GLAAEM Newsletter - Winter 2015

In This Issue:


President’s Message

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

As I write this president’s message, Thanksgiving has just passed and the winter holiday season has begun. Typically, this time causes one to reflect upon the year’s past events and to anticipate the possibilities of the coming year. Keeping with this spirit, I thought I would look back at our past year accomplishments and look forward to the goals of 2015.

While our 2014 accomplishments may seem quiet or mundane, they were still substantial for our chapter division. First, we continued to fill our member state and resident representative board positions. Not an easy task considering the size of our chapter division. Dr. David Cheng joined the board as the representative from Ohio, and Dr. Jayna Gardner-Gray joined the board as our second resident representative. Second, after finishing our first round of bylaws and organizational requirements, national AAEM asked all state chapters to reorganize under their umbrella as “subsidiaries” or divisions. Structurally, this really did not affect us to any great degree since we were already organized as such, but the change still required thought and discussion. Now, all chapter divisions are organized with common language and structure under AAEM. Finally, we got our first electronic newsletter out to our membership in October. While each of these accomplishments may seem small and insignificant, they represent the work of many individuals on behalf of your chapter division. Additionally, each accomplishment represents a step forward for GLAAEM in terms of organization and membership value.

Not wanting to rest on our past accomplishments, the challenge now is to look forward to 2015. First and foremost, we need to fill the vacancy that continues to be present for our Minnesota representative. So, this is a call out to all your Minnesotans. We need someone to serve as a state representative on the GLAAEM board. Second, we are planning on growing our chapter presence at the 21st Annual Scientific Assembly in Austin. We are planning two chapter functions. The first is our chapter annual meeting. Finally, we will be able to put faces to voices as we plan on having our second annual chapter meeting. The other function is a social gathering on Tuesday, March 3rd. The site and specific time are yet to be determined, but with so many great places to enjoy each other’s company in Austin I am confident we will have a wonderful time. So please stay tuned and I hope to meet each of you there. Finally, as a chapter division we need to determine what features and value each of you want as part of your chapter division membership. Whether this is live educational offerings or online subscriptions to items such as the Western Journal of Emergency Medicine, we need to listen to you and act on your comments.

As a chapter division I think we have much to be thankful for in the past 12 months and much to look forward to in the coming year. I wish all of our members a happy and safe winter holiday season.  I look forward to seeing you all in 2015.

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The Spread of Physician Practice Management Groups in Michigan and Ohio

Sudhir Baliga, MD FAAEM
Secretary/Treasurer, GLAAEM Board of Directors

As a lifelong Michigander and employee for the Henry Ford Health System, I have been a member of AAEM since I graduated from residency and believe in its core principles. I have heard and read about physician practice management groups (PPMs) in emergency medicine (EM) and felt fortunate that the largest groups did not have a strong presence in my home state.

However, TeamHealth, a large, national physician practice management group, recently purchased multiple emergency department contracts in Ohio and Michigan. In September, TeamHealth purchased a Michigan-based private EM group, Emergency Medicine Specialists, and its emergency department contracts in southeast Michigan.1 TeamHealth and other PPMs have been in the media over the years due to lawsuits for unfair pay practices and concerns over corporate practices.2,3 In October, TeamHealth also purchased Premier Physician Services, which provided emergency department staffing in Ohio and five other states.4

At first glance it appears that PPMs are taking over most emergency departments regionally and nationally. However, the percentage of physicians becoming hospital employees has grown.5 Opportunities for democratic practice of emergency medicine may be limited in the future given the economy of scale these large groups provide. Eventually, we may all work for PPMs. Naturally, it led me to question the future of AAEM. AAEM supports the independent practice and professional well being of board certified emergency medicine physicians.6 Ideally, AAEM believes in the democratic practice of emergency medicine with each physician having equity in the practice with a provision of due process.7 With the proliferation of PPMs, it appears AAEM principles may be weakened. Even if every EM physician wanted to practice in only democratic groups, the opportunities would be greatly limited due to the number of positions available and the geographic location of these positions.

After further thought and closer inspection, AAEM will not cease to exist. As a member of GLAAEM, each of us lives and practices in the Midwest, arguably the birthplace and heartland of emergency medicine. We must continue to support and recruit additional members to AAEM. Regardless of your type of practice, AAEM will be present to protect the rights of the individual emergency medicine physician. AAEM’s vision statement says that we should control our practice free of outside interference and that the primary duty is to the patient.4 If a PPM or other such entity asks a physician to practice emergency medicine in a manner that the physician feels compromises patient care or is an outside influence of power, AAEM will support the physician. And if AAEM is not there, then who will take up the cause for the individual practitioner? As members of GLAAEM, we need to spread the vision of AAEM among our colleagues and remind everyone in the EM community of this fact. 

  1. http://phx.corporate-ir.net/phoenix.zhtml?c=232262&p=irol-newsArticle&ID=1965883
  2. http://www.nytimes.com/2014/01/24/business/hospital-chain-said-to-scheme-to-inflate-bills.html?_r=0
  3. http://phx.corporate-ir.net/phoenix.zhtml?c=232262&p=irol-newsArticle&ID=1980405
  4. http://www.epmonthly.com/departments/subspecialties/management/aaem-does-battle-with-teamhealthagain/
  5. http://www.advisory.com/daily-briefing/2013/09/20/as-hospitals-ramp-up-hiring-one-in-two-doctors-remains-self-employed
  6. http://www.aaem.org/about-aaem
  7. http://www.aaem.org/about-aaem/vision-statement
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Michigan Update

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

By way of introduction my name is Robert Hoogstra and I am the state representative for Michigan. I graduated medical school in 1984 from the University of Michigan and completed a combined EM/IM residency in 1988 at Northwestern University. Currently I practice full time emergency medicine in Muskegon, Michigan at Mercy Health a community teaching hospital in the Trinity Health System affiliated with MSUCOM where we will be starting a new EM residency program starting January 2015. My other role is the Associate Medical Director of Quality and Safety for the hospital. 

On the state political front the tort reform bill HB4354, which increases the burden of proof for medical malpractice cases related to EMTALA care to gross negligence with clear and convincing evidence, will likely not see the light of day during the lame duck session. Look for it to be introduced next year and push your legislators to support it.

With the state Medicaid expansion the Michigan Department of Community Health has been tasked with providing recommendations to the legislature on how to reduce "inappropriate utilization" of emergency centers. Last year I attended an ED summit where all the ED directors in the Trinity Health System gather to share ideas regarding the challenges we face as emergency physicians. This meeting occurs biannually. At this particular meeting the medical leadership of Trinity Health as a system addressed us regarding our role as emergency physicians in the new era of health care reform and population health. The notion that so many ED visits are unnecessary and that we are seen as a high cost center was raised. When did we become the villains? Aren't we the good guys? The safety net seeing all those no one else will see without regard to ability to pay 24/7, 365 days a year? My sense is that the growing use of the ED is multifactorial, including lack of access to primary care, uninsured and underinsured patients, "undesirable patients" with substance abuse, mental health, or social issues that no one else wants to see. There also seems to be this growing trend of primary care providers referring to the ED what they don't feel comfortable seeing in the office. As more primary care physicians give up hospital admitting privileges and work only in the outpatient arena their tolerance for seeing a potentially "sick" patient lessens and they will actually refer most patients who need a workup. Complaints such as chest pain, abdominal, pain dizziness etc. may actually be appropriate given the efficiency with which we can work these people up, not to mention the fact that if they do have a serious and time sensitive issue such as a STEMI, stroke, sepsis, or leaking AAA, the ED is the best place for them to be. This trend will continue as our patients age and the complexity of their medical problem list increases with increases in transplant and immunosuppressed patients. Then there is the whole issue of cost vs. charges which I won't get into. And yes, there are those patients who "abuse" the ED which is certainly something that needs to be addressed but my feeling is that this is a minor contributor to ED "overutilization." Overall we should still see ourselves as the good guys who provide a safety net for our health care system and we shouldn't feel bad about promoting our specialty in that way.

If you have thoughts or comments, please don't hesitate to contact me at hoogstrr@mercyhealth.com.

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Ohio Update

David Cheng, MD FAAEM
Ohio State Representative, GLAAEM Board of Directors

Happy holiday season.

There are many reasons to be thankful this holiday season. Thankful for the creation of GLAAEM. Thankful for AAEM representing our specialty. Thankful for resolution of the northeast Ohio Ebola crisis. Thankful for having a job that impacts the patients’ lives. Thankful for the public support given to our specialty. Thankful for junior colleagues full of spirit and energy. Thankful for senior colleagues full of wisdom. Thankful for an emergency medicine family as well as our actual family. Yes, the future is bright.

Best wishes for a blessed season and New Year,

David Cheng, MD FAAEM
GLAAEM Ohio Representative
AAEM Academic Affairs Committee Member
AAEM Clinical Practice Committee Member
AAEM Founding Member

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Wisconsin Update

Caroline Pace, MD FAAEM
Wisconsin State Representative, GLAAEM Board of Directors

In the inaugural GLAAEM newsletter, Dr. Ronny Otero began a conversation regarding the American College of Emergency Physicians National Emergency Medicine Report Card. Many of us read the “ACEP Report Card” and cringed at the overall grades our individual states received. While Wisconsin fares respectably among states in its overall grade, the area of disaster preparedness is a glaring deficiency. Not one to settle for an “F,” I went to one of the prime sources for Disaster/Mass Casualty Medicine in our state, Jason M. Liu, MD MPH. He is an Associate Professor of Emergency Medicine at the Medical College of Wisconsin, as well as the Associate Director of Medical Services for Milwaukee County EMS. He is fellowship trained in Disaster Medicine and is currently working on Wisconsin’s Ebola Preparedness Guidelines.

According to Dr. Liu, Wisconsin’s grade of “F” in disaster preparedness is, unfortunately, an accurate assessment. As noted in the ACEP summary, Wisconsin was above average when last assessed (“B”), but slow progress since then has dropped Wisconsin to the bottom tier. Though there has been work done to improve emergency preparedness, the low ranking is reflective of the lack of coordinated planning and response efforts. Dr. Liu says, “Wisconsin must take the next step and develop true, multi-disciplinary integration and multi-organizational coordination.”

Fortunately, there are ways to rectify the gaps in disaster preparedness and Dr. Liu has identified some strategic goals to this effect. First, health and emergency response organizations should work together to create a formal system to reallocate large numbers of patients from an incapacitated area to other areas during a disaster. In the middle of a disaster, a formalized, agreed-upon method will off-load the burden of contacting organizations, finding capacity, and making distribution decisions from affected organizations to the entire system. The combined system resources would be better positioned to assist with these tasks and absorb the patient influx.

Another way to improve coordination is by creating joint medical information centers. These centers would monitor potential medical threats and situations, form assessments, and distribute timely, relevant information to all partners in a health coalition. During an emergency, they would assist in maintaining situational awareness. Numerous events have demonstrated the importance of having current, accurate information in preparing for and responding to any incident.

The development of regional agreements, policies, and protocols among emergency medical services agencies, health care facilities, and government agencies should also be a high priority. Having a regionalized approach would bolster interoperability and reduce confusion in a critical incident. The benefits of systemic approaches have already been demonstrated in other areas of medical care, such as trauma, cardiac, burn, transplant, and stroke care.

Finally, implementing emergency preparedness curricula in the education of all allied health and public safety professionals will help to raise the overall level of readiness in the state. This includes the involvement of Wisconsin’s physicians. Regardless of specialty, all medical providers should have a basic level of knowledge on their roles and responsibilities during a disaster. While there is much work to be done to improve our grade (and I’m certain we will again receive a failing grade on the next report card), these goals as laid out by Dr. Liu are achievable. Now, let’s get to work.

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Resident Corner

The Battle of Synchronous vs. Asynchronous Learning

Chase Deobald, DO
Resident Representative, GLAAEM Board of Directors

Online education and technologies are not viewed with the same esteem as traditional forms of medical education, such as textbooks and peer reviewed papers. There tends to be a lot of skepticism when it comes to more recent forms of educational materials such as blogs and podcasts. Doubt lies in the quality of the speaker, legitimacy of the sources used, and if assessment of the material is accurate. Yet even if all of those stipulations are met, and I’ve read through quality references, I’m still uneasy about telling my attending a treatment plan came from a podcast.

There is no doubt a wealth of medical knowledge available on blogs, pods, Twitter, YouTube, and other forms of media that I’m probably not aware of. All of these sources fit under the umbrella of asynchronous learning. They are independent activities and there may be a delay in answers to your questions. Synchronous learning, on the other hand, involves a group of learners, are often interactive, and questions are immediately answered.1 This is the ACGME required four to five hours of lecture that we attend weekly, journal clubs, and procedure labs.2

Although reading a textbook like Rosen’s or Harrison’s is considered an asynchronous form of learning, I want to focus on internet based asynchronous learning. I don’t think anyone questions the value of these tried and true textbooks for education.

Asynchronous medical resources, particularly podcasts, will continue to expand.3-8 Studies on asynchronous learning in medicine are limited, but show their educational value. 9 No matter what specialty you’re in, there is a call for more production of these resources.4,10, 11

How frequently are they being used? A survey of emergency medicine (EM) residents showed that 97% of respondents spent one hour per week in extracurricular education with 34% spending two to four hours per week. They also spent more time listening to podcasts than reading textbooks (35% vs. 33%).12 This is a sign of big changes in the education landscape. This may only be one study, but it speaks a truth about the changes in residency education. Online resources are also recognized as an important educational source with support from the Council of Residency Directors (CORD).2

Residency is certainly accompanied by time limits, particularly on long ICU months or a week of ED shifts where reading seems to take the back burner. Many podcasts are short enough to complete while commuting to work and can be played right after a related clinical encounter. With ACGME work hour restrictions, some specialties are further limited in the available time for morning report and/or the typical classroom lecture format. While podcasts and online content cannot entirely replace this education, they can help fill the void.10, 13

From an EM perspective, where we are seeing such a breadth of medical conditions, covering as much material as possible in residency is vital. This is particularly true for residents in a three year compared to a four year residency. Without this supplement, you can guarantee a resident who attends 70% of scheduled conference lectures (5 hours/week) over a three year period will receive 504 hours of education versus 694 hours in a four year program. Though 500 hours sounds like a lot of educational time, consider your mental state for learning after a night shift. You are typically hungry, tired, and not in a position to retain much. And if this was your only source of learning, reflect upon the reality that EM resident attendance at conferences has never been shown to improve in-training or ABEM qualifying exam scores.2

For the group of physicians who seem to learn better by repetitively attending lectures on the same topic, you have the ability to do this at your convenience. Others prefer to be kinetic learners, which can be possible with online procedure videos. Obviously building our own simulation devices would be time consuming but possible. More importantly, although I am not at the point in my career where I routinely comment on various podcasts and blogs, both provide an opportunity for listeners to change the face of learning from passive to active environment.8

So, what’s the downside? For starters, finding the right source can be a problem. It takes time to locate reputable, accurate and timely sources of information. One study of anesthesia residents found the primary reason that podcasts weren’t being used was the residents didn’t know they were available.9

An important thing to consider is your current educational level. A third year medical student is certainly on a different educational curve than a third year resident. But more importantly, understanding where you are between peers in the same level of training is important. To be specific, one comment I’ve heard about EM:Crit is the material is attending level. Do I disagree? No. Some material is certainly over my head, not part of the practice pattern at my institution (ED thoracotomy), or too early on in the vetting process for me to use (selective use of Epi during cardic arrest).15 Are all subjects on EM:Crit over my head? Not so much. I agree with having two suction catheters set up for intubation, particularly for traumatic airways.16 This just makes sense.

The EM resident study mentioned previously noted only 36.4% of residents “rarely” reviewed citations and 5.9% never do.12 I think this is a big concern for a lot of educators, and rightly so. I appreciate both sides of the coin. As a resident, starting to review citations for one post can consume an entire day, which may only scratch the surface for a subject. From an attending perspective, this is how to practice evidence based medicine and keep your practice up to date.

The biggest critique of online content is that it has not been vetted through the classic peer review process the way traditional textbooks are.12 While this process for textbooks is slow (months-to-years), it is often considered more reliable. That is despite arguments to the contrary.14

An important point to consider, as noted by one podcast producer, there is no “one management” algorithm for many of the topics discussed in some podcasts.17 A mix of synchronous and asynchronous learning is probably for the best, which is also supported by CORD.12 Traditional textbooks can be used for foundational knowledge, maintenance and new questions can be provided with online sources and group lectures can help solidify learning points.

Ultimately, residency is a time to learn, not only about the art of medicine but how to be successful in medicine. As lifelong students, everyone needs to assess the best form of education for themselves. In fact, your residency program is supposed to help teach you this.2 I wish you the best of luck in finding the best sources to help your learning. If you find something you find very helpful, send me an email. I’m always open to finding another gap in my knowledge bank.

  1. Asynchronous vs. Synchronous. Teaching and Learning Excellence. University of Wisconsin-Madison. 23 Jun 2014. Accessed 30 Nov 2014 at https://tle.wisc.edu/blend/facilitate/communicate
  2. Sadosty AT, Goyal DG, Gene Hern H Jr, et al. Alternative to conference status quo: Summar recommendations from the 2008 CORD Academic Assembly Conference Alternative Workgroup Acad Emerg Med. 2009; 16:S25-S31.
  3. Rainsbury J, McDonnell S. Podcasts: an educational revolution in the making? J R Soc Med. 2006 Sep; 99(9): 481-482.
  4. Wilson P, Petticrew M, Booth A. After the gold rush? A systematic and critical review of general medical podcasts. J R Soc Med. 2009 Feb; 102(2): 69-74
  5. Walkinshaw E. Medical podcasts going viral. CMAJ. 2011 Oct; 183(14): 1577-1578.
  6. Nast A, Schäfer-Hesterberg G, Zielke H, Sterry W, Rzany B. Online lectures for students in dermatology: a replacement for traditional teaching or a valuable addition? J Eur Acad Dermatol Venereal. 2009 Sep; 23(9): 1039-43.
  7. George DR, Dellasega C. Use of social media in graduate-level medical humanities education: Two pilot studies from Penn State College of Medicine. Med Teach. 2011; 33:e429-e434.
  8. Hollinderbaumer A, Hartz T, Uckert F. Education 2.0 – How has social media and web 2.0 been integrated in medical education? A systemic literature review. GMS Z Med Ausbild. 2013; 20(1): Doc14.
  9. Mayava C, Rosen D, Siu E, Bould D. eLearning among Canadian anesthesia residents: a survey of podcast use and content needs. BMC Med Educ. 2013; 13: 59
  10. Childers RE, Dattalo M, Christmas C. Podcast Pearls in Residency Training. Ann Int Med. 2014. 160 (1): 70.
  11. Henley J, Amir M, Sampson B, Tamai JM, Dellavalle RP. Dermatology podcasting: an untapped resource for continuing education. J Am Acad Dermatol. 2013; 68(3): 513-5.
  12. Mallin M, Schlein S, Doctor S, Stroud S, Dawson M, Fix M. A survey of the current utilization of asynchronous education among emergency medicine residents in the United States. Acad Med. 2014; 89: 598-601.
  13. Saichaie K, Benson J, Kumar AB. How we created a targeted teaching tool using blog architecture for anesthesia and critical care education–the A/e anesthesia exchange blog. Med Teach. 2014 Aug; 36(8): 675-9.
  14. Lin M. The Lin Sessions – contact lenses - digiblogs. EM:RAP. 2014 Mar; 14(3):6.
  15. Weingart S. EMCrit Podcast 130. Hemodynamic-Directed Dosing of Epinephrine for Cardiac Arrest. EMCrit. 10 Aug 2014.
  16. Weingart S. EMCrit Podcast 92. EMCrit Intubation Checklist. EMCrit. 5 Feb 2013.
  17. Swallow J. Development of education podcasts for GPs. Education for Primary Care. 2013; 24(3): 222-223.
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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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