currently board certified by ABEM (source: ABEM) and 3,280 board certified by AOBEM (source: AOBEM). In addition, if we assume it will take on average two years for a board-eligible residency graduate to become board certified, there are likely about 4,000 board-eligible EM residency-trained physicians. Looking at this data, it appears that the 38,000+ board-certified/eligible physicians now comprise more than 90% of the EM physician workforce. Far more emergency medicine residents graduate each year (over 2,000) than it takes to replace retiring emergency physicians (typically about 1.7% attrition, so around 700 physicians), and many EM residencies are created or expanded each year. Soon there will be more board certified/eligible physicians than there are emergency physician practice opportunities, particularly in urban/suburban areas.

In Dr. Bukata’s article he correctly points out that in many rural areas, it is very difficult to recruit board-certified emergency physicians. I expect that these difficulties will abate somewhat as the number of emergency physicians desiring urban/suburban jobs eventually exceeds the number of these opportunities available. In addition, efforts should be undertaken to make rural EM opportunities more attractive to new residency graduates (i.e., rural EM rotations). However, I do not think rural emergency physician shortages are a good rationale for increasing legitimacy for non-boarded emergency physicians. Note that shortages of neurosurgeons, ophthalmologists, neurologists, and others are also common in many rural areas. However, we do not see their professional organizations responding to these shortages by opening up membership to non-BC/BE physicians. The shortages in many areas for many specialties are significantly more acute than in EM — however we do not see emergency physicians being recruited to practice as neurosurgeons in these areas. In many rural areas, the primary care shortage is more acute than that of emergency medicine, yet we have a paradox where many of the primary care trained physicians instead practice in the ED.

I recognize that non-BC/BE physicians have the right to practice in any emergency department, assuming the hospital is willing to grant clinical privileges. However, 26 years after the practice track has closed, at a time when we have virtually enough BC/BE emergency physicians to staff all of our EDs, we should not be encouraging anything less than the gold standard of board certification. Opening up membership to non-BC/BE physicians sends the wrong message and is a step in the wrong direction.

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Sepsis: A Mandate In Search of a Meaning

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NQF and CMS are attempting to regulate treatment for a disease we can’t really define, which could force emergency physicians to adhere to non-evidenced based guidelines

The National Quality Forum (NQF) recently adopted a metric for adherence to sepsis protocols which included recommendations for initial screening and resuscitation, hemodynamic support, and other supportive therapy for sepsis patients. Subsequently, the Centers for Medicare and Medicaid Services (CMS) adopted this NQF metric for public reporting and payment programs [1]. CMS monitoring of adherence to sepsis protocols was scheduled to take effect January 1, 2015, but implementation was fortunately delayed in response to concerns by ACEP that the sepsis protocol was not supported by good scientific evidence [2].

Emergency physicians should be alarmed that CMS nearly created a national treatment standard on a diagnosis as subjective as “sepsis.” Advocates for making “sepsis” a quality measure argue that following quality initiatives can improve outcome measures and that their recommendations were based on the “Surviving Sepsis Guidelines [3].” However, imposing quality initiatives on hospitals may not have the intended effect.

First, if financial penalties are imposed upon hospitals that do not meet treatment guidelines concerning any disease, there will be a temporary improvement in the metrics regardless of the scientific quality of the protocol. Why? Once a disease is being monitored, the hospitals dedicate more personnel and resources to managing the disease. We saw this initially with stroke teams in which persons with less comorbidity were placed on the neurology ward with more professionals overseeing the care of the stroke patient [4]. However, long term quality measures for diseases such as STEMI and stroke have failed to demonstrate improvements in patient outcomes [5,6]. Initially, small observational trials looking at quality metrics may seem encouraging – until larger randomized controlled trails show no benefit in patient outcome. We would likely see this same pattern if quality metrics for sepsis were implemented.

Second, following guidelines should not be confused with practicing evidence-based medicine [7]. Guidelines are often the weakest type of scientific evidence and are often created by consensus panel arguments [8]. In addition, guidelines may not be updated on a regular basis, leaving them several years behind current scientific studies.

The proposed adoption of sepsis guidelines as a measure of quality is just another example of bad judgment – especially since the recommendations behind the “Surviving Sepsis Campaign” have almost completely been dismantled. This Campaign, sponsored by Eli Lilly, promoted early goal directed therapy, central lines, steroids, tight glucose control, aggressive transfusion parameters, and Xigris (an Eli Lilly product). The benefit of each of these therapies has since been disproven [9,10,11] leaving only fluids and antibiotics as Level C recommendations (meaning there are no studies to prove or disprove their benefit). The only new recommendation is norepinephrine as the preferred ionotrope and even this recommendation is debatable. High quality randomized control trials show no difference in outcomes between norepinephrine’s and dopamine, and any potential differences may be moot in light of recent studies advocating “permissive hypotension” (eg. allowing MAP of 50 – 65 without ionotropes) as an alternative to aggressive ionotropic support [12]. The current “best evidence” we have in treating sepsis is to administer intravenous fluids and to order antibiotics as soon as we think it is “sepsis.” This is hardly a novel concept.

Therein lies the irony: Federal mandates are attempting to regulate treatment of a disease that we cannot accurately define1. Sepsis is a nebulous diagnosis based upon “suspected infection” with “acute organ dysfunction due to the infection” using an extensive list of criteria without hierarchy. There is no clear guidance on whether a patient with a white blood cell count of 15,000 and a creatinine of 1.7 or a nursing home transfer with “mental status change” and a heart rate of 110 is truly “septic.” This is exactly why we pull from a trash bucket of terms ranging from “septicemia,” “SIRS,” “sepsis syndrome,” “uro-sepsis,” and “sepsis” as well as diagnoses that sidestep the sepsis pathway.

“Septic shock” may appear to be more obvious and therefore more accurate, however we also have no clear working definition of “shock”. The academic definition appears to be a MAP < 65; but most healthcare workers still speak and work in terms of systolic limits. Furthermore, the determination whether a patient is suffering from “septic shock” is currently made after a fluid challenge, making the data difficult to collect and pragmatically disregarded. A variance in baseline blood pressures makes even the determination of “hypotension” difficult. Ultimately, we must better measure tissue hypoperfusion as the definition of “shock” rather than some arbitrary blood pressure value.

Most troubling is that these “quality” measurements are often not based on clinical data but rather on insurance codes used by hospital billing offices.

Insurance codes are unreliable because they are not based upon a strict set of data and because coding patterns change over time. How can we ethically recommend clinical treatment decisions based upon insurance claim codes?

If we were serious about gathering quality sepsis data to benefit patients we would begin with very simple and practical definitions for all health personnel to use at the bedside. For example, use only “septic shock” (documented fever with a MAP < 65) and “severe sepsis” (documented fever with lactate > 4). We would use such very limited but easy definitions to begin a foundation of data that is more consistent and accurate to compare across hospitals and regions.
But even then, I remain skeptical. The sepsis mandate – if it is ultimately adopted – will be another scientific mistake by CMS with a financial windfall for the government. Hospitals will then be forced to spend ever-increasing amounts of time, money and resources in order to report better data so they can win in the documentation-for-dollars facade we call “quality measures”.

REFERENCES
1. Rhee,C. et al. “Regulatory Mandates for Sepsis Care—Reasons for Caution.” NewEnglJ Med., May 1, 2014: 370: 1673-1676.
2. “CMS Sepsis Quality Measure Implementation Delayed” ACEP Now, Sept. 25, 2014.
3. Cooke, C. et al. “Sepsis Mandates: Improving Care While Advancing Quality improvement.’ JAMA 2014: 312 (14): 1397 – 1398.
4. Denaro C. “Evidence-based Care and Outcomes of Acute Stroke Managed in Hospital Specialty Units” MIA October 6, 2003: 179 :386.
5. Menees, DS. et al., “Door-to-Balloon Time And Mortality Among Patients Undergoing Primary PCI.”New Engl J Med Sept. 5, 2013 ; 369: 901-909.
6. Lakshminarayab K., et al. “A Cluster Randomized Trial to Improve Stroke Care in Hospitals” Neurology 74 (20): 1634-42.
7. Djulbegovic, B. “Evidence-Based Practice Is Not Synonymous With Delivery of Uniform Health Care.” JAMA Oct. 1, 2014; 312(13): 1293 – 1294.
8. Eijkenaar, F. et al. “Effects of Pay For Performance in Health Care.” Health Policy 2013 ; 110(2-3): 115-130.
9. The ARISE Investigaters. “Goal-Directed Resuscitation for Patients with Early Septic Shock.” New Engl J Med Oct. 16, 2014; 371(16): 1496-1506.
10. The ProCESS Investigators. “A Randomized Trial of Protocol-Based Care for Early Septic Shock.” New Engl J Med 2014; 370: 1583-1593.
11. Green JP, et al., “The 2012 Surviving Sepsis Campaign: Management of Severe Sepsis and Septic Shock—an update on the guidelines for initial therapy.” Curr Emerg Hosp Med Rep ,2013; 1 : 154-171.
12. Asfar, P. et al. “High Versus Low Blood Pressure Target in Patients with Septic Shock” New Engl J Med 2014 ; 370 : 1583-1593.

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The New Payment Paradigm

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10 reasons why emergency medicine shouldn’t bear the blame for healthcare’s “value” problem

Listen up: the way that insurers pay for medical care is going to radically transform in the next 5-10 years. Along with the many health policy changes that come with the Affordable Care Act of 2010, payment reform will bring new “models” that will move away from traditional fee-for-service (FFS) medicine – where the doctor and hospital gets paid for each encounter.

In its place will be new payment models, such as global payments, episode-based payments, payment bundles, and value-based modifiers. In various ways, these new systems will provide incentives to improve quality of care, and reward providers who can deliver fewer services to manage a population’s health. The theory is that if we incentivize “value,” costs will fall, care will improve, and everyone will be able to see a doctor right away when they feel sick or get injured.

The “value” discussion in this new payment paradigm immediately brings emergency medicine into the crosshairs because it is seen by many as tremendously inefficient. First, it is widely assumed that most ED care is unnecessary. Ask your mom: ED care is about poor people getting free, government subsidized care for stubbed toes, right? Second, it is also assumed that ED care is incredibly expensive compared to alternatives, as ED doctors charge much more for low-acuity visits than doctors offices. Third, EDs are seen to provide equivalent, if not inferior, services to doctors offices because they don’t provide preventive care and they don’t know the patient. Finally, EPs order far too many tests, including unnecessary CTs and blood tests, and then tell patients to follow-up with their primary care doctors in 2-3 days whether they need a follow-up visit or not.

For these reasons, emergency medicine is under the intense scrutiny of policymakers and insurers. If they wish to cut costs and add value, surely this is a good place to start.

In reality, however, it isn’t nearly this simple. Sure, there are many inefficiencies in our emergency care system. But simply cutting reimbursements for emergency care – or closing emergency departments altogether – isn’t going to take care of the problem. Here are 10 reasons why the issue is much more complicated.

1. The high costs of ED visits are primarily hospital facility fees, not payments to doctors. When you actually break down an ED bill, more than 85-90% goes to the hospital, not the doctor.  These payments are used to support the high technology services such as CT and MRI scanners, and having a full suite of specialists available 24-7. The reason why that urinary tract infection gets a higher bill than the doctor’s office for the same nitrofurantoin prescription is because of cost-shifting: you can’t charge the sick, critically injured 2AM rollover crash $1 million for what it actually costs to maintain all the technology and staffing to have 24-7 high-quality services at the ready. Pulling the low acuity cases out of the denominator may not necessarily reduce the cost of ED care, it just means that we’ll have to charge critically ill patients more.

2. Expanding the capacity of services outside of hospitals, especially urgent care centers may not reduce ED visits. While there is some evidence that changing the way that improving access to primary care through patient-centered medical homes reduces outpatient ED visits, there is reason to believe that expanding access may actually increase overall visits. The reason is this: In many communities there is more demand than the current system can meet. Therefore, opening urgent care centers, expanding clinic hours, and providing telemedicine services will drive up service delivery use overall. The economic theory here is called supply-induced demand. While some people may choose lower cost venues like urgent care centers over EDs, this demand-substitution effect may be vastly smaller than the demand-supply problem in the old, inaccessible system that drove people into EDs.

3. Emergency departments, for the most part, don’t control their own demand. Several years ago, when Washington State Medicaid threatened not to pay for ED visits, the verdict of local policymakers was that ED visits for Medicaid patients were high because EPs were not good “stewards of resources.” Obviously, whoever said this had never spent a Friday night shift in their local ED. As we know, many ED visits are really a function of social determinants, like poverty, violence, substance use and the lack of lack of access to timely alternatives. These are broader societal problems. It’s a bit like threatening to close fire stations because fighting fires is so expensive. Effort would be better spent simply preventing the fires from happening.

4. Sharp-ended programs intended to change how emergency care is practiced could harm patient safety. The way we practice U.S. ED care today is pretty darn conservative in most places. People get admitted to the hospital or put in chest pain observation units when their risk of acute coronary syndrome is 2%. People without peritoneal signs get CT scans of their abdomens to look for serious intra-abdominal emergencies. While there are a lot of inefficiencies in these practices, the result is that patients with occult, serious disease rarely get sent home. Our system is designed to be sensitive, but not specific. This happens for many reasons, including defensive medicine, how U.S. doctors are trained, and societal expectations of EDs. Hell rains down upon EPs who miss subtle presentations of serious illness. The ACA doesn’t change this. Payment reform tells us to spend less through lowering admissions and avoiding expensive tests such as CT scans. However, if payment incentives are so strong that they interfere with diagnosing subtle cases, there could be a new epidemic of missed diagnoses creating a massive patient safety nightmare.

5. There are many ways that EDs can actually reduce costs of care without sacrificing safety. Validated clinical decision rules provide evidence-based guides to safely avoid work-ups for head injury, neck injury, pulmonary embolism, and tell us which patients with pneumonia can safely be discharged. EDs have also been able to impact re-visit rates for “frequent” users through implementing multi-disciplinary care plans. Clinical pathways are also effective in reducing variation, and promoting the use of cheaper alternatives such as ED observation units.

6. Care coordination takes time and effort, and EDs need the right incentives, extra resources, and functioning systems to do it effectively. Trying to figure out an outpatient plan for a moderate risk or complex patient is sometimes more work than admitting the patient to the hospital – where we know the patient will get the care they need. Think behavioral economics: to get an already super-busy group of people in an overcrowded system to do extra work, a few things need to happen. 1) There needs to be the right incentives to coordinate care: a real economic (or other) reason to spend the extra time and effort. 2) Care coordination needs to be made easier through increased resources in the ED like social workers and case managers. 3) There needs to be a serious system upgrade to facilitate care coordination, specifically when it comes to inter-operable health information across health systems.

7. Quality metrics for emergency care are, well, not so good. The last decade in the ED community focused heavily on ED crowding (myself included), which resulted in some of the only broad measures of ED quality being related to ED throughput and boarding.  While there are some measures for specific conditions such as pneumonia, acute myocardial infarction, and stroke, the science of knowing whether the average patient got the right ED care is really in its infancy. This presents a real problem when we want to place a “value-modifier” on ED visits. Given that value-based payment is coming whether we like it or not, the ED community needs to quickly figure out what and how to measure quality. The alternative? Rely on patient experience surveys, which are long (more than 50 questions) and have low response rates. These generate  a systematically incomplete picture of the care for the average ED patient.

8. Health reform efforts so far have increased visits to the ED through Medicaid expansion. The ACA has pushed America’s uninsured into health insurance programs, either through the Medicaid program, by increasing employer-based insurance programs, creating health insurance exchanges, and requiring people to pay a penalty if they don’t have insurance. Plain and simple: the more people have insurance, the more people use healthcare services. We are already seeing this with more and more people coming into the ED for care. Insurance gives you the ability to access services with lower out of pocket costs, but does not require that a doctor see you (thus people come to the ED more). Whether the long-term effects of payment reform will reduce ED visits still remains to be seen, insurance reform is causing a positive upward trend in visits and one that will probably be sustained.

9. ED physicians need a seat at the table for discussion about how to fix healthcare. If you ask many primary care physicians and health reformers what to do about the “ED” problem, they answer that their patients should not go to EDs unnecessarily, that they will create alternatives, and in the end, we won’t need EDs anymore. The reality is that while primary care interventions may reduce some ED visits, people will continue to flood into EDs, particularly when they are sick or injured and need to get admitted to the hospital. Because EDs are the key pivot point for hospital admission decisions and high-cost radiography, and there are a lot of interventions that can improve the value of ED care, not engaging the ED is clearly a huge tactical mistake for people who want to improve healthcare value.

10. EDs are a vital component of the healthcare safety net. One of the key functions of ED care is to be the safety net for the poor and disenfranchised. EDs perform many social service functions for the community like caring for the homeless, serving as sobering centers for the intoxicated, and seeing patients who other doctors can’t or won’t treat. This function is written into federal law through EMTALA. If payment reform efforts marginalize this system – or marginalize EDs in the system on less secure financial footing like inner-city hospitals in poor neighborhoods and rural EDs, the fabric of the safety net has a good chance of unraveling.

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FECs: New Face, Better ‘Bond’

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After transitioning from the “big box” ED to a freestanding emergency center (FEC), I was amazed by how our performance metrics, and my outlook, improved

FEC_Aut_copy_2Who’s your favorite Bond? Personally, until Daniel Craig put on the tuxedo, nobody ‘did it better’ than Sean Connery. Not even Sir Roger Moore. But during Mr. Craig’s performance in the reboot of Casino Royale, I did a double-take and palpitated. Admittedly, fickle me, I have a new favorite. Those of you who still think the original, black and white Barry Nelson, is the best – I’m going to invite you to consider something new.

Members of our specialty may be guilty of presupposing that the best place to receive quality care for true medical emergencies is within the hallowed halls of the “Big Box” hospital emergency departments. This is undoubtedly the prevailing view of emergency physicians practicing in hospital-based settings. But the ACA’s vision and support of the distributed care network (moving care out of the hospital into multiple venues that are more cost effective and convenient for patients) is challenging this conventional wisdom.

Part of that de-centralizing challenge comes in the form of freestanding emergency clinics (FECs). As an emergency physician practicing in Texas I’ve gotten to be on both sides of this fence. I’ve worked at high-volume hospital based facilities and I’m now a partner/owner in FEC’s. That gives me an obvious bias toward their existence and proliferation, but I hope the numbers can speak for themselves.

You see, while I’m not a professional researcher – and I certainly didn’t hire a team of analysts – I was able to use simple math to arrive at some startling results regarding the comparative metrics at our FECs.

I obtained data from 11 Free-Standing Emergency Centers (FEC’s) throughout the state of Texas, who cooperated in sharing metrics and laboratory “turnaround” time data for the 12 month period from May 2014 through April 2015. The results from this admittedly small data set are compelling. In these cases, acute care facilities outside of the hospital were, on average, able to deliver much faster care for “emergent” conditions than their in-hospital counterparts. This included chest pain and abdominal pain patients. Using a combination of tracking system data from the shared information technology system used at many sites, and digital records from the others, and by querying more than 25,000 unique patient visits, I found some impressive performance variation when comparing hospital-based data to the FECs.

FEC_ChartFor example, compare these sub-cycle time metrics (comparison data derived in part from CDC – National Center for Health Statistics, Ambulatory Medical Care Surveys), and additional sources referenced in the chart to the left.

Even more compelling is the comparative data on acute STEMI patients. These cases are routinely transferred to interventional-capable hospitals from a variety of acute-care facilities, including hospital outpatient departments (HOPDs), acute care hospitals, surgical centers, and even physicians’ offices for their definitive care. The FEC data shows that patients diagnosed with acute MI also receive high quality, efficient healthcare for this truly emergent condition. Though the total numbers were small, the STEMI data shows that metrics were more consistently met when the patient was initially stabilized and treated at these out-of-the-hospital venues.  Current averages on FEC “door-to-balloon” at the receiving cath lab are approximately 67 minutes overall, and as low as 38 minutes at one of the 11 facilities studied.

Admittedly, FECs do not routinely receive the kinds of high-level injury cases delivered by EMS to the trauma-level hospitals. However, my review found that the FECs recorded a few gunshot wounds, patients with traumatic brain injury, and blunt abdominal trauma with organ injury requiring critical care and stabilization. More frequently encountered were multiple-fracture cases, a significant population of walk-in assault, and a multitude of garden-variety acute trauma requiring stabilization and treatment or transfer. To date, there is not enough data to support whether these conditions might also benefit from out-of-hospital stabilization and transfer.

Certainly, we all have our own views regarding hospital efficiency. Some of us may work in departments where the metrics are better than the ones shown here. My own experience, and that of the vast majority of my colleagues, both veteran and green, is that the hospital data shown here (queried from third party references – see below) is actually rather flattering.

Some of you will insist that Mr. Nelson did Casino Royale better than anyone. I challenge you to consider my nomination for Mr. Craig – or at least someone in full-technicolor. The point is this: In our current healthcare climate where everything we do must come under scrutiny, we must challenge the dogma that dictates where we provide care. There may be alternative venues for delivering high-quality acute care, even for true emergencies. “Bonds” will come and go and so will we. However, the weapon of choice never changes – the Walther PPK has been used for over 60 years. Similarly, our shared educational and training backgrounds made us flexible multi-taskers – able to handle anything, anywhere.

The trend toward alternative venues such as FEC’s isn’t diminishing. So whether you prefer one care venue over another – you may still want yours stirred rather than shaken – let’s not be consumed by debate, but rather work together to enhance the acute care services provided in them. The fabric of the safety net has a good chance of unraveling.

REFERENCES
1. Center for Disease Control and Prevention, National Center for Health Statistics, website: http://www.cdc.gov/nchs/data_access/ftp_data.htm
2. Laboratory Turnaround Time, Richard C. Hawkins http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2282400/
3. U.S. Emergency Department Performance on Wait Time and Length of Visit, Leora I Hawkins, MD, MHS, Jeremy Green, and Elizabeth H. Bradley PhD. http://www.ncbi.nlm.nih.gov/pubmed/19796844
4. Multidisciplinary Protocol for Rapid Head Computed Tomography Turnaround Time in Acute Stroke Patients, E.M. Bershad, et al. http://www.ncbi.nlm.nih.gov/pubmed/25920753

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EPs Not To Blame for the Opiate Crisis

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Until the government stops treating emergency physicians as the scapegoat for opiate addiction, we won’t be able to address the real issues facing this challenging patient population.

The comments section of Yahoo News is a great resource to gauge the pulse of the common man. Now that Ms. Clinton has taken up the battle cry against Heroin abuse and deaths in our nation, Americans are speaking out. Physicians are being blamed for introducing pain patients to Hydrocodone and Oxycodone, after which they become addicted. When their supply is cut off by their provider, they turn to the streets. Soon they find the only drug that satisfies, and often that is heroin.

The common man has blamed physicians for the making of this crisis. The FSMB, the Medical Boards, and DEA have reacted by hog tying prescription writing of opiates. This particularly impacts the practice of emergency medicine. The Virginia Supreme Court has allowed patients to sue their physicians for malpractice for addicting them to opiates. I submit that those patients were addicts before they discovered opiates. Opiates are just a medication of convenience, and when their source dries up heroin becomes an alternative.

Our Governing bodies have made us the cause rather than the cure. This should be very alarming. We cannot screen for the propensity for addiction, and even addicts need to have acute and chronic pain managed. I would argue that a loosening of narcotic regulations rather than a tightening of them is required to reduce heroin-related injuries. The Government also needs to look at its own organizations and contractors. Why did the heroin in the US before the invasion of Afghanistan represent only five percent of the total from that country, and after it jumped to eighty percent?

We also need to be concerned about the cost of Naloxone. When pre-prepared autoinjectors of Naloxone are $360 for two, we need to question whether it is priced meaningfully for use by addicts and their kin. We cannot provide a safety net when the net is priced beyond the reach of the target consumer.

As emergency physicians we are the experts in acute pain management. It is time we address the issue to our respective governing bodies, and help them to understand that we did not create the heroin crisis. Neither did we cause the pain that led to opiate abuse. We are here to treat it, to help, and in the end to cure not only the injury and ills of our patients, but the society as a whole.

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When it Comes to Accreditation, We Need to Get Beyond ‘Publish or Perish’

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Core faculty publication requirements have turned some residencies into paper factories. Let’s take a hard look at why we do research, and what truly makes a better resident.

I recently read an article in TIME magazine about the inappropriateness of many scientific medical publications. The article discussed how money is made and careers are enhanced by numbers and locations of articles. There were references to buying authorships on Chinese papers and various other transgressions that made our profession look dirty. This got me thinking about core faculty publication requirements that exist within emergency medicine. Are they really appropriate?

I am core faculty at an osteopathic emergency medicine residency that is applying for ACGME accreditation. One requirement is that core faculty have PubMed identified publications. Now this is a worthy requirement for the nearby University of Michigan with its enormous staff, research assistants, volunteers, students, and bureaucracy. They do great work and I am grateful to have such a fine institution and quaternary hospital backing the rest of us up. But we are a small downtown hospital serving a largely uninsured patient population that cannot afford large monetary outlays for research. We have a strong clinical program and produce good emergency physicians who have successful careers. Asking for double-blind placebo-controlled research is unrealistic and unaffordable. The real quest for small programs like ours is to put something – anything! – in print. With hundreds of thousands of articles published in thousands of journals (yes there really are thousands of scientific journals) do we really need to produce more papers? Of course I can produce a paper and have it published for a fee of just $1,300 or so. But perhaps that is exactly what the TIME article was talking about.

I understand that to become a specialty Ron Krome et al had to bring some body of knowledge to the house of medicine that was emergency medicine’s own. Research was very important in the early years to even have emergency medicine become recognized as a specialty. But, what is the reason everyone must do it now? Its original purpose was not to preclude programs from existing, but it seems to have become exclusionary over time.

Very few graduates will practice in academic centers, so it is hard to contend that they need to be researching or see research being done in order to practice emergency medicine. Surely, the reason to do research now is the same as the reason one might give national level lectures or write chapters in books – to develop and bring expertise into the emergency medicine so that it may evolve and improve. But I am certain that research is not the only way to meet this need. Actually, it is probably not a particularly good way to do it.

Don’t misunderstand me. Research is very important to medicine and to emergency medicine in particular. It cannot and should not be removed from our oeuvre. What I am asking is why does everyone have to do it? Why is it an accreditation requirement? Where is the benefit for our residencies? Where is the evidence that it helps residents be better emergency physicians? Would not the goal of enhancing a residency be as well served (or better served) by lecturing to a national audience or developing an ACEP clinical policy? The participant becomes an expert in the area of concern and brings this expertise to the residency. I’m sure you can imagine many other laudable scholarly activities that would achieve the same goal.

The recent lay press has included articles on bad medical publications and the inappropriateness of ‘publish or perish’. We intrinsically know this is true, but no one seems to want to say it. Our residents need knowledgeable faculty, not people who just make papers. We need to stop this trend toward over-prioritizing faculty publications and seek a better balance. Let us ask that publications be one of many ways that the core faculty can satisfy the scholarly activity requirement for accreditation.

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Women, Take the Stage!

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Increasing the number of women speaking at educational conferences is low lying fruit for addressing some of the gender gap in emergency medicine. Here are some concrete tips to get us started.

Close your eyes and channel your mind to the last big CME event that you attended. You’ve braved the crowded coffee lines and the awkward waves to old colleagues whose names you’ve forgotten, and now you’re sitting in a blue lecture hall listening to a presenter. Got an image? Now, is the speaker in your image a man or a woman? Be honest.

It’s 2016 and the “Mad Men” days of overt gender discrimination are mostly a memory. What we are left with is a bias that is much more elusive. I bet if you were to ask most working women today if they had ever personally experienced a situation in which they were not given a professional opportunity simply because of their gender they would likely say “no.” Similarly, I’d wager that most men (and the occasional woman) who are making hiring and advancement decisions are not purposefully trying to screw over women and truly believe their decisions are gender blinded. The resounding gestalt is “yeah, there may still be a problem, but it’s not with us.”

That’s exactly where popular critical care podcaster Scott Weingart found himself earlier this winter. Weingart, who commands a sizeable social media presence with almost 25,000 Twitter followers, was called out for the lack of women presenters at his popular NYC Resuscitation conference. In response, rather than running from the hot seat Weingart partnered up with UK EM researcher Simon Carley and Dara Kass, co-founder of Feminem.org, to participate in a moderated online discussion about the dearth of national EM female speakers.

The conversation – which can be viewed on FemInEM – was candid, educational and thought provoking. For instance, according to Carley, only about 25% of speakers at the big emergency medicine conferences are women, despite the fact that at least 38% of emergency physicians are women (according to a 2014 study published in Journal of the American College of Surgeons).

Now gender gaps in public speaking may seem relatively inconsequential considering there are still much bigger fish to fry in areas like compensation and advancement. For example, a 2011 Health Affairs Study which factored in specialty, practice type and predicted hours showed an almost 17,000 dollar unexplained difference in the starting salaries of more than 8000 male and female graduating NY state resident physicians (the difference in EM was about 12,500). And a 2014 AAMC report showed that the vast majority (85%) of professors in EM are still men. Really fixing these bigger issues, however, is incredibly complicated and will require a dedicated long term multi-faceted approach. In comparison, achieving gender balance in public speaking is relatively low lying fruit and as a specialty we can facilitate change right now.

So why is targeting CME lecturing actually important? Well, for several reasons. Public speaking comes with a few obvious tangible financial perks such as travel reimbursement, waived conference fees and a possible stipend. But the real advantages arise from the intangible perks. Speakers often have unique access to networking with other well known EM experts and this can lead to future collaborations, increased citations of their work (as name recognition increases) and additional speaking opportunities. All of these things can help a speaker springboard their career and advance professionally.

As members of the EM community, we can easily increase the number of women speaking in high profile EM events. Here are 15 concrete suggestions to start moving the needle.

Strategies for women who want to become public speakers:

  • Demystify the qualities that it takes to be a speaker. Tony Robbins and Oprah were not born at the podium. Like putting in a central line, high quality public speaking is an obtainable skill through intentional practice. If you want to become a better speaker, own the process and get started reminding yourself that the goal is continued improvement not initial perfection.
  • Pick your passion. Become an expert in an area in which you want to be a life long learner. It is much easier to lecture when you are confident that you know more about your topic than 90% of the room. If skeptical listen to Amal Mattu’s interview on Rob Orman’s podcast (blog.ercast.org) in which he talks about how his interest in EKGs segued into national speaking.
  • Study the art of public speaking. Read, listen, analyze and then copy. A good place to start is a Science Of People study that analyzed why some Ted Talks went viral while others fell flat.
  • Practice and seek out feedback. Ask effective speakers who’s style you would like to emulate, for coaching tips. Of note, recognize that actively seeking feedback from a legitimate source is slightly different than overanalyzing unsolicited comments about a given talk. As Simon Carley brought up in the FemInEM discussion, if you want to be a high profile female speaker, expect that as a woman you are more likely to receive superficial or inappropriate critiques about your appearance or possibly even your educational content than your male peers. Although this is unfortunate (it can suck) understand that at least for now this is part of the territory. Scan for comments on how to be more effective in future presentations, and then consciously move on.
  • Stretch your networks. Traditionally women tend to have very small and intimate networks compared to men whose networks are broad and diverse. If you want to get to the national speaking circuit you will likely need to move beyond your natural comfort zone. Get to know your regional educational didactic coordinators and residency directors, go to national meetings and join committees that focus on your area of interest. Let people know that you are interested in public speaking.
  • Invest in social media. Use social media to educate and connect with your audience and as a vehicle to network with other source experts.

For residency program directors:

  • Reinforce that public speaking is an attainable skill that is not gender specific.
  • Provide formalized feedback. Give residents structured evaluations of their required educational talks. As physicians, most of us are occasionally asked to give some type of presentation, teaching residents the basics of how to give an effective presentation and how to use background material appropriately is an important skill regardless of whether they give 10 or 100 lectures post residency.
  • Facilitate additional opportunities. When a resident has identified that they want to become a better speaker help them gain access to additional coaching and speaking opportunities.
  • Support diverse grand rounds speakers. Whether it’s gender or race, residents need living, breathing access to successful people who look like themselves so that they can subtly reframe abstract possibilities into realistic aspirations.

For CME program directors:

  • Examine your current track record. Sometimes the simple process of consciously recognizing patterns can in itself facilitate real change. If historically the vast majority of your conference speakers have been men, decide to include gender diversity as a variable in your next planning session.
  • Include women in your planning committee. From research in other science and technology fields we know planning committees that include both men and women (versus all men) are more likely to produce programs with higher numbers of female presenters.
  • Evaluate your speaker selection process. During the Feminem discussion, Kass was clear that planners need not “dumb” down their standards or jeopardize the quality of a conference by including a speaker who may not be ready for prime time, just because they are female. Rather, she asks that planners consciously expand the current pool from which they solicit speakers, so that it includes additional qualified candidates who just happen to be female. The poster child of an EM program that has done this successfully is the international acclaimed Social Media and Critical Care (SMACC) conference. Their planning committee made speaker diversity a priority and developed innovative techniques to expand their selection process and consequently identify new speakers.

For senior male and female speakers:

  • Be mindful of coaching opportunities. If you are a big name in emergency medicine you also have a bigger responsibility because you likely have the ability to catapult the careers of individuals behind you. Use this power thoughtfully, consciously identify motivated women to coach, mentor and sponsor.
  • Have a handy list of qualified female speakers. When invited to speak, ask the program committee if they still need additional speakers and if declining an invitation yourself, share contact information for a qualified woman as an alternative.

Thanks Scott, Simon, Dara (and moderator Jenny Beck-Esmay) for starting this discussion.

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Does the Use of APPs Turn Back the Clock?

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Advanced practice providers are becoming a mainstay in the emergency department, but are we turning away from EM’s founding principles?

Recently I was arranging a memorial lecture in honor of one of the founders of emergency medicine. As I thought about this extraordinary person, I reflected upon his body of work, his leacy, and how we have safeguarded it.

In November 1954, Robert H. Kennedy, MD, gave a speech to the American College of Surgeon’s Clinical Congress. In it, he described the ‘Emergency Room’ as the weakest link in the treatment of trauma patients. The ensuing years brought increasing public awareness that the people who staffed the emergency room were not well trained. The country was alarmed to find that gynecologists might take care of a heart attack and ophthalmologists a trauma case. These physicians had four years of medical school, a year of a multispecialty rotating internship, and whatever additional years of specialized training they had received. They were not qualified. What was needed was someone who was trained to care for the broad spectrum of patients and complaints that populate the emergency departments at all times of the day and night. Emergency medicine was born to fill that need. The founders struggled for many years with the House of Medicine to recognize emergency medicine as a specialty. This specialty status was conferred on September 21, 1979.

The struggle then turned to the local recognition of the nature and value of emergency medicine. The medical staff and the general public needed time to begin trusting the physicians in “the pit.” Many years and countless patient and physician encounters have changed the perception of an emergency physician from inadequate to that of trusted colleague and caregiver. Through our collective efforts the emergency department has evolved into the nexus where patient meets hospital. Getting to this point has been arduous, and we still have some headwinds, but we accomplished most of our important goals.

It took 37 years to arrive in our current situation. It is a success story, to be sure.

Fast forward to recent times. Corporate medicine and contract vicissitudes are common, we are evidence driven, we are safety conscious, and above all, we are the leaders of all aspects emergency medicine.

Now the era of the ever-expanding physician extender has emerged in emergency medicine. Why are physician extenders needed? I doubt that anyone assumes physician extenders are better providers than emergency physicians; rather, they are cheaper and, since there are not enough emergency physicians to go around, we must need them. A similar argument was advanced in Missouri when it proposed assistant physician status to medical school graduates who did not match into residencies. They could practice in rural areas after one month with another physician monitoring them. Is it better to have an inadequately trained caretaker or none at all. This is a recurring question in medicine. Every graduate of medical school knows that four years is not enough training to practice medicine. More training to build on the 4-year knowledge base is required. The “emergency room” physicians of the 1950s and 1960s who so appalled the public had four years of medical education before they even had any opportunity to do clinical work. Then, they had additional and varying degrees of patient care training. Despite this training, they were deemed unqualified. Are extenders better trained than those physicians? In fact, are extenders necessary or are they expedient? Extenders are not hired because they provide better care than the physicians they replace. Better care is not what drives their use. They are cheaper to hire than physicians and create a fatter bottom line.

Patient safety is one of the most important topics in emergency medicine. It is inherent in our emergency culture and continues to be driven by federal mandates. How is it safer to have physician extenders and not physicians evaluating emergency patients? We covered this ground 50 years ago. We have already established that emergency physicians who were trained for the job provided the best emergency care. When did that change? When did we start believing someone with far less training could practice our specialty? Did the founders of emergency medicine just not grasp the business of medicine well enough? Perhaps the founders got it all wrong. Does the haze of 1960s idealism now in more enlightened times unfetter us?

In the beginning…there was a need for qualified emergency physicians to see emergency patients in the emergency room. There has been and will continue to be a relentless change in medicine and life, but some things are timeless. The enduring and appropriate concept from the 1960s is that: properly trained emergency physicians matter. This must be our unwavering principle.

Emergency physicians provide the best patient care in emergency departments. We were once committed to this concept. It is time to recommit.

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Less is More: Redefining Balance

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Want a better work/life balance? Hint – it’s not about being better at multitasking.

I am tired of hearing about balance. We talk about it, we go to lectures on it, we give mandatory presentations on it to our interns. Yet few people would say they have actually achieved this elusive, zen state. In fact, more than 70% of ER doctors have signs of burn-out [1] – the opposite of balance. Too many presentations on balance give insipid suggestions to “make sure you exercise and eat well,” or “find time to sleep.” I can’t imagine that advice would be very helpful to someone who is already burning out and living in the margins of their free time and energy. Something is wrong with this picture.

First of all, let’s look at the language we use. We all talk about “finding” balance. Where did it go? Did we lose it? Did we used to have it? I imagine that we did used to have balance. Perhaps it was when we were in college, or in medical school. Maybe it ended when residency started, or perhaps when we started having kids. At some point, we jumped onto a treadmill called ‘career’. We ambled along, excited at our new position. Then that treadmill started to move a little faster. If you had a kid or four, then it felt like running on the treadmill carrying the kids with you.

We are all constantly adding more to our work lives, taking on new responsibilities, chairing new committees, stepping into new leadership roles. All the while we are trying to keep the peace at home with our spouses and children, stay active, and still maintain some vestige of our former hobbies. (Hobbies you ask? Those were those things we used to do for fun before we had busy jobs and busy families, like rock climbing, crocheting, or peeing without little humans storming the bathroom door.)

If you are like me, you have started to notice signs of burnout. The struggle is real. At work we have to take care of difficult and violent patients, meet core measures, chart, and deal with patient complaints. After our shift ends we come home to kids, errands, bills, and all the household stuff, like cooking something other than grilled cheese for dinner. I hear these refrains day after day, yet we all still seek this elusive thing called balance, as though we were in search of a mystical unicorn that we’ll never find.

Why have we arrived at this state of perpetual imbalance? What can we do to start to reclaim our own wellness and find this mysterious balance? Here are some suggestions, not from someone who has figured it all out, but as someone who is in the thick of it, striving to do better.

Redefine balance
Balance should not be seen as ’doing it all’. A balanced life does not mean being in five different leadership roles at work while also coaching your kid’s soccer team, sewing hand-made Halloween costumes and growing your own organic vegetables. If we define balance as doing everything and doing it well, we are bound to fail. Perhaps we should define balance as living a life that meets your own personal goals, understanding that there will have to be compromise. Your ideal life may look like 12-hour workdays, and frequent travel in order to reach further leadership positions at work. Someone else’s might look like working part time and spending more time with kids, or working close to quarter-time to have time to homeschool. We need to define what our own personal goals are, and then try to bring our lives more into alignment with them. Now obviously, we can’t define away doing medical charts, or define a higher salary for ourselves. There are financial realities and time constraints we have to deal with. We need to figure out what we want and what is negotiable in terms of hours, responsibility, pay, and time. When the pie chart of what you are actually doing matches the pie chart of your priorities – that is balance.

Choose what brings you joy
Ask yourself what floats your boat? What gets you up in the morning (figuratively, not what actually gets you up, which is probably a loud alarm, children, and coffee)? It is easy to say yes to so many things that crowd out what you really love. That one committee that will meet once a month? Reviewing a paper? Giving a lecture? These are all good things. But they can easily squeeze away the time we have for more important things. If it is something you love and are passionate about, then do it! If it is something that you have no choice about and have to do in order to meet your other goals that you are passionate about, then do it! If you don’t really want to, and you don’t have to, then say no. Those little things can add up and tip your balance. You are not a super hero with inhuman strength or stamina. Give yourself permission to say no to things. Cull what drags you down, and focus on the things that you love, both at work and at home.

If you are so burned out that you feel nothing brings you joy, then seek help, seek friends, find people to reflect with you and remember what used to bring you joy. Give yourself permission to live your life to meet your own goals, not the goals of the other people in your department, or in your Facebook feed. There’s a phrase used by non-profit organizations about keeping out of the red that applies well to us as physicians: “No margin, no mission.” If you are constantly over-extending then you may burn out and could risk losing your mission. Plus, life is just too short to spend it doing things you hate.

Think about long-term goals
There is no prize at the end of your life for the person who ran the fastest on that career treadmill. What do you want to be able to look back on and be proud of? Perhaps it is something related to your career, making a difference in your community, or the patients’ lives you have saved. But maybe it will also be the time you have spent with friends and family. To paraphrase Dr. Mike Myer [2], think more about your eulogy than your CV.

Realize that your goals will be moving targets
Balance and wellness can be hard to maintain because our lives keep changing. Perhaps for a short season we feel like we have captured balance, and we feel good. We are exercising and eating a paleo diet, and even have time to watch something on “the Netflix”, of which I hear tell. But then we lose it again. Our shifts change, our schedules change, and the pie chart of our goals changes. The needs of our family also change. Your baby has gone from needing diaper changes to needing homework help. So maintaining wellness requires a constant evaluation of our lives, a constant pruning of things that are no longer helping, and nurturing growth in other areas.

Finally, let’s help each other
As a group, we perpetuate the ideal of doing it all, rather than living a life that is in line with our goals. We applaud people who seem to be doing everything. Perhaps instead of just saying: “Congratulations on taking on that 500th responsibility,” we should also ask, “Are you able to maintain your own wellness with all that’s on your plate?” When we see colleagues who are starting to burn out, let’s reach out to them. Burnout is incredibly prevalent, and increases the risk of substance or alcohol abuse, medical errors, and suicide. The equivalent of over three medical school classes of physicians commit suicide every year [3]!

The number one reason for burnout among physicians is bureaucratic tasks [4]. It is not taking care of patients – that’s what we trained for a decade to do. It is the system that surrounds care delivery that is making doctors lose job satisfaction and sometimes leave medicine all together. There are many things that could be done at all levels to reduce burnout, from institutional support for things like charting (let’s get scribes), core measures (let’s build systems in our EHR that make it easier), work hours (let’s schedule shifts to allow fewer day/night transitions). There is plenty more that could be done at even higher levels, but most of us have little control over those things. What we can control is our own attitudes and our interactions. Let’s build wellness into the fabric of our own lives, our departments, and our residency training.

Let’s start being realistic. Instead of talking about how to stay “balanced” while doing it all, let’s talk about what we need to do to maintain wellness, resiliency, and longevity in our lives and careers. The first step may be to figure out what the ideal pie-chart of time expenditures would look like for you to be well. Define it for yourself, pursue it, choose it, and encourage it in others.


REFERENCES

  1. AMA Wire. Specialties with the Highest Burnout Rates 1/15/2016. http://www.ama-assn.org/ama/ama-wire/post/specialties-highest-burnout-rates
  2. Emergency Physicians Monthly, Making the Most of 2016, by the EPM Community 1/1/2016. http://epmonthly.com/article/making-the-most-of-2016/
  3. Medscape Physician Suicide 06/01/2016. http://emedicine.medscape.com/article/806779-overview
  4. Medscape, Physician Burnout: It just keeps getting worse 1/26/2015 http://www.medscape.com/viewarticle/838437_3

 

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Workplace Violence – The Resident’s Perspective

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60% of residents reported sexual abuse and workplace violence

We are vulnerable.

The emergency department is among the most frequent locations for violent events in the health care setting as patient flow is ever changing and patients often present with undifferentiated complaints and social issues.

If the mention of “workplace violence” made you recall experiences you have had in the emergency department, when a patient or a visitor may have harassed or even assaulted you or one of your colleagues, you are not alone. Let me share some statistics with you:

Prior studies have demonstrated that over half of physicians working in an emergency department have been physically assaulted by a patient or visitor at least once during their career. Multiple studies have demonstrated that more than three quarters of emergency resident physicians have been the victim of one act of workplace violence. And we know that the emergency department is the most frequent site for hospital shootings.

This is a problem that we need to urgently address. This is the mission that my residency co-chiefs and I sought to accomplish in our research project entitled, Workplace Violence and Harassment Against Emergency Medicine Residents, set to be published in the Western Journal of Emergency Medicine later this year. Prior to this study, our literature search demonstrated only one prior study that examined the emergency medicine resident experience of physician harassment, which was conducted by McNamara and colleagues in 1995.

Of course, being residents ourselves during this research study, we directly identified with the subjects of our work. About one year later, we all graduated from residency. As I began my first year as an attending physician, and my responsibilities and perspective shifted, I also noted that this study was also important as residents are a vulnerable population. Residents are physicians in training, and often lack a complete set of skills to both prevent and manage incidents of workplace violence. There are also often poorly defined institutional reporting systems and support systems for those who are victimized.

The purpose of the study we conducted was to quantify and describe the incidence of violence and harassment against emergency medicine residents by patients and visitors, as well as to identify perceived barriers to safety in the emergency department. The study involved three NYC-based emergency medicine residency training programs.

The primary outcome we sought to examine was the incidence of workplace violence as reported by emergency residents. Secondary outcomes included subtypes of violence experienced by these residents as well as perceived barriers to safety while on shift.

Approximately 84% of residents at the institutions studied completed the survey. These residents were queried regarding non-physical and physical experiences of violence at the hands of either patients or visitors. Non-physical violence was defined as verbal harassment, verbal threats, and sexual harassment. Physical violence was defined as being physically attacked by either a patient or a visitor.

Almost all residents (96.6%) of residents reported prior verbal harassment from a patient in the emergency department. Approximately 78% of residents reported experiencing verbal threats from patient, and 55.5% reported receiving verbal threats from a visitor. A concerning 65.5% of emergency medicine residents surveyed reported having at least one experience of physical violence committed by a patient.

workplaceviolence703Over half (41.9% males, 68.9% of females), of resident respondents reported experiencing sexual harassment from a patient. Being female increased the odds of experiencing an incidence of sexual harassment threefold. This finding is in line with other studies, particular those by Gates and colleagues who found that female emergency department staff reported a statistically significant higher frequency of sexual harassment from patients when compared to male staff. Few emergency department-based studies have looked further into the relationship between gender and vulnerability to and experience with workplace violence. As such, this area of focus is ripe for future study.

A statistically significant correlation was noted between post-graduate (PGY) level and frequency of violent incidents from patients (p = 0.002), with more incidents reported as PGY year increased (excluding PGY IV year). This emphasizes that there is a steady pattern of exposure over time of violence. It also demonstrates that years of experience do not appear to have a protective effect with regard to resident victimization.

When asked regarding patient factors that contribute to incidents of ED-based workplace violence, alcohol and illicit drug use, along with psychiatric and organic causes (i.e. dementia) were most frequently cited. Over two-thirds of residents surveyed reports that environmental factors, particularly lack of security or police presence and/or security or police not responding in a timely manner were the most common contributors to physical violence.

Alarmingly, almost half of the residents surveyed reported that they were either very or somewhat dissatisfied with the current security system in their emergency department.

Residents in the study were also queried regarding their prior training with violence prevention or de-escalation techniques that occurred within the past year. Only less than one fifth (16.8%) of residents had reported participating in such sessions. A study by Fernandes and colleagues looked at the use of an educational program, the Prevention and Management of Aggressive Behavior Program, would lead to a decreased in incidents of ED-based workplace violence. While some positive short term effects were noted, this intervention did not appear to decrease the incidence of violence in the long-term. Other studies have looked at staff confidence and attitudes related to ability to handle episodes of workplace violence should they arise, and similarly found short-term gains in provider confidence in managing these situations, without long-term changes in staff attitudes. While currently there is lack of evidence that de-escalation and violence prevention techniques may work in the emergency department, this should not be taken to say that resident physicians (and all ED-staff) should not be empowered by these techniques. Perhaps a more sustained, longitudinal curriculum that focuses on violence prevention, factors related to patient proclivity towards violence, and safe, effective methods to deal with violence when it occurs, can lead to decreased incidence of violence and increased feelings of staff safety.

This data not only confirms that violence against emergency medicine residents is a significant concern, but also, is truly disconcerting. The majority of residents reporting being the victim of at least one incident of physical violence (hitting, slapping, punching, kicking, spitting, shooting, stabbing, biting, hitting with an object, throwing an object) or sexual harassment (unwelcome sexual advances, insulting gestures, requests for sexual favors, offensive contact) in the emergency department.

I plan on expanding this research interest as have started my career as a junior faculty member. There is more data to be collected regarding incidence of violence against resident physicians, as well as expanding this data set to include other emergency department staff. Future directions of this work would entail evaluating strategies to prevent workplace violence and steps to manage violence if it occurs.

What can be done now?

You can conduct your own research – this work needs others to validated its data with their own prospective observational data.

You can bring your concerns to your respective institution and hospital leadership can commit to a comprehensive violence reduction plan. Workplace violence has huge costs related to the need to bolster security teams that is already in place, as well as in terms of absenteeism, medical and psychological care of victims, and increased career dissatisfaction.

You can lobby on a state or national level for policy changes that clearly outline a no-tolerance policy for emergency department based violence.

Collectively, the above will effect change that will improve the quality of the residency experience and enhance resident wellness.

Let’s continue the dialogue.

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With Aetna Gone, Is ACA Dead?

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The latest blow to the ACA exchange is bad news indeed, but some perspective is warranted.

Aetna announced they will be departing from the Obamacare marketplaces in 11 of the 15 states they currently offer plans. This certainly does not look like a good sign, particularly on the heels of UnitedHealth and Humana cutting back their presence on the exchanges as well. I’m not completely sanguine about it, but I don’t think it means Obamacare is in its death throes. To understand the impact of Aetna’s departure, some perspective is needed.

First of all, the nature of Aetna’s exit raises some questions. As recently as April, Aetna’s CEO said the exchanges were “a good investment” [1]. Aetna appears to have been threatening to exit the marketplaces in order to strong-arm regulators into approving a their merger with Humana, and their bluff got called. Ultimately, big insurers like Aetna probably don’t care much about having a presence in the exchanges – most Americans get their health insurance through their employer (43%), Medicare (17%) or Medicaid (19%), and big commercial insurers make most of their money in the employer sponsored insurance game. Only 6% get their insurance through private plans (up from 5% before the ACA). Enrollment in Obamacare marketplaces has been lower than supporters of the law expected (and hoped), however the low enrollment numbers is largely because employers are keeping people in their plans, not shifting them to private plans in the exchanges – despite the delays in the employer mandate [2]. And while Aetna and others’ exits from the exchanges have left a few areas with only one insurance carrier, health insurance markets were similarly consolidated before the ACA.

Insurance companies like Aetna and United are household names, because their main business is employer sponsored insurance, the kind of insurance plans that most people (particularly those who read and write newspaper articles) have for themselves. These companies’ main experience is with employers: their main business is getting employers to get their companies to enroll in their plans.  Very little of what they do is getting individuals to sign up for plans. Less well-known companies like Centene and Molina, however, are posting profits on the Obamacare exchanges [3]. These companies have a lot of experience running managed lower cost, narrow-network Medicaid plans, getting people with lower incomes to enroll in their private but largely government-financed plans. Now, they’re succeeding in the marketplaces, where people with low incomes sign up for government-subsidized individual plans with lower costs and narrow networks. Markets are supposed to have winners and losers. Is it any surprise that the companies with more experience in this kind of work are succeeding?

Rising deductibles are another bad sign. But again, this is not new. There has been a mostly linear increase in deductibles that started in the 1990s and, like premium increases, it’s difficult to attribute to Obamacare (see graph online). And unlike the status quo ante, Obamacare protects people with an annual out of pocket maximum. Sure, a $6,000 deductible means that people have to pay a lot out of pocket before their coverage kicks in (some might call this “skin in the game”). But with an annual out of pocket limit of $6,600 in 2016, after that, they are 100% insured – no more copays, no more paying anything out of pocket for their care for the rest of the year. Additionally, people with incomes less than 250% of the poverty limit also get cost sharing reductions (specific subsidies for copays, coinsurance, and deductibles) on their exchange plans. Again, far from ideal, but far from the worst tragedy in our health system.

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High out of pocket costs will continue to be a problem for many ED patients. Insurers know that EMTALA (appropriately) requires that we evaluate and treat patients in the ED regardless of their ability to pay, and insurers continue to play hardball in negotiating prices and networks. Balance billing doesn’t make us look good, and we need to reframe the issue from “surprise ER bills” to “surprise lack of emergency coverage.” Sadly, I suspect this will worsen before it gets better, particularly as cheaper plans with narrow networks corner the markets, and patients with big surprise bills look very sympathetic to state legislators who can limit balance billing much more easily than they can address the root of the problem. One good sign: despite all the bad press, the number of people with high out of pocket health costs actually declined as people started getting plans on the exchanges [4]. And paired with that, EDs are seeing a better payer mix (fewer uninsured, more Medicaid) while volumes growth is stable [5].

More bad news: exchange premiums are going to increase more in 2017 than they did in 2015 and 2016. Of course this is not good. It would be much better if premiums stabilized. But for individuals, most of the premium hikes will be absorbed by an increase in subsidies. That’s not good for taxpayers or the federal budget, but most shoppers on the marketplace will not feel those hikes. More importantly, premiums in the first year of the marketplaces were much lower than expected. Insurers anticipated a lot more inertia in the marketplaces – once an individual signed up for a plan, they would stick with that company each year, accepting premium increases rather than looking to change plans. Consumers, however, have been savvier than expected, and many more have been shopping around for cheaper plans each year [6]. Now, it seems that premiums are catching up to where they were expected to be.

Perspective is important. Not only are premium hikes in line with historic averages, but it’s also useful to make accurate comparisons. Remember that before the ACA, individual plans had annual and lifetime coverage limits, there was tons of variation in what plans did or didn’t cover, and millions of people were excluded from getting a plan at all because of preexisting conditions, so comparing premiums today to premiums before 2014 is far from apples to apples. And even with all of these caveats, premiums are 20% cheaper than what CBO predicted, and at least 11% below what they would have been without the ACA [7].

Here’s another key comparison: Average premiums for a single individual in an employer sponsored plan are $6,251 in 2015 [8]. Average annual premiums on the Obamacare marketplaces for a single individual are $4,583 in 2016 [9]. And, 85% of people in the Obamacare exchanges are getting subsidies [10], so they’re actually paying even less for their plans. And the individual with employer-sponsored insurance is paying their premium with pre-tax money – that’s a form of subsidy, too.

There has been other mixed news. Some prominent ACOs have left the program; others are posting decent savings. Readmissions have decreased – and despite early indicators to the contrary, readmissions are not being hidden in observation stays [11]. We’re seeing another wave of health system consolidation, which is a mixed bag: integrated health systems offer opportunities to integrate care, but they also consolidate market power and will likely continue to drive up prices. As the concisely titled article “It’s the Prices, Stupid” [12] notes, high health costs in the US are largely due to the high prices we pay for health services compared to other countries. But we are also the only developed nation that doesn’t have some sort of government price controls in place.

Bottom line? Things aren’t rosy, but it’s not all gloom and doom either. I’m still cautiously optimistic. Underinsurance remains a problem, but uninsurance has decreased, and preexisting conditions are no longer a thing. My wife is a very healthy dietitian, and a few years before the ACA, she was charged an increased premium (after pages and pages of paperwork) for the preexisting condition of having had a worrisome looking mole removed. The market was punishing her for her responsible behavior, because insurers are only motivated to keep people healthy enough until they move on to their next job or age into Medicare. Now, that equation is a bit better. People can get insurance plans without being punished for having diabetes or having had Hodgkin’s or a getting a mole removed or having a uterus. Insurers can’t deny people access to plans just because they have preexisting conditions, or only offer them plans that don’t cover their medical condition, or charge them more. In fact, insurers don’t even make applicants fill out the same reams of paperwork they used to. There’s room for improvement, but I believe that despite the scary headlines, we’re moving in the right direction.

Medicare has made some big steps towards moving away from fee for service and expanding value based payments, but also recently toned it down. It’s hard to predict how EM will fare in this sort of brave, newish world, and it’s tough to predict how emergency-specific quality measures will impact EDs and hospitals. We continue to be portrayed as expensive and avoidable. We need to figure out better ways to demonstrate the high value care we provide, both as a safety net and as the hub of care coordination.


REFERENCES

  1. Kodjak A. Aetna Joins Other Major Insurers In Pulling Back From Obamacare. NPR. 16 Aug 2016. http://www.npr.org/sections/health-shots/2016/08/16/490207169/aetna-joins-other-major-insurers-in-pulling-back-from-obamacare
  2. Carman KG, Eibner C, Paddock SM. Trends In Health Insurance Enrollment, 2013-15. Health Affairs. Oct 2015;34(6):1044-1048 http://content.healthaffairs.org/content/34/6/1044.abstract
  3. Laszewski R. Why Are Centene And Molina Making Money On The Obamacare Exchanges? Forbes. 6 May 2016. http://www.forbes.com/sites/robertlaszewski2/2016/05/06/why-are-centene-and-molina-making-money-on-the-obamacare-exchanges/
  4. Glied SA, Solís-Román C, Parikh S. How the ACA’s Health Insurance Expansions Have Affected Out-of-Pocket Cost-Sharing and Spending on Premiums. The Commonwealth Fund. 12 Sept 2016. http://www.commonwealthfund.org/publications/issue-briefs/2016/sep/aca-expansions-and-out-of-pocket-spending
  5. Pines JM, Zocchi M, Moghtaderi A, Black B, Farmer SA, Hufstetler G, Klauer K, Pilgrim R. Medicaid Expansion In 2014 Did Not Increase Emergency Department Use But Did Change Insurance Payer Mix. Health Affairs. 1 Aug 2016;35(8):1480-6. http://content.healthaffairs.org.ezproxy.galter.northwestern.edu/content/35/8/1480.abstract
  6. Sanger-Katz M. High Rate of Shopping and Switching in Obamacare Plans Is a Good Sign. The New York Times. 26 Feb 2016. http://www.nytimes.com/2015/02/27/upshot/high-rate-of-shopping-and-switching-in-obamacare-plans-is-a-good-sign.html
  7. Adler L, Ginsburg PB. Obamacare Premiums Are Lower Than You Think. Health Affairs Blog. 21 July 2016. http://healthaffairs.org/blog/2016/07/21/obamacare-premiums-are-lower-than-you-think/
  8. Claxton G, Rae M, Panchal N, et al. Health Benefits In 2015: Stable Trends In The Employer Market. Health Affairs. Oct 2015;34(10):1779-1788. http://content.healthaffairs.org/content/34/10/1779.abstract
  9. Levitt L, Cox C, Claxton G. How ACA Marketplace Premiums Measure Up to Expectations. Kaiser Family Foundation. 1 Aug 2016. http://kff.org/health-reform/perspective/how-aca-marketplace-premiums-measure-up-to-expectations/
  10. Leonard K. Insurers Fret Over Obamacare’s Grace Period. US News & World Report. 14 Sept 2016. http://www.usnews.com/news/articles/2016-09-14/insurers-fret-over-obamacare-grace-period
  11. Zuckerman RB, Sheingold SH, Orav EJ, Ruhter J, Epstein AM. Readmissions, Observation, and the Hospital Readmissions Reduction Program. NEJM. 21 Apr 2016;374(16):1543-1551. http://www.nejm.org/doi/full/10.1056/NEJMsa1513024
  12. Anderson GF, Reinhardt UE, Hussey PS, Petrosyan V. It’s the prices, stupid: why the United States is so different from other countries. Health Affairs. May 2003;22(3):89-105. http://content.healthaffairs.org/content/22/3/89.abstract

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Why I Call My Patients

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Why patient follow-up calls might actually deserve your time

It’s 2:30 am, and I am taking a quick break in the call room after a busy start to the night shift in my small town ED. The nurse calls me out to see a 22-year-old male with abdominal pain. The patient has a history of 35 visits to our ED, including eight in this year alone. After an unremarkable work up including a CT scan, the patient is discharged home, moderately unhappy at not having gotten the pain medicine he requested. On his way out, he calls me, the nurses, and the hospital several colorful, unflattering names. Obviously, one of the last things I want to do is call this guy back and talk to him again.

So why am I even considering this?

Several years ago at an ACEP conference, I heard a speaker discuss the benefits of calling patients back the next day. Although I have read that this is the gold standard for patient follow up, I am not aware of any ED providers that actually do it. The idea intrigued me and stuck with me for years, but it always seemed unfeasible.

It’s never been hard to come up with reasons not to call patients back. Personally, I thought it would take too much time. But on a deeper level, I think that part of me was apprehensive about the whole idea. Perhaps I was afraid to hear that they were not doing well. Perhaps I did not want to find someone upset and angry. Or perhaps calling them to check in on them would be seen as an admission of my wrongdoing or insecurity. Still, I thought, if patients were not doing well, would it not be better to talk to them and find out? Have a chance to help them?

Our department already has a very limited follow-up call policy. Certain patients get a phone call from a nurse when they have time. Perhaps two to three call attempts are made a day, but many are unsuccessful due to non-functioning numbers.

As time passed, I found ample reasons to postpone making the calls. I was too busy. I had to study for boards. I always had a good excuse. But two-and-a-half years ago, I decided to give it a try.

I started by calling only select patients back the day after their visit. This lasted for about a month and then progressed to my current practice of calling every discharged patient back after every shift.

At the beginning of my shift I start a list of the patients I have seen, with their room number and diagnosis, to give me a quick reminder of who they are. Just before discharge, I ask for a good phone number. I have learned it is best to get two. Initially, I would make the calls in the afternoon before work, but I have found that I am able to make them at the beginning of my shift. Between seeing patients, looking through records of previous visits, entering orders, and documenting, I make my calls. The calls typically only take one to two minutes each. When I’m not at work, I make the calls from home. I have never had problems with patients abusing my phone number, and in over two years, only once or twice have patients called me back after several days to ask additional questions.

I usually start the calls with, “This is Dr. Jaffe from the ED last night. Is this (Patient Name)? I just wanted to call and check on how you are doing.” This typically results in one of three basic responses: the patient is feeling better, the same, or worse. My experience has been that about three fourths of the patients are better or much better. These are the quickest calls. I ask if they are taking their prescriptions and if they plan on following up as directed. I always ask if they have any questions.

In many cases, they express how much the call means to them. On a daily basis, I hear: “Wow! No one has ever done this before!”, “This really means a lot to me,” or, “I really appreciate you taking the time to do this.”

Honestly, it feels good to hear their genuine appreciation. If they are not better, I ask if they are the same or worse. At this point, using clinical judgment, I advise them to seek follow up either with their primary care doctor or specialist, or I advise them to return to the ED. Documentation of the calls is important, especially for those patients instructed to seek follow-up.

When I had finished my calls, I had a reassuring sense of relief and completion. I would think to myself, “Good, I didn’t miss anything this shift.” I soon started calling all discharged patients back, even the most problematic. Through this practice, I discovered that even the most difficult patients, those that appeared to be drug seeking, angry, or dissatisfied at the time of their visit, were often apologetic and pleasant the next day. It occurred to me that those patients that left unhappy, those that I least wanted to call, were perhaps the most important to call back. If they deteriorated or if something was missed initially, these patients could present a significant liability.  Calling them back, in spite of the potential discomfort, gives me a second chance at helping the patient. Often, I am surprised at my success in repairing my relationships with difficult patients.

Initially, I started making the follow up calls in an effort to improve my patient satisfaction scores, and it worked. In fact, my overall scores have improved by about twenty percentile points. Yet as I continue to make these calls, my primary motivation is not to improve my scores, but to feel the appreciation of my patients.

As emergency medicine physicians, we see patient after patient and do our best to assess and treat them appropriately. We diagnose problems and prescribe treatments the best we can based on the information we have. Honestly, at times, I feel like I am forcing a square peg into a round hole. I’ll think: Was my diagnosis correct? Did the treatment work? Did my patient get better? Did they get worse? These are questions all EPs certainly ponder on a daily basis.

After many years of practicing emergency medicine, I have gotten somewhat used to these questions. But have we not all felt that blow to the gut when a colleague or staff member asks, “Remember that patient you saw the other day?” We often assume the worst, thinking to ourselves, “Oh shit, what happened? What did I miss?”

Following up does not remove the possibility of a bad outcome or the worry of one, but I do believe it significantly reduces both. I believe that patient after patient, shift after shift, and year after year, these doubts and vulnerabilities add up. Yet each time I finish making my calls, I get a sense of relief, the reassured feeling of knowing that I didn’t miss anything serious, that my patients are all okay. The ones that are not, I know that I have done all I can by instructing them to return to the ED. While I have heard the argument that making follow up calls can contribute to burnout, in my experience, the opposite is true! Making these calls actually counteracts burnout.

The effect of calling patients back has motivated me to continue this practice after each shift.

I am now expanding to call more people back; patients seen by the mid-levels, those that I pick up at change of shift, and those that are transferred out. When time allows, I even check in personally on some admitted patients. I also use the follow-up call as an opportunity to confirm that any questionable X-ray reading I have made is consistent with the radiology reading.

Patient feedback as a result of these calls helps me to gradually improve and refine my clinical practice. On occasion, I will talk to a patient the next day and they will need an antiemetic, something for pain, an antibiotic, or a work excuse that they did not get initially. I will help them as I am able, often obviating the need for another ED visit.

Knowing that I will talk to the patient the next day has helped me to better anticipate their needs. Generally, after a patient leaves the ER, we have little information regarding their outcome unless they get worse and return. Feedback is important in any learning situation, and I have discovered that these follow ups create an opportunity to gain valuable feedback on which practices work well and which may need to change.

After two-and-a-half years, I still look forward to completing my list of calls and the peace of mind that comes with it. These calls have become an indispensable part of my practice.

This brings us back to the twenty-two year old male who stormed out the night before. I call him and he answers. To my surprise, he is actually doing better and apologizes for his behavior. At his next ED visit, he now tells the nurse, “Dr. Jaffe is great—he even called me up at home the next day to see how I was doing.”

With the current focus on moving patients through the ED quickly, taking the time to connect with my patients and show them that I care has been a powerful choice. I have found this to be one of the few opportunities where mere minutes per patient can make a meaningful difference in creating a positive patient experience.

Try it for a month, and see if you and your patients don’t feel better.

My Callback Routine

  1. At the beginning of my shift I start a list of the patients I have seen, with their room number and diagnosis, to give me a quick reminder of who they are.
  2. Just before discharge, I ask for a good phone number. I have learned it is best to get two.
  3. I make the calls at the beginning of a shift, between seeing patients, looking through records of previous visits, entering orders, and documenting. When I’m not at work, I make the calls from home.
  4. The calls typically take one to two minutes each.

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Obamacare’s Future: Repeal, Replace or Revise

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While the first attempt to repeal and replace the ACA came up short, it’s anyone’s guess what will happen next. One thing is for sure: This isn’t our first rodeo, and we’d be wise to take a few lessons from history. 

Repeal? Replace? Who will be covered? How will emergency care be affected? As emergency physicians and the public ask questions and anticipate the promised changes in the 2010 Affordable Care Act, a.k.a. Obamacare from the new Trump administration and a Republican-controlled Congress, it may be useful to look at the history of government-sponsored health insurance programs.

Unlike many Western democracies, the United States, despite many runs at universal health insurance, has favored private, commercial insurance with some element of federal and state insurance for the elderly and poor in the form of Medicare and Medicaid. The battle between those who believe that health care is a right and should be funded and guaranteed by the federal government, and those who believe that it should be a private, purchased commodity has been fought in our nation since the early 1900s. Universal health insurance was a post-WWII priority of FDR and later Harry Truman, but was opposed by the AMA, and defeated three times in Congress. Senators and House members did agree on one major boost to medical care—the Hospital Survey and Construction Act, signed into law by Truman in 1946. The law became better known as the Hill-Burton program, and through it billions of dollars went to the cities and hometowns of congressmen to fund new hospitals and their new EDs [1].

A confluence of factors in the 1960s made the eventual passage of Medicare and Medicaid possible. President Lyndon Johnson’s Great Society vision, a Democrat-controlled Congress, and the grudging support of Wilbur Mills, the powerful Chair of the House Ways and Means Committee, launched Medicare and Medicaid in 1965. A key provision of the law was Part B, which was supported by the AMA, other physician groups, and Republicans. Part B provided government–subsidized voluntary insurance for physicians’ fees [1].

The impact of Medicare/Medicaid on the finances of emergency care cannot be understated. The early emergency physicians, who were usually employed by or under contract with hospitals and who usually did not bill for their services, figured out that they could do much better if they formed groups outside the hospital and did their own billing. Physician incomes grew sharply under Medicare/Medicaid. Early groups like the Alexandria Plan physicians and a collaboration of EPs in Michigan were now profitable and able to grow. In the end, the financial boost brought on by Medicare and Medicaid stimulated the overall viability of emergency medicine as a profession, and the subsequent creation of residency programs and the specialty as a whole.

As the elderly and poor now had health insurance, their consumption of health services jumped dramatically. Physician practices became overloaded, with long waits to be seen. The predictable result was that patients showed up in EDs for care with “deferred pathology” from previously untreated conditions [2]. In the five years after Medicare/Medicaid was enacted, annual US ED visits in the now plentiful Hill-Burton hospitals increased from 29 million to 43 million [3]. As it has been in the 50 years since, emergency medicine started out as the back-stop and safety net for unmet medical needs of patients who had no place else to turn.

Unlike in other nations, where universal health insurance was matched with support for increased primary care services, the number of primary care physicians was not proportionately increased post Medicare/Medicaid. In fact, the percentage of non-primary care specialist physicians was increasing dramatically at this time. Part of the incentive to specialize was that in the early years, Medicare Part B paid the full charges of physicians for evaluation, treatment, and procedures. The elderly, previously a low-or-no-pay group, were now a goldmine for specialist physicians.

Like the Affordable Care Act, Medicare and Medicaid greatly increased access to care, and improved the health of millions of people. But Medicare, in particular, required considerable tinkering and revision after its initial roll-out. Cost was a major issue, as in the initial law there were not limits on reimbursement to physicians who could charge “customary fees.” Hospital procedures were reimbursed at a much higher level than those done in outpatient offices. National per capita health expenditures rose sharply from $198 in 1965 to $336 in 1970 [1]. Thus, Medicare and Medicaid as originally conceived and implemented were unsustainable and over the next decade major revisions were enacted that put fee limits in place, reviewed physician utilization, and encouraged the formation of HMO’s and other managed care models.

Many emergency physicians who saw a sharp drop in the percentage of their patients that were uninsured in the past several years will be watching to see if this is reversed by new federal policy. The take home lesson from Medicare/Medicaid in their early iterations is that a complex, multi-faceted law will require analysis, revisions, and new approaches. Like Medicare/Medicaid, the ACA initially focused on access, but has been bedeviled by costs, especially for states that have had a large increase in Medicaid enrollees. Paul Starr, the famous sociologist, notes that federal programs aimed at improving the lives of the population serially go through stages of expansion, equity, and cost-containment [1]. The ACA is just emerging from the expansion phase, has made good gains in equity, but is not adequately addressing cost containment.

Fortunately, previous administrations did not repeal Medicare/Medicaid when problems arose; they revised the programs and made them sustainable. The Trump administration has vowed to repeal and replace the ACA, but would be wise to study the history of public health insurance to see that throwing out the baby with the bath water may not be necessary or financially prudent. Emergency physicians who are in the real world milieu of patients and have been affected by the ACA over the past six years can testify to the positive impact of the law, while offering suggestions on how to improve quality and reduce costs.


REFERENCES

  1. Starr, P. The social transformation of American medicine. Basic Books, Inc. Publishers, New York, 1982.
  2. Zink, B. Anyone, anything, anytime – a history of emergency medicine. Mosby Elsevier, Philadephia, PA, 2006. Interview of Karl Mangold, MD.
  3. Data from the American Hospital Association Statistics, 1954-2002 and the American College of Emergency Physicians.

The post Obamacare’s Future: Repeal, Replace or Revise appeared first on Emergency Physicians Monthly.

How the PMG Became the Mother of All Physician Support Groups

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How the Physician Moms Group (PMG) became one of the most powerful physician communities on the internet.

On the day my husband’s mother fell suddenly into a coma, I was over an hour away, and I felt helpless. I sent my husband ahead immediately and then sweated it out as I waited for my own child care relief to arrive, so that I could join him. It was excruciating, but I knew I wasn’t alone. I logged onto the Physician Mothers Group (the PMG) online, and posted a quick status and in less than five minutes I had more than 50 “bumps,” hearts and prayers. A relative of the head of the ICU at the hospital where my mother-in-law was being treated reached out to me, as did four residents at the same hospital. The head of the ICU came to see my mother-in-law immediately and gave me his cell phone number. Never before had I felt such a power in finding my tribe.

In November of 2014, emergency physician Hala Sabry, MD, had an idea. “I wanted to create an online group of physician moms to network with and create a support system,” said Sabry. “I was in a really rough place – lots of pressure I put on myself. I thought about what type of therapist I needed, and what I needed was a peer support group! My initial idea was small and simple – hoping the 20 people I invited wouldn’t reject me!” But clearly, she wasn’t the only one who had been craving connection. Within one month, over 3,000 physician moms had joined. By the end of the first year, that number had scaled to 50,000. Now, nearly 69,000 members are a part of this growing phenomenon that includes multiple specialties in a culturally diverse group of physician moms around the world.

Sabry spends at least 40 hours per week on the PMG, calling it a true labor of love. But she isn’t alone anymore. Joined by PMG partner Dr. Dina Seif, the two have grown the group in several ways, including branching into new research. Dr. Eleni Linos is the director of research and heads a 14 person team that is hard at work in support of professional women. The team published a JAMA article about the very real discrimination that physician mothers face in the workplace.

In partnership with Medlita, Sabry and Dr. Kim Jackson succeeded in a social media celebratory blitz. They pushed Doctors Day to Physician Week and invested in making National Women Physicians Day on February 3rd.

Due to its size and strength of its founder and members, the PMG has been selected as one of the top 100 meaningful Facebook groups. Sabry said, “It was definitely a surprise” when she was contacted by Facebook’s team and had the honor of being invited to Facebook headquarters to meet with executives to help further the goals of building communities on and offline. Sabry has also been invited to attend Facebook’s Global Health Summit and was hand selected to attend their first Group Summit. The PMG is the sole physician organization to have this honor. “It has felt like such a good dream, especially traveling to Facebook headquarters to meet with their executives. Such a cool place, simple mission and admirable company,” said Sabry. “I wish hospitals ran that way!”

Despite all of the accolades, the mission of the PMG has remained strong and steady. When starting it, Sabry asked herself what type of advice she would give a patient like herself. She was pregnant and working at the time and was feeling the effects of all of the pressure that being a physician mom carries. She thought about what would be the most effective form of stress relief therapy and reached out to her peers. But how can you gather busy doctor moms? Online! The group grew quickly with like-minded moms who had questions and needed support.

PMG posts are a wondrous variety of topics, from shoes and fashion to travel advice to parenting highs and lows. There are clinical questions and personal crises and plenty of nerding out on science or cracking up on Meme Monday. Members have shared their personal stories of devastating diagnoses and have received words of encouragement. Women have shared tales of divorce, abuse, and recovering from pain. Like me, women have reached out in moments of crisis with a sick family member far away and the group has rallied and connected the poster to doctors all across the world. And when a member isn’t connected to the hospital or able to help, she will reply BUMP (bring up my post) so the emergencies will go to the top of the list until their PMG sister’s need is met. It is swift and incredible how many total strangers but virtual friends will hug you through the internet at any given moment to honor and support their tribe.

The PMG sisterhood has suffered some losses recently. Sarah Beadle, an EM doc, tragically lost her life while trying to save her two children as they were hiking in the Grand Canyon. Her children survived, as did her legacy. The PMG has participated in a meal train service for her family, fundraising, and memorial services. Likewise, Dr. Christina Bereda was driving with her three young children when they were struck by a semi truck. Only one of her children survived. In true PMG fashion, the generous outpouring of love and support (meals, financial) has been remarkable. Total strangers are online family, and the losses have strengthened the PMG bonds.

Sabry remarked, “Clearly we have moved far beyond my simple hopeful success – and now our goals are set so much higher! We would love to have an organization which formally offers so many resources women physicians need that aren’t available just yet. We would also love to partner with other medical organizations to give a stronger voice to their women physician members and issues affecting recruitment, retention and equity of female physicians.”

The group continues to grow in new directions, from PMG retreats to local meet-ups to partnering with professional organizations to support physician moms in the workplace. PMG has partnered with HealthECareers as a way to communicate with employers the vital concerns on best practices for the recruitment and retention of physician parents. The PMG is helping to lead the way and blaze a trail to improve treatment of physician parents. The group has even been featured in Forbes Online, helping to give a voice to the ongoing compensation disparities that female physicians continue to face.

The Physician Mom Group began as a small group of doctor moms looking for their tribe. Now, the support system, advocacy group, and friendship circle has become a force to advance women physicians worldwide.


Image at the top – Sabry and company have branched beyond Facebook into hosting events, such as a three-day “girls weekend” in Palm Springs that includes spa treatments and a personal chef.

The post How the PMG Became the Mother of All Physician Support Groups appeared first on Emergency Physicians Monthly.

The Calculus of Emergency Medicine

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Have you ever dealt with a patient or specialist who is confused about the scope of emergency medicine? Here’s a quasi-mathematical way to think about it.  

As a relative newcomer to the pantheon of medicine, emergency medicine sometimes requires more of an explanation than other specialties. Patients ask emergency medicine residents, “So what type of doctor do you want to become?” Older attending physicians of other services often seem unfamiliar with the full scope of emergency medicine practice, which now may be quite different than during their years of training. In all fairness, defining emergency medicine does require a different approach than defining other realms of medicine.

Unlike most medical and surgical specialties, emergency medicine does not address a specific organ system or disease process, as in cardiology or oncology. Nor does it limit itself to any specific diagnostic or treatment modality, as in radiology or anesthesiology. We also work in a liminal space between inpatient and outpatient medicine. And while it’s a good start to simply state that emergency medicine deals with emergent pathology, treating truly emergent pathology constitutes a small percentage of how our time is spent in a modern emergency department.

I have developed my own approach to explaining to medical students how to conceptualize the practice of emergency medicine. I explain it using the concept of derivatives. Students are closer to the study of calculus than I am, so I lay it out in the simplest terms possible, without using any numbers, to avoid embarrassing myself. It goes something like this:

Imagine that we can predict the full course of a disease process and model it as a mathematical function. The x-axis is time, the y-axis is health. As an example, consider the hypothetical course of a patient with coronary artery disease presented in Graph 1 below. At the start, the gradual process of atherosclerosis advances slowly and persistently. Then one day, with little warning, a plaque ruptures and causes an acute myocardial infarction. The patient promptly seeks medical care and the coronary artery is appropriately reopened, reperfusing the myocardium and stabilizing the patient. As a result of the MI, the patient develops congestive heart failure. For years they intermittently suffer and recover from CHF exacerbations. Throughout this time, their ejection fraction gradually deteriorates and they eventually die.

Now let’s look at this model in terms of derivatives. The first derivative (the slope at any given point) of the mathematical function of a patient’s disease course is the rate at which a patient is moving from wellness to death. At Point A in our example patient, with the slow progression of atherosclerosis, the patient moves towards death at a constant but slow rate. At Point C, in the midst of a myocardial infarction, the patient moves towards death at constant but fast rate. Patients moving at a high rate are “sick,” patients moving at a low rate are “not sick”. When emergency physicians identify a sick patient, moving towards death at a high and constant rate, we are tasked with decreasing that rate–we resuscitate the patient. When we identify that our patient is at point C on their illness curve, our role is to bend that curve to a lower rate.

But resuscitation is a small part of our job. The rest of our job can be better understood with the concept of a second derivative (the rate of change of the slope of the function at a given point). On a patient’s illness course, the second derivative is essentially the rate at which a patient is becoming more or less sick. It represents a change in the trajectory of their disease course. As emergency physicians, we search for points on a patient’s illness trajectory when the value of the second derivative is high. At these inflection points, a patient may not yet be moving rapidly towards death, but the rate which they are moving towards death is increasing; they are becoming sick. On our example chart, this is point B. The patient’s ruptured plaque is growing and be-coming a major ischemic event, and while the rate at which the patient is moving toward death may be currently slow, that rate is increasing.

Most of our time as emergency physicians is spent estimating this rate of change at which a patient is becoming more or less sick. This estimation drives the other key roles of our specialty: identifying dangerous conditions and determining appropriate disposition. It requires us to obsess over risk stratification and prognosis even more than other specialties, trying to determine where a patient lies on their illness curve. Is this patient with chest pain at Point A, moving to-wards death at a slow and constant rate, or point B, at a currently slow but rapidly increasing rate? Will this patient’s pneumonia improve or worsen if I treat them as an outpatient? Did I just appropriately treat this patient’s migraine or did I mask the sentinel bleed of their sub-arachnoid hemorrhage? Answering these questions is no easy task, in fact often harder than decreasing the rate of change when we resuscitate a patient. This role as skilled decision-makers in patient disposition places us in a critical position in the continuum of care.

Usually, at this point in my overly pedantic explanation, the medical student’s eyes have glazed over. But if they have continued to pay attention, I think they progress beyond a glamorized version of emergency medicine towards a more realistic understanding of our very difficult specialty.

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ABEM Should Set an Example for Board Transparency

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ABEM is growing wealthy, alongside the other medical boards, but they should remember their roots and choose a path of transparency.

Drolet and Tandon, in their research letter to JAMA on August 1, dug up some numbers and gave some context to what a lot of practicing physicians were undoubtedly wondering: How does my specialty’s medical board finances compare to others? And the authors begin to shine a light on the question: What are my exam and MOC fees paying for?

ABEM acquits itself well enough. Emergency medicine has the least expensive written board certification fee among 24 specialties – and the only one under $1000. Our overall certification and MOC fees were around the mean for medical boards.

But the JAMA paper shows, in general, medical boards enjoyed an average annual growth rate of 10.4% over the period from 2003-2013, nearly tripling their net balance (assets minus liabilities) which rose to a cumulative $635 million. Wow – that is a great run. And this research into finances doesn’t include foundations and board subsidiaries – if anything, the revenue gains by medical boards are underreported here.

The vast majority of this revenue to these non-profit medical boards is coming from a captive audience of physicians, paying fees. I think it’s fair for physicians to ask, however, why it was necessary for ABEM to raise so much revenue over that time period. It’s possible, I suppose, that board exams are getting more complicated to write and administer. One might think that teleconferencing and web communications would make it easier and faster to write exams. One might think moving from paper to computer-based testing would decrease expenses. Instead, the opposite seems to have occurred.

As is typical for non-profits, Drolet and Tandon’s research shows almost half of revenue is going to officer and employee compensation. So again, questions come to mind – Did the medical boards go on a hiring spree? Or did everyone just get big raises?

There’s a lack of transparency, and an increasingly transactional feel, to the act of certification. When I signed into ABEM.org last fall, I was prompted to agree with a new mandatory arbitration clause, as well as ABEM’s sharing of my personal information with Elsevier. There’s no opt-out, and no explanation of why these measures are necessary, let alone desirable.

Look, every EP owes a huge debt of gratitude to ABEM. Emergency medicine’s existence as a specialty was by no means assured in those early years – it took the effort and brains of a dedicated group at ABEM to silence the critics and blaze this trail.

But ABEM would do well to remember that pioneering spirit today. There’s widespread dissatisfaction among physicians when it comes to our various specialty medical boards. MOC and its associated fees have quickly been adopted and standardized across specialties, without much discussion or evidence. A 2016 survey showed that only 15% of physicians felt MOC was worth the effort; 81% believed it was a burden.

The AMA has come out against MOC, and in August, 33 state medical societies and several national specialty societies – including ACEP – signed a letter to ABMS, highlighting member concerns with MOC. These groups are concerned that a MOC process that’s seen as expensive and irrelevant to practice is a threat to physician self-regulation, and are urging a path forward to solving this, before state legislatures develop their own solutions.

Our specialty exists today because there was a need, and emergency medicine constantly had to assert itself over objections from the other houses of medicine, to best serve patients. ABEM should remember its roots at a time like this. Instead of falling in line with the other medical boards and striving for the mean among specialty fees, ABEM could light a path among medical board, choosing transparency. Let emergency physicians know what their certification fees are buying – and why board revenue needs to rise. Let emergency physicians know what’s behind the arbitration clause and Elsevier agreement.

I am grateful for all that ABEM has accomplished for our specialty. But EPs are a captive, vulnerable audience (if board certification seems expensive, the alternative is even worse). ABEM has an opportunity to inspire a new generation of emergency physicians – just when medical student debt and regulatory burden is at its highest. “This is what everyone else is doing” has never been good enough for emergency medicine.

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Do EPs Need to Unionize?

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Emergency physicians often find themselves on an uneven playing field when it comes to contract negotiations. And yet a union’s greatest weapon – the strike – runs contrary to the ethos of emergency medicine.

Emergency physicians today often find themselves on an uneven playing field with their employers. Emergency physician practices have become increasingly consolidated, with a disproportionate number of emergency physicians now employed by large contract management groups or by large hospital networks. Several of these employers have multi-billion dollar market capitalizations, thousands of employees, and substantial legal resources, creating a huge power imbalance compared to an individual emergency physician employee.

Many large emergency physician practices insist upon draconian employment contract terms, such as waiving the physician’s right to due process or imposing restrictive covenants prohibiting the physician from working in the area with a future employer. Lack of transparency is standard, i.e., most physicians in large practices cannot see what is billed or collected in their name, even though they are potentially responsible for any billing fraud. The physician practice has much control over the physician’s ability to make a living, including the ability to limit hours or take the physician off the schedule entirely. Many large physician practices and hospital networks, often controlled by non-physicians, are aggressively blurring the line regarding the “practice of medicine,” setting clinical expectations and metrics that are not compatible with patient safety or physician well-being. Unfortunately, due to this uneven playing field, individuals employed as emergency physicians face tremendous difficulty in advocating for practice rights, fair working conditions, and fair compensation for themselves, as well as advocating for patient safety and the autonomy to practice emergency medicine as they feel is in the patient’s best interest.

Within and outside of healthcare, unions have afforded an opportunity for groups of individuals to band together to advocate for their interests through collective bargaining. Salaried physicians in the U.S., whether employed by a private company or the government, can currently join a union and collectively bargain. Non-salaried physicians can join a union as individuals but cannot collectively bargain. Unions for healthcare workers are not unusual in the United States. In fact, 13% of all healthcare workers are unionized, slightly higher than non-healthcare workers. The largest U.S. nursing union, National Nurses United, has ~ 190,000 members. Nursing unions have helped to improve nurse working conditions and salaries. However, opponents have been critical that nursing unions may drive up costs and could have a negative impact on patients due to actions such as strikes and nurse/patient ratio mandates.

The American Medical Association created a physician’s union, Physicians for Responsible Negotiation (PRN), in 1999. The PRN leadership took the position that they would never call a strike, which significantly limited PRN’s potential clout during collective bargaining. Just five years later, PRN was shut down, after only signing up about 40 physicians.

In 2016, after three years of negotiation, resident physicians working for the United Kingdom’s National Health Service (NHS) went on a series of strikes in response to the NHS’s plan to expand required after-hours work and limit the pay for this work. Ultimately, the strikes ended with little change in policy, and the perception of physicians by the public was tainted.

Even the U.S. is not immune from the physician strikes. In 2015, physicians staffing student clinics in the University of California system went on a limited strike for one day in January and four days in April, after failing to come to terms regarding working conditions and compensation over 50+ negotiating sessions. The Union of American Physicians and Dentists (UAPD), the largest physician union, led the strike, which was its first in its 44-year history.

An emergency physician union would need to have the ability to strike to maximize its effectiveness. However, a strike by emergency physicians would be an extremely serious action, with the possibility for significant adverse impact on our patients and our communities, as well as emergency physicians’ public image. An emergency physician strike would be an incredibly powerful and dangerous weapon. Emergency physicians have proven themselves time and time again as the champions of the most vulnerable patients, often at much personal cost, so I think it would be a huge leap for an emergency physician union to ever put our patients at significant risk.

An emergency physician union that does not strike would not be toothless. Currently, large contract management groups and large hospital networks can easily marginalize or terminate an employed physician who brings legitimate concerns to the table, if they want to eliminate the “squeaky wheel.” With a union collectively bargaining on its members’ behalf, it is much more difficult for the employer to reciprocate inappropriately. An emergency physician union with much representation with a particular contract management group or hospital network could certainly be more effective in negotiating a fair contract on its members’ behalf.  If the employer was unwilling to negotiate in good faith, they could find themselves losing a large portion of their workforce at their next contract renewal date, with the need to expend large sums on temporary coverage in order to ensure continual staffing.

I practice in an independent, fully democratic group with supportive hospital partners. A physician union isn’t the solution for me (and my partners and I would not have the ability to collectively bargain under current law). Unfortunately this is not the case for far too many employed emergency physicians, who simply do not have a fair, respectful, transparent relationship with their contract management network or hospital network employer. For these physicians, a union might make sense. If many large emergency medicine employers continue to let physician practice environment and workplace fairness issues take a backseat to profits, I expect we will see an emergency physician union materialize soon, with potentially major implications for these groups.


Read More

Dr. Judith Tintinalli asks the question, “Do we need to put emergency medicine on the endangered list?”
Gary Gaddis weighs in on emergency medicine’s prospects in Europe.

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