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 first appeared on Emergency Physicians Monthly.

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.

The post The Calculus of Emergency Medicine first appeared on Emergency Physicians Monthly.

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.

The post ABEM Should Set an Example for Board Transparency first appeared on Emergency Physicians Monthly.

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.

The post Do EPs Need to Unionize? first appeared on Emergency Physicians Monthly.

In March of 2017, I was among various members of AAEM who were invited faculty for the 26th Winter Conference for Emergency Medicine and Critical Care in Karpacz, Poland. We were distressed to learn that emergency medicine is under dire threat in Poland.

When a resident matches into a residency slot at a given hospital or university, they may be one of only one to five residents in the specialty, across all five years of training. Further, at most hospitals, the emergency department director must fill an ambitious clinical duty schedule, so that the residents are strongly compelled to repeatedly, week after week, “take one for the team” and fill unscheduled hours as an independent contractor. The EU has work hour limits, but it is difficult for the resident to decline a chairman’s “request” to work beyond these limits. Some Polish emergency medicine residents spoke of being on clinical duty in excess of 90 hours per week. Is it any wonder that Polish EM residency training programs have such difficulty attracting new classes of trainees, and that the majority of “open” positions in EM go unfilled each year?

And it’s not just about the residency hours. Even after graduation, working conditions in Poland are so bad that many recent residency graduates actually commute to Great Britain to work in their National Health Service, because the working conditions in Britain are so much better.

Reading the previous sentence should give you pause. As you may be aware, British emergency physicians engaged in widespread strike activity earlier this year when health ministry leaders there essentially mandated that British emergency physicians work more evening, night and weekend hours than before, without a commensurate adjustment in pay.

The fact that Poland’s young emergency physicians voluntarily flock to the British system, which has been beset by strikes by its own doctors, puts the ongoing calamity faced by Polish emergency medicine in stark relief.

The elected government in Poland, leading a populace that became accustomed to free healthcare during its Communist era, doesn’t seem to understand that health care workers will become unlikely to willingly show up for clinical duty if they aren’t given a workable system while earning a competitive wage.

Read More

Dr. Judith Tintinalli asks the question, “Do we need to put emergency medicine on the endangered list?”
Dr. Mark Reiter asks the question, “Do emergency physicians need a labor union?”

The post In Poland, EM Labor Battles Are A Matter Of Survival first appeared on Emergency Physicians Monthly.

Dear Editor,

In his opinion column, Nicholas Genes, MD, PhD, maintains that ABEM should set an example of transparency, particularly financial transparency. We believe we have. ABEM complies with all federal reporting requirements, making detailed Form 990 financial information available to anyone. At the recent 2017 ACEP Council, ABEM presented distributions of assets and expenses, and our Annual Report will include that information, plus detailed tables and graphs about ABEM’s assets, revenue sources, and expense distributions.

ABEM stands by its fiscal decisions. Since 2008, the stock market tripled, and so have ABEM’s holdings. The result has allowed ABEM to hold fees fixed the past six years, which has saved ABEM-certified physicians $1.24 million. The new, computer-based Oral Examination is extremely expensive, but the additional cost has not been passed on, saving early career physicians $1.3 million every year.

ABEM’s largest expense (about 40 percent) is allocated to staff – not surprising, as staff helps develop, administer, score, and report examination results. ABEM has not gone on a “hiring spree” or given “everyone…big raises.” ABEM has 41 employees, and has grown at the rate of one person per year over the past eight years to address the annual growth in our specialty. ABEM’s compensation is benchmarked by independent consultants, with physician pay based on Association of American Medical Colleges indices.

ABEM receives over 20,000 survey responses from emergency physicians every year and we read every one. We publish many of our surveys – the good and the bad – to provide the Emergency Medicine community helpful information. ABEM recently reached out to every ACEP state chapter and the leadership of AAEM and ACEP, for ideas about MOC.

To suggest that ABEM is doing “what everyone else is doing” is incorrect. ABEM is proud of the good work of our 19 volunteer directors and 500 physician volunteers. We welcome continued conversation about how ABEM can be in greater service to the physicians in the greatest specialty in medicine.

Sincerely,
Terry Kowalenko, MD
ABEM President

The post ABEM President Responds to EPM Critique Calling for Greater Transparency first appeared on Emergency Physicians Monthly.

The book “Why Hospitals Should Fly” misses a big part of what makes emergency medicine unique.

When I went through orientation at my latest hospital, there was a lot of talk about building a culture of patient safety and emphasis on how the organization wanted to reach that goal. As part of that effort, we were all asked to read the book Why Hospitals Should Fly.

Now, I’ve been an Air Force officer for over a decade. I’m a graduate of the U.S. Air Force Academy. I was weaned on aviation metaphors and the culture of safety that protects our aircraft. I eagerly started into the book. I only made it a few pages before I threw it down in disgust.

Why does that book annoy me so much? People aren’t planes, and trying to equate a machine to a complex biological system with free will is disingenuous at best. Many techniques that we borrow from the aviation industry are good steps toward safety, but checklists and call backs won’t fix safety in medicine. There are key provisions that we allow pilots that we do not allow physicians, and that omission undermines all of our safety.

I’ve flown a few planes in my time, but I’m a terrible pilot and should remain in the passenger seat for all of our sakes. However, I still remember the bold faces and check lists. I am familiar with a lot of the procedures that keep even incompetent pilots like me safe. By contrast, I’m a damn good doctor. I’ll tell you the difference in how those two roles function.

1. We don’t get to preplan our missions – Pilots carefully preplan every mission they take. They calculate fuel, weight, distance, weather, a million variables. They are able to control for all of those things, and if things don’t look right, they stop the planning process and the mission is scrubbed. How often do we get to work to be told the CT scanner is down? Or that we’re out of saline? I had one memorable day that we ran out of all morphine, fentanyl, and hydromorphone in the hospital. The logistics folks suggested I use meperidine. I closed the ER to all ambulance traffic until they were able to find an alternative, and the C suite lost their mind. Would you ask a pilot to fly if the ground crew was out of hydraulic fluid for the plane? Of course not. That would be dangerous. We deal with supply shortages and maintenance failures every day, and are expected to safely make do without. 
2. We can’t insist on perfect staffing – Every member of the flight crew has a specific function. Large aircraft have pilots, copilots, navigators, flight engineers, load masters, and multiple other essential personnel. If one of them is missing, the plane doesn’t take off. How many people have had a flight delayed because the airline was waiting on a crew member? Lots. How many times does your ER or hospital function with less than full staffing? Mine does it daily, because we don’t have enough nurses to safely staff our ER. Planes don’t take off without a full crew, because that would be dangerous.
3. Medicine is too complex for pre-flight checklists – Have you ever tried to land a septic 90 year old? How about bring a 25 week precipitous delivery with no prenatal care down on a correct glide path? Medicine doesn’t follow these neat rules. We have guidelines but the infinite variability of biologic systems makes it impossible to have a set plan of care predetermined for every situation. The septic 90 year old and the precip 25 weeker would never pass the preflight inspection. No pilot in her right mind would take off with the kind of odds stacked against her with some of these high risk presentations. However, especially in emergency medicine, we’re handed these mid-air inflight emergencies that are in progress and have to try to safely navigate them down. We don’t have a choice in the takeoff, but we’re still expected to land safely every time.
4. Docs don’t get to focus on one patient at a time – Pilots are responsible for one plane at a time. They have other people who help them avoid others who are also flying in the area; they are called air traffic controllers. While I’m on shift, I will have anywhere between a dozen and 30 individual flights take off and land, with no one to help me run interference. Some of these are short puddle jumps, and some are epic journeys with bad weather, dangerous approaches, and difficult landings. When an inflight emergency occurs, all other flights are diverted, and full support is given to the emergency to get them landed safely as soon as possible. There is no mechanism to support this in modern emergency departments. In fact, I usually get a nasty comment from the next patient because they had to wait so long.
5. We can’t abort the mission – In the end, the pilot has the ultimate safety tool. It’s called the safety of flight rule. A pilot can ground a mission for any reason if he has a valid concern that something may endanger the safety of flight. The pilot is the final ultimate authority on if that aircraft takes off, and the aviation industry honors that responsibility by giving him the authority to intervene if something threatens that aircraft. Can you think of a shift that you took over a department that you would have called a safety of flight risk and aborted the mission?
6. Our mistakes don’t make headlines . . . and that might be a problem – Physicians and pilots hold lives in their hands every day. When a pilot makes an error that kills people, they usually do it in a spectacular manner which is splashed across headlines for weeks. Physicians and hospitals allow many smaller errors to occur, and statistically cause many more deaths than commercial and military aviation every day. The medical errors are not as sensationalized, because we usually only kill one person at a time. However, the cumulative weight of these errors could fill two 777 jumbo jets per day. Some researchers into patient safety estimate that medical errors contribute to 210,000 deaths per year, or roughly 575 patients per day across the US.

Conclusion
Patients are not planes. Our jobs are exponentially more difficult because of the variability of human physiology. Please don’t tell me if we would all just be more like pilots, we would stop hurting people. However, there are lessons from aviation that we can, and should take to heart. We need no fault incident analysis and we need standards for minimum staffing, supply, and maintenance standards so that we can hold our hospitals accountable. Fatigue management systems should not just consist of more caffeine, but rather comprehensive change to staffing and shift design to safeguard our patients. When we are handed mid-air catastrophes, we need support to deconflict other flights and help us land safely. Finally, we need to empower physicians to raise safety of flight concerns when patients are being endangered by conditions in our hospitals, and instead of crucifying doctors who raise these issues, they need to be rewarded for being patient safety advocates.

Two Boeing 777 planes a day is a lot to crash. If we were afforded some of the protections built into the aviation community, we could make significant strides in patient safety.

Three legitimate Lessons Emergency Medicine Should Learn from Aviation

1. Sleep is sacred – Sleep is a sacred right for pilots. Pilots must have protected rest time, called crew rest, before they are allowed to take the controls. If you look at requirements set out by the Air Force, they require 10 hours of restful activity in the 12 hours prior to flight. Then, depending on how many pilots there are staffed on the flight, they may only fly 12-16 hours before they must sleep again. Commercial aviation is limited to 30 flying hours in any 7 day period. Those numbers seem almost laughable when we debate duty hours restrictions for residents. We allow doctors to almost triple what we allow pilots, and we not only allow it, we expect it. The FAA has a long paper that talks about the effect of fatigue on safety and flight performance. The house of medicine should do a little research and see what aviation already knows about sleep and safety.
2. When mistakes happen, look for solutions, not scapegoats – When an aircraft mishap happens, there is a board from the FAA who investigates every bit of the incident. Pilots, ground crew, maintainers, flight attendants; they all get drug testing, interviews to account for days before the incident, examinations of flight logs, maintenance logs, every record available, plus flight data recorders and in person interviews. This is all done in a non-partisan non blaming way to find all of the errors that led to the incident. In medicine, we call this many names: standard of care review, root cause analysis, morbidity and mortality conference, witch hunt. Medicine has much to learn from the impartial aviation investigations that aren’t looking for someone to blame, but are instead looking for the factors that allowed an incident to happen. They start out with the assumption that everyone is smart and qualified for their job, and look for factors that degraded that ability. In medicine, it seems that we assume someone is incompetent and look to prove that. Much of this is our own fault; we need to get better as physicians in advocating for a non judgmental process for looking into medical errors to identify systems issues, including things like fatigue management, substance use, cognitive fatigue and overload, crowding, supply and maintenance issues, and staffing.
3. Find better ways to assess patient satisfaction – The last time I flew, I received a text message with a survey while I was waiting for my luggage. It was about five questions long, and they asked me while I still remembered everything about my flight. I would argue this is better methodology than Press Ganey. They asked about the gate agents, the flight attendants, the baggage service. There was not a single question about whether or not the pilot was nice to me, or if I felt like he cared if I liked the inflight snack. The pilot’s job is to get the plane to its destination safely. Period. My job as a physician is to get people safely through their illness, but I often tell them things they don’t like. I tell a woman she’s lost her early pregnancy. I tell a chronic pain patient that he nearly died because of his opiate pain medication, and that I will not be giving him more. I tell smokers to put down their cigarettes. I tell people with viruses that I’m not treating them with antibiotics. I can do that all in a nice manner, but sometimes those messages are not pleasant nor well received. That does not mean that I have failed my primary job of getting a patient through their illnesses safely; in fact, it reinforces that goal. But it doesn’t make patients happy.

The post Why “Be More Like Pilots” Just Doesn’t Fly in Emergency Medicine first appeared on Emergency Physicians Monthly.

The growing role of clinical informaticists in making EHRs more satisfying.

Last month I reflected on the 10 years that have passed since the Meaningful Use incentive program spurred widespread adoption of electronic health records (EHRs). In EDs, we mostly went from an eclectic mix of paper systems and customized (‘best of breed’) ED information systems, to a state where most EDs are functioning on one of several ‘enterprise’ vendors like Epic, Cerner or Meditech.

Using an enterprise EHR system, particularly in the ED, wasn’t very fast or efficient, but there was a hope that the mass influx of customers would drive improvements in usability.  Instead, studies show EHR usability remains poor, and in fact contributes to physician burnout.

In Part 1, I covered some modest improvements EHRs have introduced to patient care and safety, but at significant cost. In this final part, I’ll talk about some specific shortcomings of EHRs that, 10 years ago, seemed poised for improvement, and yet continue to persist. I’ll highlight the growing role of clinical informaticists in making EHRs more satisfying and efficient for doctors, and safer for patients.

The Unrealized Promise of Clinical Decision Support

Clinical Decision Support (CDS) takes many forms – from subtle nudges to hard-stops. Ten years ago, CDS was basic, inelegant and heavy-handed – and it hasn’t gotten nearly as sophisticated as I had expected it would.

I can’t say it’s all bad. Protocols implemented through the EHR have led to improved outcomes and efficient throughput, for well-defined entities like stroke and STEMI. We’ve also seen and reduced error and promoted standardization for things like procedural sedation and post-intubation care. But for less clearly-defined ED presentations, like sepsis or CHF, we find ourselves often battling against the EHR’s suggestions.

Trying to manage a young, otherwise healthy ED patient with the flu in 2020 is an exercise in frustration – constantly dismissing pop-ups and alerts about ordering serial lactates, and 30mL/kg of fluids, and prompts for special SEP-1 documentation. This effect is insidious, and ultimately leads to more workups for minor complaints – it’s just the path of least resistance.

We have mountains of evidence that the majority of drug-drug interaction warnings are worse than useless: they’re routinely ignored, which leads to alert fatigue, which means the occasional important warning is also missed.

Countless mitigation strategies have been proposed and evaluated, including pharmacy-driven monitoring of alert responses, and clinician-driven ratings of alerts. Researchers estimate that it takes hundreds of alerts to prevent one true adverse drug event, and that the volume of alerts could be cut by more than half without appreciably increasing risk to patients.

A few institutions have developed progressive alert monitoring strategies: they have infrastructure to collect and act on feedback, and have cut back on the volume of alerts, or tailor future alerts to the appropriate audience. Yet for the most part, US hospital administrations are fearful of rolling back anything that may lead to a bad outcome. Most of us continue to click away, despite the alert fatigue and evidence for safe alternatives.

At the start of the last decade, I naively assumed that a lot of the mindless cruft that got entered into charts would get cleaned up. But it’s 2020 and we still see too many allergy alerts that are meaningless, or just wrong. Wouldn’t someone, or some bot, go into each chart and decide that vomiting with codeine wasn’t actually allergy, and shouldn’t pop up when docs are ordering a fentanyl patch?

Or take the patient who has reported a penicillin allergy — if they’ve received Keflex on other occasions without incident, can’t the EHR suppress a warning when the doc is ordering a cephalosporin? Yet, any kind of rollback of alerts, or bulk-editing of charts, is viewed as too risky.

Further, I had expected for context-aware alerting to be more widespread by now. A good example is mixing heparin and aspirin — EHRs typically discourage mixing anticoagulants with big, bold, red warnings — even in cases where it’s indicated, like an NSTEMI. You’d think by now, an EHR could “detect” an elevated troponin and guide physicians through an NSTEMI protocol, but instead it continues to caution EPs trying to do the right thing.

Similarly, the new radiology decision support mandate (Appropriate Use Criteria for CTs and MRIs) is another a missed opportunity. If we had systems that used natural-language processing of our notes, and took chief complaint and other factors (pregnancy, creatinine) into account, that might be worth something.

But instead, this primitive pop-up usually forces the ED doc to pick a diagnosis from an unintuitively categorized drop-down list that includes mostly non-emergent conditions, and routinely recommends an MRI instead (the system never understands that we’re in the ED and it’s 3am).

After years of hearing about the benefits of big data, we’re only now starting to see alerts based on predictive analytics.  Our shop has been looking to implement predictions for inpatient admission — the promise is that, behind the scenes, the EHR can look at a patient’s demographics, vitals and lab results, and predict admission about an hour before the ED doc activates the admission.

Our case managers and bed planners say they’d find this extra lead time helpful, even if it’s occasionally too sensitive. I worry that the computer’s prediction will cause us to second-guess ourselves — this occasionally happens with EKGs, for instance, but at least EKG criteria are finite and readily verifiable — it’ll be harder to debate a Greek Oracle. And, as with sepsis, how many times will we take the path of least resistance, admitting a patient who seems well, rather than taking a risk and documenting our disagreement with an algorithm?

Things EHR could’ve fixed — but didn’t

Some frustrating aspects of practicing medicine in the US today aren’t necessarily the fault of EHRs themselves. They could be the effect of local implementation decisions, or responses to regulations. Yet EHRs seem to have highlighted these problems, or encouraged them.

Take e-prescribing. Please. This was billed as a solution to the problem of Rx pad legibility, and gave agencies access better access to drug prescription data, making prescription drug monitoring programs (PDMPs) possible. Some states like mine mandate it. But, when you have EHRs that can print Rx, you’ve already solved the problem of legibility (and you’ve also got order sets and error-checking to minimize inappropriate choices and doses). Plus, pharmacies already contributed data to prescription drug databases to cut down on drug diversion — they never relied on e-prescribing.

And e-prescribing doesn’t work like modern cloud-based messaging – you can’t write an e-prescription and have your patient pick it up anywhere. Instead, you’ve got to send it to a specific pharmacy. It’s like faxing, only without confirmation the message went through. So what do we gain by e-prescribing?

From my ED perspective, we gain nothing — and we lose a ton of time helping stuck frustrated patients, by re-routing prescriptions to pharmacies that are open later, or aren’t running short of the drug the patient needed. We lose a lot of time entering and re-entering pharmacy addresses into the chart. The patient loses the ability to comparison shop. E-prescribing has been an expensive, frustrating, time-wasting replacement of a serviceable paper system — sort of a microcosm of many complaints of EHR.

The informatics textbooks say, to properly implement an electronic system, you should redesign the entire workflow, and not just digitize a byzantine, paper-based process. But too often, that’s exactly what happens. For instance, there’s a good chance when you order a CT scan with IV contrast, you’ve got to print out a form about contrast reactions, for the patient to fill out and bring to Radiology.

There’s no option for the provider to fill out the questions in the EHR, or to give the patient a web-based form on a tablet — no option to even scan the paper into the chart. Why not? Radiology was probably reluctant to train their techs to use the EHR, to log in to view responses. Fewer clicks for their staff forced a more convoluted process upon the rest of us.

Similarly, anytime I watch a nurse waiting on hold to “give report” before a patient can go upstairs, I see a failure to adapt workflows to the electronic era. Every time I have to recite a patient’s history and labs to a consultant, or call a clinic to arrange a follow-up appointment, it’s a lost opportunity to take advantage of the information in the EHR. I’m not saying “warm handoffs” and human conversation are inherently wasteful, but too many workflows don’t even incorporate the EHR, let alone leverage it to make calls brief and timely.

Enter the Informaticist

Emergency Medicine is still considered a young field. Clinical Informatics (CI) — the study of information technology and how it can be applied in healthcare — is even younger. The first subspecialty CI board exams were offered in 2013, at the height of Meaningful Use adoption. There are now dozens of ACGME-accredited Clinical Informatics fellowships, and ACEP’s Informatics Section boasts 400 members.

It’s a start. There’s emerging evidence that departments with dedicated clinician informaticists have more satisfied docs. This makes sense: informaticists can’t rewrite the code behind an EHR like Meditech or Cerner, but they can smooth out some rough edges, and streamline common workflows. Informaticists can identify docs who aren’t making the most use of EHR automation and personalization tools, and work with them to bring up their efficiency. When a well-meaning administrator wants to ensure compliance with some new mandate, the local informaticist can work to insert it into clinical workflows so it’s not such a disruption.

Informatics is a natural fit for the ED — nowhere else in the hospital is it as crucial to bring together patient data, records and evidence-based guidelines to help bedside decision-making. It’s what initially drew me to this new subspecialty. I’ve since been immersed by efforts to make our system more capable, intuitive and efficient, for me and my colleagues. And there’s plenty of work to be done (I doubt any enterprise EHR vendors made a sale to the hospital C-suite on the strength of their ED module).

Medicine and EM in particular need more informaticists, but I think we can also do more with the informaticists we already have. This fall, I had the honor of being named as the first chair of ACEP’s new HIT committee. Our purpose is twofold — to gather and disseminate best practices for making the most of your EHR — be it documentation, or achieving interoperability or submitting quality metrics. Our second goal is to work directly with vendors, other medical societies and policymakers on improving the experience of EHRs.

Our committee has lofty goals, and the support of ACEP leadership. Most importantly, we are motivated by tens of thousands of practicing EPs who want a better, more efficient experience using their EHR to care for patients. It’s these voices that will guide us, as we work to make sure the next 10 years of EHRs in the ED are more satisfying than the last 10.

The post Meaningful Use, 10 years Later Part II first appeared on Emergency Physicians Monthly.

Even as legislation makes it more challenging, physicians have to provide the best care for their patients.

What are the ethical obligations of a physician when laws are in conflict with patient care?

Regardless of one’s political opinion, we have reached a place where we must call upon medical ethicists to help lead the way in clarifying ethical physician behavior.

I just read an article from Associated Press that reported in part about Dr. Jessian Munoz, an OB-GYN in San Antonio, Texas, who treats high-risk pregnancies. Munoz said doctors are struggling to decide if a woman is “sick enough” to justify an abortion when they develop pregnancy complications.

In the wake of the recent Roe v. Wade decision, Munoz lamented “the art of medicine is lost and actually has been replaced by fear.”

Munoz faced a scenario with a recent patient who started to miscarry and developed a dangerous womb infection. Since the fetus still had signs of a heartbeat, Texas law made the typical standard of care — an immediate abortion — illegal.

“We physically watched her get sicker and sicker and sicker” until the fetal heartbeat stopped the next day, “and then we could intervene,” he said. The patient developed complications, required surgery, lost multiple liters of blood and had to be put on a breathing machine “all because we were essentially 24 hours behind.’’ (1)

Do Your Duty

How does the duty of the doctor differ from the obligation of law enforcement officers who stand outside a classroom when children are being executed?

As physicians we have always expected ourselves to perform to the highest ethical standards.  There are many situations where conflicts exist.

We know that too much morphine can cause respiratory depression and death.  Yet we understand that a dying hospice patient should not be in pain.  We know that if we give adequate medication to manage their pain, they might succumb from respiratory depression.

And we understand that the intent was not death, but pain control and that it is ethically appropriate to treat the pain.  I would also argue that it is morally incumbent upon us to treat pain.

Given a woman who is bleeding to death and septic, the life of that patient requires intervention that will result in fetal loss.  The intent is to save her life.

Legal Interference

Legislators have demonstrated time and again that they do not know or understand medicine. Nor should we expect them to.  They are not doctors, they are legislators.

Yet, for some time now, we have allowed them to dictate rules for physicians.  How many of us now have to follow rules about pain medications for our patients?

But for doctors to lie down in a fetal position and cover their eyes and ears out of fear, when they know patients are dying in front of them (or worse, telling them to go home and die), cannot be considered moral practice or ethical behavior.

Doctors have a higher duty to take care of patients. It has often been said that the practice of medicine is a vocation.  We don’t just sign a contract for a job.  We take an oath and are committed to protect the health and life of our patients. There is always the potential of unintended consequences we have to accept.

Patient Care Still Priority

Now, more than ever, we need to ensure the privacy of our patients’ medical records and to deliver life-saving care. We need to define for our legislators what the overturn of Roe vs Wade means.

• Legal termination of pregnancy is no longer allowed. That is, elective termination dictated by a patient’s choice not to be pregnant.
• It does not have relevance to a patient with a spontaneous abortion. Nature has already aborted the fetus; the doctors just need to save the mother from those complications.

Doctors need to clarify to legislators the difference between these situations.

We need to practice medicine ethically.

We need our heroes to show up now.  We need our leaders to put themselves on the line to lead the way.

(1)Abortion laws spark profound changes in other medical care | AP News

The post “We need our heroes to show up now” first appeared on Emergency Physicians Monthly.

Joining a professional medical organization provides many benefits. Members can network with other professionals who share similar interests and organizations provide access to many educational resources and conferences. Participating in a professional medical organization also allows members to work toward common goals improving the practice environment for physicians and improving the access and quality of care for patients.

It was 20 years ago that I submitted my application for fellowship in ACEP. The day I earned my “FACEP” designation, I was proud. I had reached the pinnacle of my profession. Residency trained, board certified in two specialties, and now a fellow of the organization that was the “leading advocate for emergency physicians, their patients, and the public.” When public officials and news organizations seek information about emergency medicine, ACEP was their first stop. And I was a fellow in that organization.

I became involved in the Medical Legal Committee and met some of the smartest and most influential people in emergency medicine. I remember sitting at the back of the room during my first meeting and thinking to myself “Wow. I can’t believe I’m part of this group.” Through the years, many of those people became mentors with whom I forged long lasting friendships. As I became more involved in the issues affecting emergency medicine, I was elected Chair of the Medical Legal Committee.

We had lively debates during meetings and the resulting policies and recommendations from our committee seemed to further the goals of improving emergency medical care. I remember creating my first policy statement: Admitting physicians have responsibility for a patient once the patient has been admitted to the hospital – even if the patient is being “boarded” in the emergency department. The policy passed through the ACEP Council vote with little debate. From that point forward, physicians could use ACEP’s policy as a basis for clarifying hospital admission policies and could use the policy as a defense against allegations that they failed to actively manage patients being boarded in the emergency department after admission. We really were improving the practice of emergency medicine.

Unfortunately, things have changed.

I proposed another policy: ACEP should extend the ethics procedure for reviewing expert testimony to include experts from other specialties. Currently ACEP members can only file ethics complaints against other ACEP members for egregious expert testimony. Once a complaint is filed, it is reviewed by the Executive Director and one or more committees, then referred to the Board of Directors. If disciplinary action is recommended, a respondent can request a hearing on the matter where evidence can be presented and witnesses can testify. However, non-ACEP members face no scrutiny. If a neurologist testifies about emergency medical care of a stroke, that testimony involves the standard of care for emergency medicine, yet the neurologist is not held to the same ethics standards as an ACEP member.

If the new policy was implemented, ACEP might not have standing to discipline egregious testimony from other specialties, but ACEP certainly could provide due process and issue a written letter of censure if outside experts provide inappropriate testimony about the practice of emergency medicine. ACEP could also notify an expert’s professional society and state medical board of such censure. During debate on the issue, one ACEP member quipped that ACEP’s current system for reviewing expert testimony is similar to having a home alarm system that guards against your own family members, but not against outside intruders. A former ACEP Speaker cautioned that ACEP had more than $20 million in assets that would be at risk from lawsuits brought by aggrieved experts. Nevertheless, the Council voted overwhelmingly in favor of the resolution and there were cheers after the vote.

Nothing happened. An internal e-mail from ACEP’s General counsel lamented that a “mob mentality” took over before the Council vote and that “nothing rational seemed to resonate at that moment.” She opined that a policy of reviewing outside expert witness testimony puts ACEP at significant legal risk and may amount to “witness tampering.” ACEP’s ethics procedures already amount to witness tampering with expert witnesses who are ACEP members if that is the case. The assertion that censoring experts who testify untruthfully could amount to “witness tampering” also demonstrates a lack of legal knowledge. An exception to any allegation of witness tampering is conduct intended to encourage a witness to testify truthfully – which is exactly what the policy was intended to do. I wrote many follow up e-mails to ACEP’s Executive Director over several years asking why the policy had not been implemented.

In one e-mail I provided excerpts from a neurosurgeon’s testimony against an emergency physician stating that it is the standard of care for an emergency physician to insert ventriculostomy shunts in the emergency department. The expert admitted he had not had any emergency medical experience since medical school. After receiving that e-mail, ACEP’s General Counsel said that ACEP had decided not to “carry out the will of the Council” due to issues regarding “jurisdiction and potential liability.” What about the potential liability of ACEP members subjected to egregious testimony? I remember thinking to myself “is ACEP really protecting its members or is ACEP just protecting ACEP?” I considered canceling my ACEP membership in protest. After expressing that intent to one of my mentors, she implored me “Please don’t do it! ACEP needs people like you to speak out.”

I helped draft another policy at the request of the then-current ACEP president. This policy called for states to consider activities involving medical expertise – such as expert witness testimony and insurance coverage determinations from physicians working for insurance companies – as the practice of medicine. Egregious testimony or egregious denials of insurance coverage for patients could then be reviewed by state medical boards and could subject the offending physicians to licensure actions. ACEP supposedly had support for this measure from several other professional organizations and the ACEP Board was reportedly looking forward to implementing the policy. The policy got shelved before the Council meeting. Another pocket veto that took away potential protections to emergency physicians and to patients.

I drafted a white paper about indemnification clauses in physician contracts. Indemnification is a legal concept requiring one party to pay all costs and expenses related to damages another party suffers. If a hospital is sued for a physician’s actions and an indemnification clause is in place, the physician would have to personally reimburse the hospital for all expenses related to the lawsuit. Indemnification clauses can also negate medical malpractice insurance coverage. Indemnification agreements pose a significant financial risk to all emergency physicians. Ask an attorney to personally indemnify you for anything and you’ll be mocked.

Insurance companies have even taken notice of the risk of indemnification – some medical malpractice insurance applications now ask physicians if they have previously entered into any indemnification agreements with other parties. The white paper I wrote for ACEP condemned any form of indemnification in physician contracts. Despite condemning others who demand indemnification from ACEP members, ACEP ironically demands indemnification in its own contracts. Earlier this year I was invited to provide three presentations about medical malpractice at the upcoming ACEP Scientific Assembly. ACEP’s physician speaker agreement contains a broad indemnification agreement which ACEP refuses to remove. Because of this, I turned down the invitation. I’ve been invited to speak in many venues and ACEP has been the only organization to demand indemnification.

ACEP’s Medical Legal Committee was created to develop policies and work on legal issues affecting the practice of emergency medicine. Last year, the Committee received a survey inquiring into which of six gender identities and nine sexual orientation categories respondents fit, whether respondents had experienced “discrimination,” and if there was a “need for more diversity.” The survey sought no information about Committee members’ work experience, professional interests, research, or other areas of diversity. Questions on how answers to those survey questions would help the Medical Legal Committee in its mission were dismissed and a modified questionnaire was submitted to the ACEP Board without further discussion.

I also became disappointed with ACEP’s message boards. In keeping with the advice I was given many years ago, I sometimes “spoke out” about unpopular opinions. However, I also tried to encourage debate about those opinions. When I posted new information about COVID treatment, I was warned not to discuss ivermectin because it was “too political.” When I mentioned the word “ivermectin” in a follow-up post, ACEP censored me. Egregious posts in which ACEP members suggested that patients refusing the COVID vaccine should be refused insurance or even refused medical care went uncensored. Scholarly debate on ACEP message boards apparently can’t occur when positions run counter to ACEP’s political views.

During committee appointments, ACEP makes each member agree to a “fiduciary duty” to other ACEP members. That’s quite a high bar. Fiduciary duty means that each committee member must put the interests of all other ACEP members above his or her own interests. Agreeing to such a duty puts committee members in an untenable position. What if a committee’s action helps most ACEP members but harms a minority of ACEP members? Have the committee members breached their fiduciary “duty” to those that were harmed? Could the committee members be liable to those members for such a breach? Committees work hard on behalf of all ACEP members, but this silly agreement is just another example of how ACEP seeks to protect itself at the expense of its members. How ironic that ACEP demands a fiduciary duty from its members when it won’t agree to that duty itself.

I’m a member of other emergency medicine organizations including AAEM and ACOEP, both of which seem to better focus on the interests of emergency physicians and our patients. I recently renewed my memberships in both those organizations but rejected ACEP’s requests to renew my membership. Now there’s one less dissenting voice in the ACEP echo chamber and one less middle-aged cis-gendered white guy skewing ACEP’s diversity statistics.

ACEP is a once great organization that has strayed from its mission. ACEP has come to value diversity of gender more than diversity of thought. By censoring ideas that are contrary to its political ideology, ACEP values directives more than it values discourse. ACEP appears more interested in furthering the interests of ACEP than with furthering the interests of ACEP members.

I cannot continue to support such an organization. Leaving ACEP will mean I forfeit my once-coveted FACEP designation. It will also mean that I won’t see my mentors, friends, and colleagues at future ACEP meetings. While I’ll miss those times, I’ll also look forward to helping AAEM, ACOEP, and other emergency medical organizations work toward better protecting our profession, our physicians, and our patients.

Disagree with these opinions? Write me and we can discuss them. I promise I won’t censor you.

The post Why I Canceled My ACEP Membership first appeared on Emergency Physicians Monthly.