GLAAEM Newsletter - Fall 2016

In this Issue:

President’s Message

Michael Walters, MD JD FAAEM
President, GLAAEM Board of Directors

Welcome to fall and membership renewal season. I would like to take this president's message to encourage all Great Lakes members to renew their membership in our state chapter division and to bring along a friend. As a thank you to our members and an enticement to garner more, we have lowered our membership dues from $50 to $40 (residents and students can still join at no charge). I know that this does not seem like a lot, but it is something. Right now our membership in the state chapter division stands at 1,034. That is 62% of the available AAEM members in our chapter's geographic area. While we have grown considerably since our inception as a chapter division just a few short years ago, we want more! Just a few years ago we started this chapter division and our membership has grown considerably. However, we are the largest chapter division within AAEM geographically, but not by membership. We want to change that. That is where you, the members come in.

If you are reading this, then you are probably already a member of the Great Lakes Chapter Division and I am preaching to the choir. So, please bring a friend. Talk to your colleagues at work, if they are not a member then get them to join. Heck, have the whole group sign up. Talk to your other emergency medicine friends and get them to join. By the numbers, there are 1,657 AAEM or AAEM/RSA members within the region of our chapter division, and 62% are members. Our goal is 100%. It may take us a few years to get there, but we will. Additionally, if you are at a medical school, sign up medical students. They can be anywhere and join the chapter division.

You might be asking what membership will get you. Well, here are just a few of the benefits:

  1. A subscription to the Western Journal of Emergency Medicine. This is an excellent journal that I have found useful over the past several years.
  2. A local voice to emergency medicine issues. While we are a chapter division comprised of 7 states, our structure includes representatives from each state that bring forth issues. Just this year, we worked with our Iowa representative, Dr. Michael Takacs, on an issue related to Medicaid in Iowa.
  3. A wonderful social at the Scientific Assembly. This has been a great time to meet folks in the chapter division.

Finally, you may be asking what is next. Here are a few of the things we are working on:

  1. Increasing our membership. With increasing membership comes more ideas and involvement.
  2. An annual educational conference. We are looking at having a one or two day conference in conjunction with the Midwest Medical Student Symposium, which is held annually.
  3. Increasing our state advocacy efforts.
  4. An interactive map of CMG penetration in our member states.

I am excited about the future of our chapter division. Please sign up a colleague. Also there will be some announcements coming out in a few months regarding elections. If you would like to be more involved, please consider running for one of the executive positions or as a state representative.

Have a wonderful fall season,

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Michigan Update - The Lost Art of the Physical Exam

Robert A. Hoogstra, MD FACP FAAEM
Michigan State Representative, GLAAEM Board of Directors

I have a confession to make. About a month ago, I took a position at The Medical College of Wisconsin in Milwaukee. Given that my term as state representative for Michigan runs out at the end of this year, this will be my last article for the GLAEEM newsletter and given, I am no longer practicing in the state of Michigan, I thought I would write about something I find a disturbing trend in medicine, the lost art of doing a good physical exam.

I have been practicing for 26 years now and it seems that I am seeing more patients not fully undressed or examined being sent for testing for some form of advanced imaging.

I will admit that doing an unfocused complete physical is seldom helpful, but a focused exam that is congruent with the patient’s chief complaint can be extremely helpful. For example, a complete neurologic exam (including looking in the fundi and checking for Babinskis) in the patient who presents with a headache is rarely done before sending the patient for a head CT. The patient is whisked off to the scanner with their cowboy boots and jeans still on. Usually they at least have a gown on, sometimes thrown over their shirt.

Sadly, I have seen many patients who have had upwards of double-digit head CTs (all negative) for again the worst headache of their life, yet the resident is ready to check the box again for another head CT but failed to do a fundiscopic exam or even a complete neurologic exam. In these cases, if you discuss with the patient that their exam shows no evidence of increased ICP, their neurologic exam and vitals are normal, and all their other scans have been normal (and likely this one will also be normal) the majority of patients will elect to defer another CT scan, which I believe is in the patient’s best interest.

A case that illustrates what I’m getting at presented to me a couple of years ago with a young woman in her 20s with a chief complaint of positional unilateral numbness. She endorsed that her whole one side of her body went numb when she would lie down and resolve when she would sit up. My first impression was that this must be psychogenic in origin, however for some reason I listened to her neck for a bruit (something I hardly ever do and certainly not in a patient without a neurologic complaint). Much to my surprise, I heard a distinct bruit which got my attention, enough to where I admitted her later to find out she had had a carotid dissection that required treatment.

It feels like we spend more time discussing diagnostic pathways that are heavily lab and imaging based and seldom feel comfortable relying on a good history and good physical exam to rule things out. Most testing we do is to rule out disease, often when we know the pretest probability is very low based on out history. Could more diagnostic pathways emphasize the value of a good, normal physical exam? Enough that we would feel comfortable deferring more expensive testing and feel confident in our physical exam findings that we are not missing something? We already have examples of this with the PERC rule reducing the number of CTAs we order for PE and the HINTS exam performing maybe even better than MRI for posterior fossa pathology.

I’ve heard it said that the stethoscope is a relic and will be replaced by the ultrasound machine. I disagree. I see the ultrasound as complementary to listening with your stethoscope, one using your sense of hearing, the other your sense of vision.

Recently, I attended the ACP Scientific Assembly in Washington, D.C. They had breakout sessions that involved honing your physical exam skills. One session was taught by an ophthalmologist on how to do a good fundiscopic exam, including looking for spontaneous venous pulsations and signs of papilledema. Another session was led by a cardiologist on how to listen for heart sounds and murmurs. Yet another session emphasized doing a good knee and shoulder exam. Should we be doing more sessions like this in our teaching programs instead of learning how to play the game to pass the oral board exam? Might honing our exam skills be more beneficial to providing more value to our patient’s care?

Sorry for the rant, but given it is my last newsletter for GLAAEM I wanted to take this opportunity to raise something I feel is an issue. It has been my pleasure and privilege to serve as state representative of Michigan for GLAAEM these last two years and I encourage more of you to get involved with the only organization that truly advocates for the working ED doc … AAEM.

Thank you.

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Opinions expressed are those of the authors and do not necessarily represent the official views of AAEM, its chapter divisions or affiliates.  These articles are intended for the individual use of AAEM members.


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