Addressing Psychiatric Boarding within the Emergency Department
Issue: November/December 2022
Authors: Aislinn D. Black, DO MPH FACEP, Brian Kenny, DO MA, and Akiva Dym, MD FAAEM
As emergency department visits in the United States continue to increase year over year, overcrowding and understaffing within emergency departments has become a growing concern and unfortunately the “new normal.” Few EDs within the country have been immune from the troubling phenomenon of overcrowding and understaffing. The specific causes of ED overcrowding and understaffing are numerous. One specific area which has contributed to ED overcrowding and staffing shortages relates to the rising number of ED visits for psychiatric causes. Psychiatric visits to EDs have been increasing at a steady rate over the past two decades, with a recent surge noted during the COVID pandemic. Mental health complaints make up 7-10% of all ED visits, and nearly 80% of EDs have reported boarding psychiatric patients in their ED, often with extended lengths of stay. Numerous issues have led to the current psychiatric crisis in EDs across the country, including a shortage of mental health professionals, limited access to out-patient psychiatric care, and severe shortages of in-patient psychiatric beds across the country. Over the past 40 years, inpatient psychiatric beds have shrunk to nearly 20% of previous peak levels. As psychiatric ED volumes continue to increase, emergency departments must be prepared to address the impacts this will have on ED operations.
The boarding of psychiatric patients in emergency departments has widespread effects on overall ED operations. In its simplest form, boarding psychiatric patients in emergency departments reduces the functional capacity of the ED and thus reduces throughput capacity. Furthermore, psychiatric patients board in an ED bed significantly longer on average than medical patients, often upwards of three times as long. The near-constant use of ED beds for boarding psychiatric patients thus effectively reduces the overall capacity of an ED, and can have a significant impact on overall ED operations. Furthermore, if psychiatric volumes continue to increase yearly as many predict, the detrimental effect of psychiatric boarding will only continue to worsen and continue to affect ED throughput and capacity.
The increase in psychiatric boarding also has a major impact on staffing levels. As a majority of psychiatric patients require some form of constant observation, ED staff must frequently be utilized as “sitters” to monitor these patients. While institutions have varying guidelines regarding the staff to patient ratios required (e.g. 1:1, 1:2, or higher), this will effectively reduce the volume of staff available to assist with performing EKGs, drawing labs, or performing other patient care tasks. Many EDs are forced to employ ED techs or even nurses as psychiatric sitters. While some institutions are attempting to alleviate the staffing shortages by hiring additional dedicated patient sitters, this option is not always available or financially feasible.
In addition to the effects on ED bed availability and ED staffing, the boarding of psychiatric patients in an ED also poses safety risks to the patient themselves, to other patients and visitors, and to ED staff. The ED is frequently a noisy and chaotic place, which can be very disturbing and nontherapeutic to the potentially unstable psychiatric patient. Psychiatric patients ideally require a calm and therapeutic environment, which the average ED unfortunately cannot provide. These patients paradoxically suffer from both overstimulation—alarms, constant bright lights—and understimulation—lack of any recreational or therapeutic activity. As such, psychiatric patients remaining in an ED for extended periods of time may be more prone to developing agitation or violent outbursts. These patients are exposed to the risks of repeated restraint and sedation in an effort to protect the patients themselves, other patients and visitors nearby, and ED staff.
Lastly, like any other form of boarding, the increase in psychiatric boarding can increase the workload of both the physician and nursing staff. Physicians will have to spend an increasing amount of time managing psychiatric patients, many of whom may be acutely agitated or psychotic and who would benefit from being cared for by a dedicated psychiatric team. Furthermore, as patients become agitated within the ED, physicians will have to further divide their time to manage psychiatric patients to prevent further patient harm and ensure overall patient safety. Similarly, the ED nursing staff will have increased tasks to be performed for psychiatric patients with regards to frequent medication management and screening checks.
Faced with the many problems of psychiatric boarding, there are many potential strategies which can be implemented to help alleviate some of these specific concerns. Developing a close working relationship between the emergency department and psychiatry department is critical to ensure a streamlined process and to help reduce the ED length of stay. Streamlining the process for medical clearance and consultation can ensure a smoother process and potentially shorter ED length of stay.
By standardizing the requirements to “medically clear” a psychiatric patient, it can reduce provider variability and potentially prevent delays due to being unable to medically clear a patient. Identifying subsets of psychiatric patients who do not require any specific testing in order to be medically cleared can also help reduce patient LOS and reduce associated costs/resource utilization. The criteria required to medically clear a patient will likely vary from institution to institution, but often involves a combination of screening labs (including a EtOH level, urine drug screen, and metabolic workup), EKG, and/or chest X-ray. By working with your psychiatric service to standardize these requirements, it can help reduce the time needed for a patient disposition. The development of dedicated order sets within your EMR can also help ensure standardization of workups and reduce unnecessary testing. It is also critical to work with local psychiatric admitting facilities to determine any specific admission requirements that they may require for an inpatient admission. Furthermore, streamlining the consultation process can help reduce delays in obtaining psychiatric evaluation. In our facility, we have developed a process by which the psychiatrist on call can be reached 24/7 via a direct dedicated phone number. In addition, the use of real-time Epic chat can help with communication regarding consult status and psychiatric recommendations/disposition.
Another strategy to help reduce ED psychiatric boarding and potentially improve throughout is the use of twice daily “psych huddles”. Multidisciplinary psychiatric rounds (MDR) should involve the ED physician, psychiatrist, social worker, case manager, nurse manager, case workers, and psychiatric screeners. MDR can provide a time for an overview of the status of every psychiatric patient, including the status of medical clearance, psychiatric recommendations, placement concerns, or potential re-evaluation for discharge. The use of MDR within our facility has allowed us to update the entire clinical team regarding patient status, as well as ensure that patient disposition (e.g. transfer to outside facility) was not delayed due to a missing facility admission requirement such as urinalysis or chest X-ray.
Addressing the staffing shortage requires a more creative approach. Unfortunately, many EDs do not have the ability to have a dedicated psych ED or “crisis” area, and as such, are often forced to board psychiatric patients within the main ED. However, by identifying a specific area within the ED to dedicate to psychiatric boarding, this can potentially reduce the required number of staff to be utilized as patient sitters, as well as potentially reduce the rate of agitation and violence and its effects on other patients within the ED. In our ED, we were able to convert a smaller clinical space within our ED into a makeshift overflow psychiatric boarding area, which helped reduce the required number of psychiatric sitters and staff utilized, as well reduced the risk of elopement or acute agitation. Another potential solution for both staffing shortages and ED boarding would be the development of a short-stay psychiatric observation unit within another area of the hospital. This area could then be utilized for psychiatric patients who have been identified as likely only requiring shorter periods of psychiatric monitoring and observation before being cleared for discharge home. The use of such observation units can help reduce ED boarding and potentially reduce the staffing required for dedicated constant observation sitters. By working with hospital leadership and psychiatry, the development of a dedicated clinical area within the hospital can be extremely beneficial to addressing ED overcrowding and psychiatric boarding. Studies have shown that dedicated Psychiatric Observation units (such as an EmPATH units—Emergency Psychiatric Assessment, Treatment, and Healing units) can help reduce psychiatric LOS as well as reduce the overall ED rate of patient left without being seen by freeing up ED capacity.
As the volume of patients presenting to emergency departments for psychiatric care continues to increase, EDs will continue to face increasing challenges with ED staffing, psychiatric boarding, and other associated effects. By proactively working with hospital leadership, psychiatric services, and receiving facilities to identify and address these concerns, multiple strategies can be undertaken towards improving psychiatric care within the ED and reducing the effects of psychiatric boarding in the ED.
- Hazlett, S.B. (2004) “Epidemiology of adult psychiatric visits to U.S. emergency departments,” Academic Emergency Medicine, 11(2), pp. 193–195.
- Nicks, B.A. and Manthey, D.M. (2012) “The impact of psychiatric patient boarding in emergency departments,” Emergency Medicine International, 2012, pp. 1–5.
- Alakeson, V., Pande, N. and Ludwig, M. (2010) “A plan to reduce emergency room ‘boarding’ of psychiatric patients,” Health Affairs, 29(9), pp. 1637–1642.
- Purushothaman, S. (2020) “Patient flow from Emergency Department to Inpatient Psychiatric Unit – A narrative review,” Australasian Psychiatry, 29(1), pp. 41–46.
- Zhu, J.M., Singhal, A. and Hsia, R.Y. (2016) “Emergency department length-of-stay for psychiatric visits was significantly longer than for nonpsychiatric visits, 2002–11,” Health Affairs, 35(9), pp. 1698–1706.
Rural Medicine Interest Group: Critical Access
Issue: September/October 2022
Authors: Robyn Hitchcock MD FAAEM, Rural Medicine Interest Group Chair
AAEM recently started the "Rural Medicine Interest Group." A case I had recently reminds me why this is an important forum.
I am working at a new Locums job on the Oregon coast. When people that live in the northwest have a hankering to see the ocean, this is typically where they go. The Washington coast for the most part is unapproachable and rocky, but the Oregon coast has many areas of approach and a plethora of sandy beaches and little seaside towns. Somehow, despite the fact that I've lived in the "Upper Left" for nearly 20 years, I have never made it to the Oregon coast. So this is a great opportunity for me to finally go, explore a little, and get paid to be here. I think it's a win-win.
I was working my first full shift after orientation. Within minutes of taking sign outs in the morning, half a dozen people checked in. That's quite a few in a single coverage critical access facility. So I was chugging through the list, trying to get all my workups and evaluations started. A 39-year-old woman presented with a chief complaint of vomiting blood, so I focused on her chart. This unfortunate young lady was now sober, but already had severe liver damage from alcoholism and carried a diagnosis of alcoholic cirrhosis. She had no prior history of GI bleeds. But the high volume of blood she described vomiting is typically from esophageal varices in somebody with cirrhosis. She was tachycardic to 126 but normotensive, kind of gray looking and jaundiced. She had not vomited since that one episode that nearly filled her bedside garbage at home.
I started of course with standard labs and some volume resuscitation with saline. Her hemoglobin came back at 9.3, her INR was 1.9, and she was not on blood thinners. I reached out to the general surgeon on call who does endoscopy at this facility. Unfortunately, they typically can't manage esophageal varices because they don't have the right specialty equipment or training. He was performing a colonoscopy so I had to wait for him to finish, but he confirmed that he was unable to care for this patient.
Then I think I made a decision that saved this young lady's life. At least I like to think so. She was less tachycardic but still had an elevated heart rate around 110. I had already ordered vitamin K to try and bump up her clotting function. I knew I was going to have to transfer her and wanted to do everything I could to stabilize her. So despite the fact that she was not bleeding in the ED, I ordered TXA which helps blood clot better and decided to continue her volume resuscitation with FFP to avoid further dilution of clotting factors (as a critical access place of course, we do not have platelets or cryo on hand).
Just as the TXA was hanging and the FFP was almost ready she started vomiting blood again. About 500 ml of clotting blood into the emesis bag. She continued to vomit off and on over the next hour. But since I already had the clotting factors hanging, the total amount she threw up was only about 750 ml. By the end of the hour she was just dry heaving bilious saliva. We got her under control.
Of course I was busy during this hour. I wasn't just sitting there watching her throw up. I called the nearby (60 miles away) hospital and spoke with gastroenterology. We added rocephin, reglan, and octreotide. I ordered a repeat hemoglobin and made sure I got her type and crossed with several units of packed red blood cells. We pulled out our oral tube which can help tamponade these bleeds through pressure in the esophagus. I haven't done one since residency so the nurse and I reviewed the instructions together in case we had to go there. And of course all this time I'm desperately hunting for a bed.
The closest hospital is an hour away and although GI accepted, they had no ICU beds. I tried to do an ED to ED transfer, but got refused. I tried to pull the EMTALA card, but the ED said they can't do a scope in the emergency department; it has to be an ICU bed. So they didn't have the capacity to care for her, I had to keep looking. The transfer center called all up and down the coast and inland and we finally found a bed in Portland, 3 ½ hours away by ground. The Oregon coast is often foggy and overcast but luck was with me that day because the helicopter was flying. The helicopter had been on standby for some time, and now finally had a place to go.
I got on the phone with the intensivist and told her all about the patient. When I updated the vital signs, repeat hemoglobin, blood transfusion, etc., the young woman who was probably an ICU fellow said to me, "Is it really safe to transfer somebody in that condition?"
"Well, I could keep her here until we run out of blood products and then she dies," I replied. "That is my only other choice."
I heard the squeak on the other end of the line. "Oh, ok. We will be waiting for her."
This is why we need a rural medicine interest group. People at large academic institutions have no idea what it's like being at a place with limited resources. When people live in a small town they're making health care choices they don't realize they're making. A ruptured aneurysm, massive trauma, or a bad head bleed is going to die before we get them to a facility capable of caring for them. Every. Time. Sometimes we have to ship unstable people. We do our best to stabilize them within the capacity that we have, but then we have to take the chance that they're going to deteriorate or die in route. Because the other choice is they will die here. The problems we face on a daily basis are seldom addressed in national discussion. I'm hoping to engage this conversation on a national level for awareness and facilitation both from the emergency medicine community, and the people we care for.
Back to the case...The repeat blood count which should have taken 10 minutes somehow took 40 minutes. The helicopter doesn't come directly to our facility, our paramedics have to take the patient to a rendezvous point 20 minutes away from the hospital. I made them wait for the blood test, and sure enough her repeat hemoglobin was 6.2. So I got two units of red cells hanging as she headed out the door, and sent a third one with them. The helicopter has a fourth.
As of today I haven't heard back what happened. Typically if she deteriorated en route somebody would have let us know. So I think she made it okay.
I made a lucky or perhaps intuitive decision to start aggressive clotting factors before she started bleeding again. We did not have to go with the pressure tube in the esophagus which has a huge complication rate and a high morbidity and mortality just placing it. The team of nurses who I had just met did not question my decisions to be proactively aggressive. And I'm pretty sure we saved a life.
A good day at a critical access hospital.
This Meeting Could Have Been an E-mail: How to Succeed in Managing Your Project
Issue: July/August 2022
Authors: Erin Muckey, MD MBA, Akiva Dym, MD, and Anthony Rosania, MD MHA
We’ve all been there. We’ve all had one of “those” meetings. They come in several flavors: The ‘this meeting could have been an email’ meeting. The ‘Groundhog Day’ meeting. The ‘flight of ideas,’ but in reality, a ‘no next steps’ meeting…
On the other hand, we have all experienced a project that never fully launches because organizing over email is also full of roadblocks. Most of us would agree that there is a value in the collaboration, idea generation, and organizational management that comes from gathering stakeholders together in real time. But how do we capitalize on that benefit while effectively managing a project with a diverse group of very busy stakeholders who all have other competing interests for their time? To put it in other words, how do we consistently achieve this ambitious goal and ultimately develop a “unicorn” of meetings?
Meeting organization and structure.
The first step in any successful meeting begins upfront, with the design of the meeting itself. The goal is to pull off that white buffalo of meetings: one that is both high-yield and highly efficient. One of the keys to unlocking such meetings begins prior to the day of the meeting. Consider ahead of time what the desired goals of the meeting are and setting an outlined agenda to help you ensure a productive and focused meeting. Ideally, distribute the agenda to all participants the day before. This allows for the development of a shared mental model before the meeting even begins. If the topic is expected to be sensitive or controversial, it may be helpful to consider a ‘pre-meeting’ with some of the project’s key stakeholders to ensure that everyone is on the same page for the upcoming discussion.
The next step is to focus on the management and flow of the meeting itself. Set clear expectations at the beginning of every meeting about the goals of the meeting and what you and your team hope to accomplish at the end of it. This allows everyone to begin the meeting with the same end goal in mind. The agenda will be very helpful with this part, as it will serve as a clear roadmap for the goals of each meeting. Remember that sometimes less is more. Don’t fall into the trap of trying to accomplish too much with each meeting. Often, a clear, focused agenda can lead to deeper discussion and more productive outcomes. It can also be helpful to level set early with the team on what the scope of the meeting is and what the scope of the meeting is not. This will help reduce tangential or unproductive discussions which may not align with the current meeting’s focus.
Even the best planned meetings can at times have a mind of their own and take on a new direction. Sometimes, these tangents may be productive, other times they are not and detract from the original intent of the meeting. In particular, meetings related to process improvement can derail into a session with attendees voicing complaints or concerns about the current state. It is critical to have a plan to guide the meeting back on track with a thoughtful and diplomatic approach. Reminding the team of the focused agenda and offering to table the other concerns for an upcoming meeting, can help bring the focus back to the original goals.
Once you’ve had your perfect meeting, it is now important to capitalize on that momentum and avoid the dreaded ‘Groundhog Day’ phenomenon—where you return to the follow-up meeting and feel like you are repeating the exact same thing as before, with nothing having changed or been accomplished. Without a concerted effort to promote and maintain momentum, even the best of projects with good intentions can stall or fail. Before each meeting ends, develop action items for the group. It can be helpful to identify these tasks in real time during the meeting itself so that there is a sense of responsibility and accountability to the group. In particular, assign tasks to specific individuals or small groups, and set a target goal date for each next step.
Develop your individual style for organizing the outcomes and planned follow-ups from the meeting. One such option is to maintain a spreadsheet with a row for each agenda item. There can be a column for the individual(s) assigned, goal date for next steps, and current status. After each meeting, send out the action items with a very clear subject line so that you can refer to (and reforward) this e-mail to ensure accountability in advance of future meetings.
Prioritizing goals is also critical in order to maintain momentum. Focusing on too many initiatives at once can often dilute and distract from the main goal. Assign lower priority items to a formal ‘parking lot’ which can be re-visited at a later time or future meeting. By formally outlining this list, you can continue to acknowledge good ideas without distracting from the high priority goals or the project’s next steps.
Lastly, it is important to remember that projects are generally more successful with delegation. However, part of this is also understanding that not everyone who is assigned a task will complete it the way you would have. Part of empowering others includes avoiding micromanaging each individual step in the process.
Feedback and Messaging
Understanding the response to a new initiative is key in targeting messaging and anticipating roadblocks. Be intentional about getting buy in—especially from the person completing the action items. As a project progresses, elicit individual feedback from those not directly involved to anticipate the general response and get a temperature check on progress and overall direction of the workstream. Lastly, as you are nearing the end of your project, develop the plan for communicating the change or efforts. This process should be multimodal and iterative. Make sure to celebrate wins and delegate success/kudos to key contributors, this will reinforce team ownership, and set the stage for future projects with similar participants who will now see you as an effective, team-focused leader who is worth supporting.
If all these steps seem like extra work, it’s because they are. However, it is a much more effective use of the entire teams’ time, and will yield more effective results. Overall, the keys to effective project management include prioritization, communication, and accountability. While this is something we all expect from our teams, it is important as a leader ourselves to reflect these principles and walk the walk to build a genuine culture.
28th Annual AAEM Scientific Assembly: Thank You for Joining Us!
Issue: May/June 2022
Authors: Co-Chair Laura J. Bontempo, MD Med FAAEM, Co-Chair George C. Willis, MD FAAEM, and Vice Chair Christopher Colbert, DO FAAEM
The 28th Annual AAEM Scientific Assembly was held in Baltimore, MD from April 24-27, 2022. With a focus on cutting edge clinical medicine as well as practical application to patient care, this event was one of the most anticipated academic conferences of the year.
This year’s Scientific Assembly took an innovative and practical look at various topics within emergency medicine that are shaping our field of practice. We were excited to provide the opportunity to expand the conversation on the topics of toxicology, cardiology, critical care, infectious disease, and many more. By combining discussion from leading scholars with innovative medical nuances, we were able to provide a resource to enhance the understanding of our beloved specialty. Additionally, special attention was dedicated to ensuring that participants’ health and safety were maintained throughout this phenomenal conference.
Powerhouse plenaries included Drs. Haney Mallemat (Resuscitation), Michael Winters (Resuscitation), Corey M. Slovis (EMS), Ilene Claudius (Pediatrics), Mimi Lu (Pediatrics), Deborah M. Stein (Trauma), and Amal Mattu (Cardiology). Drs. Al’ai Alvarez, Cortlyn Brown, Italo M. Brown, David Davidson, and Joanne Williams joined us for the Justice, Equity, Diversity & Inclusion Panel. Dr. Jack Perkins and Joshua Morales were joined by sickle cell patients Kenya Thompson, Tenesha Dudley, and Isaiah Dudley for the Sickle Cell Patient Panel. There was also a transgender patient panel to discuss the challenges of being a transgender patient and caring for one in our current healthcare system.
This year’s keynote presentation, “Our Patients, Our Specialty: AAEM-PG Versus Envision and the Future of EM,” featured Drs. Robert M. McNamara and Mark Reiter who broke down what the lawsuit means for emergency physicians and our patients. The AAEM suit against Envision (EmCare) is a momentous event for our specialty and our patients. AAEM is asking the courts to invalidate the contractual scheme used by Envision to skirt the patient protections inherent to the prohibition on the corporate practice of medicine. This is an enormous undertaking, but this is the hill we must fight on for the soul of our specialty.
Another highlight of AAEM22 was the “Six EM Docs Walk into a Shift Show” talk which featured speakers from the AAEM Critical Care Medicine Section, EMS Section, Emergency Ultrasound Section, JEDI Section, Women in EM Section, and Young Physicians Section walking attendees through a series of patient encounters during a natural disaster. Dr. Molly Estes walked us through treating multiple patients in the wake of a hurricane and shared her thought process as she drew insight from all six AAEM sections to manage the storm after the storm.
With the conference being near Washington D.C., we were also able to have a few members of Congress lead a discussion on current health care advocacy issues and give attendees an opportunity to voice questions and concerns on how Congress can assist emergency physicians take better care of our patients.
The ever-popular Breve Dulce sessions returned this year and continued to be some of the most attended sessions of AAEM22. “Meeting of the Minds” also returned for a second year which featured EM practitioners debating the pros and cons of the latest practice-changing articles in critical care and medical ethics. For the fifth year in a row, the interactive Small Group Clinic sessions gave attendees hands-on practice in a variety of settings. The AAEM/RSA Resident Track - selected by residents, for residents - prepared students for their careers in emergency medicine by concentrating on topics such as career success, clinical topics, and social determinants of health. This session concluded with the AAEM/RSA Breve Dulce Competition which featured five resident presentations on the theme of “Great Catch: A Difficult Diagnosis,” a challenging presentation, or a near-miss that might change the way that you approach that topic.
We had an energetic group of medical student ambassadors, who were omnipresent and ever helpful in keeping the conference going. Special educational sessions were targeted toward their benefit. Thank you, student ambassadors!
There were also a wide variety of networking opportunities available at Scientific Assembly. Whether in the hallways, at receptions, or near the coffee stations during breaks the level of interactions between attendees was high. The JEDI off-site reception, Women in EM lunch, the AAEM Chapter and Sections social, and Airway at AAEM were all highly anticipated and attended. The Wellness Committee also hosted a Wellness Room for all attendees to relax and recharge throughout the conference.
We sincerely hope that you enjoyed the Assembly this year. Our goal is to continue in the tradition of bringing in a combination of your perennial favorites and some new speakers to keep you educated, inspired, and coming back every year for more.
Please let us know your thoughts and we hope to see you in New Orleans, Louisiana for the 29th Annual AAEM Scientific Assembly from April 21-25, 2023!
An Interview with Congressman Dr. Michael Burgess (R-TX)
Issue: March/April 2022
Author: Lisa A. Moreno, MD MS MSCR FAAEM FIFEM
For this issue, it was my pleasure to interview Congressman Dr. Michael Burgess (R-TX), an obstetrician-gynecologist by training. Dr. Burgess’ bio follows.
LM: What factors contributed to your decision to run for public office?
MB: Actually, I never planned on this! I have always loved medicine. In my early 50s, like many doctors at that age, I began cutting down on practice. I was part of a group practice with six other physicians, and while I continued to take obstetrics call, I made the decision to have no OB patients of my own. I was very happy in the practice. In September 2001, I found myself in the operating room, doing a case with a urologist when the events of 9/11 started. The twin towers went down, and you know how that went: one tower is hit and you think it’s some horrible accident. The second tower is hit, and you know it’s terrorism. I immediately became concerned about my son, who was at the time in the Air Force and stationed in New Mexico. I was also concerned for a general surgery colleague who was in New York City at the time, taking a review course. When this surgeon came back, he told me about how the course was abruptly stopped, and the doctors were instructed to go to the lobby of the hotel. Details of the attack shortly became available, and the doctors were informed that a bus would arrive to take volunteers to Ground Zero to attend to the wounded. As I listened to my colleague speak, I had to honestly question whether I would have had the courage to get on that bus. At that point, I made myself a promise that “if a door opens, I will walk through it.”
Shortly thereafter I found out that Dick Army was going to retire. I asked myself, “Is this the door that has opened, and I am supposed to walk through it?” All over Texas, TV news anchors were asking, “Who is going to be next for the 26th District?” During this time, I often reflected on how my son was serving in the military, but what was I doing to serve the country. So, I went online and I learned that it’s actually very easy to register to run for Congress. The forms are not complicated to fill out, but to actually run? Well, it’s very difficult to actually run. In Texas, the winner must have 51% of the vote. I came in second in a race of several candidates so I had a four week run off with the number one candidate. Up until now, I had not had to restrict my medical practice. There was a three month wait for appointments with me, so I was continuing to honor the scheduled appointments. I easily won the primary since it was in a Republican District. Texas requires 90-day notice to patients before leaving a practice, so I sent a letter letting my patients know I was leaving the practice of medicine to serve in Congress. I expected them to continue their routine care with one of my partners, but almost all of them decided they wanted one last appointment with me. It was during these visits that I really became aware of the power that physicians have just in the care that we give patients every day. My patients share with me examples of how I had changed their lives. This wasn’t something I had previously thought about. It was a little like having your eulogy read and not having to die to hear it.
LM: It isn’t something we often think about, and yet we have this privilege of impacting people’s lives so profoundly. I remember being in Walmart and having a young woman run up to me and tell me that she thinks about me every day when she puts her makeup on because I had sewn a laceration of her face. “You promised me I’d barely have a scar, and you were right!” she told me. But discussing the impact we have on patients, there are some very disturbing statistics related to our outcomes in OB/GYN. The US is arguably the richest nation in the world, and we spend more by far on health care per capita than any other nation, yet the US maternal mortality rate is 6.2 and the rates in PR and the US VI are 8.4 and 7.5. As an OB/GYN, how do you make sense of this and what is the government's role in improving this critical metric?
MB: This is one of my major areas of focus. There are many OB health shortage areas in the United States. In 2018, I was the Chair of the Health Subcommittee of Energy and Commerce. Rep. Butler from Washington State had a bill that passed which outlined the structure on State Directed Maternal Mortality Review Committees. At that time, I recalled the maxim of an epidemiologist friend of mine, “A chance to measure is a chance to fix, but you can’t measure if people are afraid to tell you the truth.” So, we decided to keep trial lawyers out. This was not going to be an investigation. We would try to drill down on what happened in cases of maternal mortality, and what went wrong is usually multifactorial. We have had two hearings on this, one when Republicans were in charge and one when Democrats were in charge. The first case was from a hospital in California. The woman died in the recovery room less than 12 hours after a Caesarian section. When I reviewed the deposition, it seemed to me that any number of people should have realized that the new mother needed to go back to the OR. There were so many indications that she was hemorrhaging from a laceration to the uterine artery. It was a tough case for me to read as an OB. I asked myself, “How do I write legislation that mandates that doctors do the right thing—the thing that any reasonable doctor would have done.”
The second case was a Georgia patient who was herself a member of the public health service. According to the deposition, she went home from an appointment, came back, presented to the Emergency Department, saw different care givers at different levels of expertise, and despite a diastolic blood pressure of 118 mm/Hg, she was sent home to rest. Again, how can you legislate that doctors and other health care workers do the right thing?
Honestly, I think it comes down to training. Many people believe that race and ethnicity are factors in maternal mortality, and while the statistics bear that out, that’s not the way it has to be. I trained in Parkland. Parkland takes care of the highest risk obstetrical patients: Black and Brown, uninsured or underinsured, late to getting prenatal care, and yet Parkland has some of the best mortality statistics in the country. They have post-partum hemorrhage crash carts all over the place. And they have strict protocols about who does what. When a patient is crashing, everyone has a job to do, and they do it simultaneously. And then they have a debriefing. We know that even the best doctors have complications, but at Parkland, complications happen in a setting that is prepared to respond to the complications. You can’t tell me that it can’t be done. If you can do it at one of the hospitals where the highest risk OB patients in the nation are treated, you can do this anywhere. It comes down to training. It comes down to being prepared for the complications.1
The Joint Commission has a role to play here. When they do an accreditation, we’re all familiar with their citations for dust on a shelf. Why are they worried about that? OB units should be scrutinized. Anything that can happen that can be lethal, how is the hospital prepared to deal with this to prevent it from becoming lethal? Our country counts maternal mortality as anyone who dies within one year of giving birth. This is not the same in other countries, where the time since delivery is shorter for a death to be considered a maternal mortality. But this is not an excuse. The numbers are still too high, and we can get it down. All the agencies need to work together. Fragmentation of care contributes to this. CMS might have a role in this, but here’s the bottom line: We have to care as doctors---I mean, we have to set the tone there. We need to make sure that we don’t get the “agency practice of medicine”—they don’t always know what’s best for patients.
LM: Your comments are so in line with the AAEM philosophy that all health care teams need to be led by a board certified physician. We also believe that it all comes down to training, to being adequately prepared to deal with all the exigencies of your specialty through the rigorous process of residency training and board certification. Midwives, nurse practitioners, and PAs all have a role in the health care team, but as you say, we physicians have to set the tone, we have to set and maintain the standards. AAEM is also in alignment with your contention that we physicians, and not agencies and administrators, know what’s best for patients. Our education and training uniquely qualify us for that.
AAEM is also focused on the need for physician advocacy. As both a legislator and a physician, you are uniquely qualified to identify the most critical health related issues facing the nation currently. Could you talk about that?
MB: PHYSICIAN WORK FORCE! Without a doubt, this is the biggest issue. As we age out, younger doctors are leaving because it’s hard work and doesn’t pay as well as other professions. At a meeting of the Congressional Doctors Caucus, the Surgeon General told us that he is seeing significant physician burnout throughout the nation since the pandemic, but I think burnout started long before this. Practicing physicians are constantly facing reimbursement issues, fee cuts by CMS, an aggregate of issues that make it difficult for doctors to feel that they are valued. Look what happened in the midst of the pandemic when physician employers said, “Hey hero, here’s your pay cut.”
Other major issues are physician mental health and physician opiate abuse and how we deal with this. We need to allow people to get the help they need without being penalized. Even medical students and young docs are experiencing so much pressure that fewer people are signing up to do the job.
Another issue: There are those that don’t care if the nation does not have enough physicians—just use MD extenders—but this is not acceptable. We need to have physicians leading the team in order to insure patient safety.
I’m also concerned about the time it takes for knowledge translation from the lab to the bedside. I am introducing a bill called CARE FOR THE 21st CENTURY. We demonstrated our ability to do this with OPERATION WARP SPEED in development of the COVID vaccine. Traditionally, we have not paid attention to how is anyone going to be able to afford the things we are developing. Will patent rights and individual ownership rights be taken over? These issues can be disincentives to drug and clinical practice development. Look, it’s been 40 years since a sickle cell drug has been developed! It’s hard to believe that we have not seen improvement in something like sickle cell disease in so long. But if we hit a home run with some of these things, wow. But what if it’s so expensive that no one can afford the drug? And what is the cost of doing nothing for 40 years? What is the cost in human life, quality of life? Insulin is a prime example. The cost of the medication is so high! When we ask pharma why, they tell us that this is because the rebates they have to pay to the federal government are so high. Why shouldn’t the rebates be given to the patient? Our goal, after all, is create the situation in which the patient is taking their medication. So much of what we are doing is not logical, but the problem is multifactorial, so the answers will require collaboration between several entities.
LM: The Academy shares your concerns about the appropriate use of non-physician health care professionals, and we are firmly committed to the model of the physician led team to protect the safety of our patients. We’ve also been outspoken about the pay cuts and decreased work hours that so many corporate groups imposed on physicians who had given their all during the pandemic. Your comments really demonstrate how you combine your skills as a physician and as a legislator. What are the traits that made you a good physician that are now making you an effective legislator?
MB: Physicians are lifelong learners, having to sort through a huge volume of information and cull out what really matters. This is what you must do in Congress. Another trait of a good doctor and a good legislator is being a good listener. In both jobs, you need to understand what people are concerned about, what matters to them, what they are worrying about. Both physicians and legislators need to realize the tremendous impact that we have on people’s day to day lives. And physicians especially need to realize the power that we have. I recall how Ross Perot once told me that doctors have a lot of power. Perot said that if his staffer hands him a stack of letters and one is from his doctor, he opens that first. Physicians hold a position of huge respect in the population. When I am asked whether I prefer to be addressed as “Congressman” or “Doctor,” there’s no contest. I prefer to be called DOCTOR.
LM: Dr. Burgess, thank you so much for taking the time to talk with me today. Regardless of specialty, we physicians put patients first. It was a pleasure to explore the issues that impact our patients’ daily lives, and AAEM looks forward to continuing our relationship with you to ensure the highest level of care for the nation.
1. The bolding in this paragraph is the author’s emphasis.
Congressman Dr. Michael Burgess Bio
After spending nearly three decades practicing medicine in North Texas Dr. Michael Burgess has served the constituents of the 26th District since 2003 in the United States House of Representatives. He currently serves on the House Energy and Commerce Committee, House Rules Committee, and House Budget Committee.
As part of the 115th Congress, Dr. Burgess is the most senior medical doctor, on both sides of the aisle, currently serving in the House of Representatives. Because of his medical background, he has been a strong advocate for health care legislation aimed at reducing health care costs, improving choices, reforming liability laws to put the needs of patients first, and ensuring there are enough doctors in the public and private sector to care for America’s patients and veterans. He has voted to repeal the Affordable Care Act over 50 times, and has played an important role in bipartisan efforts to reform the Food and Drug Administration.
Ever since he came to Congress, Dr. Burgess has made repealing Medicare's Sustainable Growth Rate (SGR) formula a top priority. At the beginning of the 114th Congress, over 90 percent of both chambers of Congress supported the formula's repeal and it was signed into law. As one of the largest entitlement reforms in the past few decades, this landmark policy will ensure greater access and quality for seniors, more stable reimbursements for providers, and a more fiscally solvent Medicare system as a whole.
As a member of Congress representing one of the fastest growing areas of the country, transportation is also a top priority. In 2005, Dr. Burgess successfully amended the Highway Bill to include development credits, design-build, and environmental streamlining. During his time on Capitol Hill, he has worked to build, maintain, and improve the safety of our roads, bridges, air service, and transit in the North Texas region.
As a fiscal conservative, Dr. Burgess believes Americans deserve a federal government that is more efficient, more effective, less costly, and always transparent. He is a proponent of a flat tax and has introduced a flat tax bill every term he has served in Congress. He follows a strict adherence to the Constitution and opposes unnecessary expansion of the federal government’s control over the personal freedoms of Americans. Instead, he believes in giving people more control over their lives and their money. Dr. Burgess is committed to reducing illegal immigration into our country and has taken action to ensure our borders are secure and our immigration laws are enforced. He strongly opposes any proposal to grant amnesty to illegal immigrants.
During his time on Capitol Hill, Dr. Burgess has earned a reputation as a problem-solver who seeks sensible solutions to the challenges Americans face and has received several awards including the Guardian of Small Business award by the National Federation of Independent Business (NFIB), the Spirit of Enterprise award by the U.S. Chamber of Commerce, and the Taxpayer Hero award from the Council for Citizens Against Government Waste, among others. In 2013, he was named to Modern Healthcare’s 50 Most Influential Physician Executives and Leaders.
Today, Dr. Burgess represents the majority of Denton County and parts of Tarrant County. He was raised in Denton and attended The Selwyn School, graduating in 1968 as valedictorian. In addition, he graduated with both an undergraduate and a master’s degree from North Texas State University, now the University of North Texas. He received his MD from the University of Texas Medical School in Houston, and completed his residency programs at Parkland Hospital in Dallas. He also received a master’s degree in Medical Management from the University of Texas at Dallas, and in May 2009 was awarded an honorary Doctorate of Public Service from the University of North Texas Health Sciences Center. Dr. Burgess and his wife, Laura, have been married for more than 40 years and have three children and two grandsons.
An Interview with Dr. Rich McCormick
Issue: January/February 2022
Author: Lisa A. Moreno, MD MS MSCR FAAEM FIFEM
Dr. Rich McCormick is an emergency physician from Georgia who is running for Congress from Georgia's 6th Congressional District. Dr. McCormick took an active role in AAEM's recent Health Policy in Emergency Medicine (HPEM) meeting in Washington, D.C. and he is a member of the Academy. His position on the corporate practice of medicine is aligned with AAEM's clearly stated position and AAEM board members and HPEM attendees really enjoyed discussing these issues with him in person in October. At this critical time in the life of our specialty, Dr. McCormick agreed to an interview with me to explore some of these fundamental issues and his own decision to run for public office.
LM: What prompted you to change your focus of service from the clinical practice of EM to politics?
RM: Well, you know I am still clinically active, even working night shifts. I feel this is an obligation I have to my community and my colleagues during the pandemic. But yes, there was a specific event that prompted my decision to run for public office. I had come up with a fair and reasonable solution to the problem of surprise billing. Special interest groups have the time and money to lobby the legislature, and their focus is on business, not patients. I decided to bring my ideas directly to the legislature in my home state of Georgia, and when I did, I watched a Republican who chaired the committee (despite what I believe is a conflict of interest due to his former employment with an insurance agency) fail to vet my ideas during the meeting. One of the other attendees told me, "If you're not at the table, you're on the menu. If you want to make a difference, you need to get involved. Are you willing to do that?" A consultant told me there was an open seat in Congress. This was a big move, so like any good member of the military and our specialty of emergency medicine, I got a consult from my wife and my buddies. They pointed out that I have the experience of being an emergency physician, a combat pilot, and an active member of my community. Who better to serve our country in the legislature? Health care is 20% of our federal budget and the emergency physician is an expert on what's going on in health care in America. I have experience in the military that has shown me that government programs often result in waste. Our health care costs have increased by 10% and a single payer system will end up costing even more. As I had these important conversations, I realized that this was a logical move.
LM: So, Dr. McCormick, this line of discussion leads logically into my next question. What traits that make you an effective EP will you carry forward to make you an effective legislator?
RM: As emergency physicians, we know how to identify the problem. We witness failed policies daily, and we see the impact of these failed policies on our patients. Look at the practices in the health care and pharmaceutical industries. Patients are unable to afford basic medications such as insulin. Major hospital corporations are setting policies that interfere with the physician's ability to do the right thing for the patient. These practices have come about as a result of government policies that favor corporations and pharmaceutical firms.
A second thing we do well is taking leadership. We lead resuscitations, we advocate for patients, we make decisions about admission and discharge, and we own those decisions. My experiences in the ED and the military have provided me with these leadership skills, but beyond that leadership is the ability to work well under pressure. Emergency physicians and fighter pilots have the courage to make decisions in high stress situations. We are trained to maintain logic and calm, to weigh the facts even under stress, and to come up with the best response to the situation that is presented to us. We're also very adept at dealing with unexpected events and pivoting when the situation changes or new information comes to light. We are bold and decisive. I can't imagine better preparation for dealing with the Congressional environment.
I've had some unique experiences being a white male conservative who went to medical school at Morehouse (author's note: McCormick was elected president of his class at this HBCU medical school) and did residency at Emory. Those environments taught me a different kind of leadership. I learned the power of collective bargaining and I learned that it's okay for people to disagree. We may have different opinions from colleagues we respect, and that's okay. This is often what the environment is like in Congress.
LM: So you've talked about the large hospital corporations setting policies that put business before patients. You've talked about how they set policies that result, essentially, in poor outcomes for patients and interfere with the doctor-patient relationship. What is your position on the corporate practice of medicine?
RM: Huge corporations taking over the practice of medicine is going away from one of the basic principles on which our country was founded, and that is fair competition. Large corporations have a huge advantage over individual practices and democratic group practices, and that's antitrust and that drives prices up. My wife is an oncologist, and she told me about an instance where the cost of a B12 injection at a particular hospital system went from $12 to $150. It's the same drug. It's the same nurse administering the injection. It's the same pharmacy dispensing it. But the hospital system is allowed to set separate charges for each step in the process and to drive the cost up because they have no competition. Look at what insurance companies can do with prior approval regulations. Physicians can't automatically do what they know the patient needs. The insurance company decides what treatment they will allow the patient to have. Look at the cost of drugs like Epipen, insulin and colchicine. These prices exist because pharmaceutical corporations have a monopoly on drugs. A fair market solution in medicine is possible. It happened with Lasik. That procedure is safer and cheaper than it has ever been because there has been open competition in that marketplace. What we have now with mega-corporations buying out hospitals and hospital based medical practices is no competition at all. And the losers are the physicians and the patients. Emergency physicians aren't self-regulating within our own organizations. Look at the proliferation of residency programs that are being accredited by the ACGME. Very soon, there are going to be too many of us, and this is just what large corporations want because then we'll be dirt cheap to employ. And now, these corporations are putting mid-level health care professionals into positions where it would be better for patients if the position were filled by a physician. This makes the job market worse for us and the outcomes worse for patients. The government is regulating us into unfair business practices instead of allowing physicians, who are the experts in health care, to control medical practice and instead of allowing fair competition which would actually improve health care for all and ultimately make it more affordable.
LM: As you know, AAEM is fully committed to maintaining the sanctity of the physician-patient relationship and we are opposed to the corporate practice of medicine. We also fully support the physician-led health care team and oppose independent practice by mid-levels. It's great to hear that members like you want to bring this message to Congress and support workplace fairness.
One of the other things about the practice of EM is that it affords us the opportunity to identify emerging trends in public health. I believe that maintaining a standard of public health and educating the public about health issues are responsibilities of both emergency physicians and our government. What are your thoughts on this?
RM: I agree 100%! And there's a lot of false information out there. This has become especially evident over the past two years as we've been experiencing the COVID pandemic. One of our biggest problems is that we can't seem to separate medicine from politics. We’ve made COVID political. And that's ridiculous. This is not a political issue. This is an issue of public health. Getting vaccinated, social distancing, and wearing a mask should be decided based on the evidence, not on the basis of political affiliation. And even within parties now, members are criticizing other members for decision making that is not along party lines, when what they should be looking at is scientific evidence. We should be leading by example, both in medicine and in government. We've made racism political as well. Racism is not a political problem—it's a human problem. This is all about respect. I don't know what your political affiliation is or what your religion is, but every major religion teaches respect for others and the value of treating others as we want to be treated. People want to be respected. They want to feel valued. Let's break bread together and talk about it. You can’t force people to see things your way. You won't win anyone to your side by calling them names. One thing I learned when I got my MBA is to take the emotion out of it. You can't sell something unless you show people the value of it to them, what makes it attractive to them.
LM: Interesting you say that. My son got his booster a couple of days ago, and he came home and told me that what he observed at the pharmacy is that we have so demonized the anti-vaxxers that we have created an environment where those seeking information about the vaccine, who just have some questions and want some information, are afraid to ask anything for fear of being demonized and lumped in with the anti-vaxxer group.
RM: Precisely. When we demonize people for holding a particular opinion rather than engaging them in respectful, logical conversation; hearing them out and listening to their point of view, we lose the opportunity to present them with medical evidence and the facts they actually need to make the right decision. We don't explain how they will benefit from best practices. We just make them feel like we think they're wrong. And that shuts down the dialog.
LM: You've mentioned the politicization of COVID in the US, and you're giving a cogent explanation of why we seem so polarized around what we as physicians know to be best practices. Many other nations have managed the COVID pandemic more effectively than the US has done. Why do you think this is, and what measures will you advocate for as an elected official to better control the spread of COVID and ensure better outcomes for those who do become infected?
RM: So, yes, I definitely think the politicization of the issue has been one of our major errors. Make it a medical issue, a science issue, because that's what it is! We're just confusing the public and drawing their attention away from what actually matters: the science. Now, this is the novel coronavirus, and we've learned a whole lot since March 2020, but we still have more to learn. So, we also need to create an environment where doctors are allowed to disagree with each other. That's part of the process of analyzing evidence and developing best practices. We don't demonize doctors for having disagreements about antibiotics. Why can't we have the same respect for differing opinions on COVID? If we've learned anything, it would be that no one has been 100% correct about anything COVID related since the beginning. Each variant will be different and we will need to learn more. A healthy environment that fosters scientific inquiry and respectful discussion of the evidence and interpretation of the evidence is what will lead us forward in defeating this pandemic.
LM: Dr. McCormick, I want to thank you for taking the time to talk with me today and to share your perspectives with our AAEM members. You mentioned that you don't know my political affiliations. Most of the AAEM members who've heard me speak know that I am a pretty far left liberal, although I vote as an independent. I enjoyed our conversations in Washington, D.C. tremendously and I really enjoyed our conversation today. I think our differing political affiliations but our closely aligned positions on the corporate practice of medicine, the importance of respectful dialog, and the need to depoliticize COVID prove a really important point. That point is that as emergency physicians, what we value most is giving the very best to every patient, providing the best value for time and money spent, and being able to practice medicine without unnecessary interference since no one knows medicine better than we do. I think the most important things that people like you will bring to Congress is exactly what makes for a great EP: being a good listener, having respect for all people no matter our differences, the ability to look at the facts without emotion, and wanting the best outcomes for everyone. We will be excited to follow your legislative career, and we hope you will join us at the Scientific Assembly in April for further discussion about the important health care issues facing the nation today.
Biography of Dr. Rich McCormick
With over 20 years in the U.S. Marine Corps and Navy, Dr. McCormick served in combat zones in Africa, the Persian Gulf, and Afghanistan. As a Marine, he flew helicopters and taught at Georgia Tech and Morehouse College as the Marine Officer Instructor. In the Navy, Dr. McCormick earned the rank of Commander and served as the Department Head for the Emergency Medicine Department in Kandahar, Afghanistan. Dr. McCormick is a graduate of Morehouse School of Medicine where he was also student body president, and completed residency in emergency medicine through Emory while training at Grady Hospital in Atlanta. He also received his MBA from National University in California. Dr. McCormick and his wife, Debra, an oncologist, have seven children and live in Suwanee.
An Interview with Congresswoman Dr. Kim Schrier
Issue: November/December 2021
Author: Lisa A. Moreno, MD MS MSCR FAAEM FIFEM
Welcome to the next installment of Legislators in the News. In this issue, we interview Congresswoman Dr. Kim Schrier (D-WA, US House of Representatives) who is a board certified pediatrician and only one of twofemale physicians, and the only Democratic female physician, currently serving in Congress. The Congresswoman is a staunch advocate of children and public health and supports the role of women in public policy. She generously accepted AAEM’s invitation to do a presentation at our annual Health Policy in Emergency Medicine Day, held on October 19, 2021, and allowed me to interview her on that day.
Dr. Moreno: Dr. Schrier, was there a particular event or series of events that led you to change your primary service focus from medicine to politics, or was it a more organic transition?
Dr. Schrier: I’ll tell you very simply what it was: Trump got elected. I started to think about the implications ofthat election on my patients and their families. I realized that this election had the potential to havesignificant adverse impacts on the lives of children and on their health care. Many of our nation’s children were able to get quality healthcare under the Affordable Care Act (ACA). ACA’s exchanges have provided coverage for upwards of 10 million people annually. The Trump Administration reduced the support for advertising the program and reduced the annual enrollment period by almost half. There was a plan to exclude pre-existing conditions. This impacted me directly, as a Type 1 diabetic. It was disturbing to realize how many families and children would be left without medication, without care for congenital conditions, without the vaccines, and early detection that is facilitated by regular well child visits to the pediatrician that become impossible for those without insurance. Under that administration, immigrant children were not accorded the Child Tax Credit on the income tax returns of their parents, directly impacting the money available for food and housing. Public education was under attack during the campaign, with talk of issuing school credits that could be used at charter schools and religious schools, most of which are unaffordable or not accessible to our most vulnerable families. This plan threatened to decrease the support for public schools and increase the disparities in education that the poor are already experiencing. Even the general tenor of the conversation during that campaign was troubling. There was name calling, mocking of individuals with disabilities, disparagement of women. As a pediatrician, I know that the morale of children, of all individuals, is related to their mental health and to their ability to succeed. I felt it was my responsibility as a pediatrician and as a citizen to take a stand for the rights and wellbeing of children and families, and so I ran, and I won.
Dr. Moreno: Many women in leadership experience “the only woman in the room” or “the only woman at the table” phenomenon. How does this play out for you in Congress?
Dr. Schrier: Well, I certainly experienced this as an undergraduate. I was an astrophysics major and I wasoften the only woman in the room. But in Congress? Never! Remember, I was elected as part of the group ofDemocratic women who turned Congress. This is the Grand Sisterhood, and we are focusing on legislation that supports women in their roles as working mothers and supports children as the future leaders of our nation.
(Author’s note: Dr. Schrier joined the House of Representatives in a cohort of remarkable, record breakingwomen: Congresswoman Ayanna Pressley, the first Black to represent Massachusetts; Congresswoman Alexandria OcasioCortez, the youngest woman ever elected to Congress; Congresswomen Ilhan Omar and Rashida Tlaib, the first Muslim women ever elected to Congress; and Congresswomen Deb Haaland and Sharice Davids, the first Native American womenever electedto Congress.)
Dr. Moreno: How does your knowledge and experience as a physician empower you in your interactions with other lawmakers?
Dr. Schrier: Who better to take on information sharing than a physician in Congress! Everything I docarries additional weight because I’m a doctor. I can help set the trend for healthy behavior. Members watch to see, “Does Schrier replace her mask between sips and bites?” Other members even ask me to diagnose their kids; they seek my opinion about their children’s medical care. Concern for your children is bipartisan; it knows no bounds, and this fosters good relationships with other members, regardless of party or political stance. And MDs speak the same language, so it’s easy to gain bipartisanship with the other doctors serving in Congress. We understand the priorities. I worked with Republican Congressman John Joyce, MD (Pennsylvania), on strengthening the Vaccines for Children Program. This is a program that provides free vaccines for children whose families are unable to afford them and covers not just vaccines given at clinics or vaccine centers, but also in the pediatrician’s office. The VACCINES Act of 2019 is another example. This bill requires the Centers for Disease Control and Prevention (CDC) to develop a national surveillance system to monitor vaccination rates, and to conduct a national campaign to increase awareness of the importance of vaccines. These are non-partisan issues that physicians agree on, and physicians are regarded as experts on these issues by other members of Congress. We were able to come together with the same passion as the antivaxxers bring to their movement. Some of the older physician members who saw the results of unvaccinated kids who got polio were able to share their experiences. This carries weight. You have actualphysicians who are your colleagues in Congress reporting on actual patient cases that are relevant to what we are working on in the House of Representatives.
I’ve also been able to help other members to make the connection between housing and health, a connection that is critical not just for kids, but for our constituents at every age. I can communicate with the Health and Human Services officials and with the White House regarding creative ideas to get kids vaccinated, such as school parties. Our expertise and experience are respected when health policy is under consideration.
Dr. Moreno: What do you see as a woman leader’s responsibility for mentorship and how do you choose who to mentor from the myriad requests you must receive?
Dr. Schrier: I share advice with everyone! But since there is only so much time available, the caliber of the candidate impacts the extent of the help I give. If a woman is running for office, this would be a strong consideration. Also, I want to be pretty certain that the people I am helping are intent on helping other people. I try to be visible in a way that will inspire girls to think of politics as a real career option. You give a press conference, or you speak to a student body, and you never know who will suddenly realize, “I could do that, too. That could be me up there someday.”
Dr. Moreno: From your vantage point as a physician legislator, what do you believe are the three most critical legislative issues that physicians need to focus on in the coming year?
Dr. Schrier: I would love to see physicians working with legislators to get home COVID test kits to be readily available to the public, but when I think of the three major legislative issues that practicing physicians should focus on, they would be these:
- Universal access to affordable medical care
- Physician autonomy in practice, and this includes in prescribing and in the development of telemedicine services
- Fair reimbursement for all physicians. Physicians should not have to be responsible for fighting for reimbursement; they should be able to spend their time taking care of patients.
And while this is not necessarily a legislative issue, we all need to be concerned about the mental health of the nation’s physicians.
Dr. Moreno: Congresswoman Schrier, you are reflecting many of the issues that are core to the mission of AAEM. We support the right of every patient with an emergency condition to be cared for by a board certified emergency physician, and we hold that the physician, based on training and experience, is best positioned to make decisions regarding treatment within the privacy and sanctity of the physician-patient relationship, and that these decisions should not be legislated or controlled by non-physicians. The Academy has beenactive in the movement to de-stigmatize mental health disorders and to eliminate penalties for physicians who seek help for depression, burnout, and moral injury. We value your support of physician legislators such as yourself. Thank you so much for your support of our Health Policy in Emergency Medicine seminar and for taking the time to meet with me today.
Dr. Schrier: It was my pleasure. I certainly look forward to seeing healthier children and stronger families as a result of all of our combined efforts.
About Dr. Kim Schrier
Congresswoman Kim Schrier represents Washington’s 8th Congressional District, which includes much of King, Pierce, Kittitas, and Chelan Counties, and portions of Douglas County. Prior to being elected to Congress on November 6, 2018, Dr. Schrier spent her career as a pediatrician in Issaquah, working with children across the Puget Sound region and helping families navigate the health care system. In Congress, Dr. Schrier uses this expertise to inform her work on issues that improve the lives, health, and wellbeing of children.
As the first pediatrician in Congress, Dr. Schrier brings a critical voice to issues related to health care. Through her own experience as a patient living with Type 1 diabetes, Dr. Schrier understands the very real fear of health care costs and access for people living with pre-existing conditions. And as a physician who has worked in a broken health care system, Dr. Schrier understands what changes need to be made to make it work better for both patients and providers.
Dr. Schrier grew up the daughter of a public school teacher and an engineer. Her father, an engineer, instilled in Dr. Schrier a love for science, a passion that led Dr. Schrier to a degree in Astrophysics at U.C. Berkeley and then to medical school. Her mother taught her the value of education and teachers, and the importance of unions and collective bargaining. As a child, Dr. Schrier watched her mother’s union successfully negotiate for increased school funding, smaller class size, and improved benefits.
The product of public education from elementary through medical school, Dr. Schrier is passionate about helping every child thrive in school. After graduating from U.C. Berkeley Phi Beta Kappa, Dr. Schrier spent a year working at the EPA before attending medical school at U.C. Davis School of Medicine. She completed her residency at the Lucile Packard Children’s Hospital at Stanford University. In 2013, Dr. Schrier was named Best Pediatrician in the Greater Seattle Area by Parents Map Magazine. Dr. Schrier’s experience as a pediatrician gives her a unique understanding of the needs and struggles facing 8th District families. She lives in Sammamish with her husband, David, and son, Sam.
An Interview with Representative Troy A. Carter, Sr.
Issue: September/October 2021
Author: Lisa A. Moreno, MD MS MSCR FAAEM FIFEM
Welcome to the next installment of Common Sense’s Legislators in the News column. This column is designed to help you get to know your legislators, understand the legislative process and how you can influence it, and strengthen the Academy’s relationship with our lawmakers for the purpose of improving the working conditions of physicians and the health care of the nation.
In this issue, we interview Congressman Troy A. Carter, Sr. (D-LA). Rep. Carter is serving in his first term as the Congressman from Louisiana’s 2nd Congressional District and currently serves on two House Committees, the Transportation and Infrastructure Committee and the Small Business Committee. His brief bio follows this article.
Dr. Moreno: You have a long history of serving New Orleans as a city councilman, Louisiana State Representative, and Louisiana State Senator. What factors prompted you to make the move to the federal government?
Rep. Carter: It’s been an honor and a privilege to serve my community on essentially every level of government. From each experience I’ve learned so much and gained a better understanding of what public service is.
Public service is so many things. It’s making sure the garbage gets picked up. It’s fighting to get healthcare to cover more essential medical procedures. Public service is listening to the people, and being in the community, then taking action on their behalf. After all of this public service at the local and state level, I wanted to be of service in a new way. After decades of debating how to spend federal dollars, I was ready to be the one fighting to bring those dollars into Louisiana and the 2nd District.
Dr. Moreno: What do you consider the most important health related issues that Congress will address this year?
Rep. Carter: The top issues for me are recovering from COVID-19, combating racial health disparities, prescription drug affordability, and expanding eligibility for Medicare.
Dr. Moreno: You have a strong record of opposition to expanding gun rights. This is a major issue for AAEM. We are one of the founding organizations of the American Foundation for Firearm Injury Reduction in Medicine. The immediate past president, Dr. David Farcy, and I recently published our research on how Emergency Physicians can improve our role in the prevention of firearm injury.1 As a native New Yorker living in NOLA, and as an EP in these cities, I am acutely aware of the devastating toll of firearm injury and the disproportionate burden borne by young males of color. Please share with me how you came to have such a strong position on the expansion of gun rights and tell me what you believe physicians can do to support your position in Congress.
Rep. Carter: Communities of color in my district are hit hardest by gun violence, and it’s clear something has to change. As a policymaker, as a neighbor of yours in New Orleans, and as a Black father of two Black sons, we are in full agreement on that.
I am open to discussing strategies to comprehensively address this scourge of violence, and I think a wide coalition could help make this discussion more effective. If this nation is going to see less gun violence we have to change policy and we have to change culture – they go hand in hand. As a group trusted by way more people than Congress is, I think emergency physicians can be an incredible voice to policymakers and to members of the community. As physicians, you have seen the damage guns can cause and tried to repair it within people’s bodies. That must be devastating. It’s time for everyone to step up and join you in repairing the damage they cause within our communities. I look forward to being a partner in this effort.
Dr. Moreno: One of your appointments is to the Committee on Small Business. AAEM supports physician ownership of democratic medical professional groups as opposed to the control of physician practice by large corporations. We share the view you expressed in a recent interview that corporations wake up each morning thinking about how to make a profit, while governments need to focus on service. We hold that while large corporations have a fiduciary duty to make a profit for shareholders, physicians have a fiduciary duty to provide the best medical care to every patient, regardless of race, ethnicity, religion, sexual preference, gender identity, age, ability to pay, or any other human condition. We feel physicians should control our medical practices so that we can put the patient first. Do you see a role for physicians who hold these ethical standards to collaborate with the Committee on Small Business to control our medical practices so that we can keep patients before profits?
Rep. Carter: I think emergency medical physicians should tell their stories fully in both their roles: as a physician and as a business owner. That’s a unique perspective that needs to be heard more. Congress should explore how to make it easier for physicians to open and run their own businesses, and support your efforts to make healthcare more affordable, accessible, and culturally competent. There are a lot of federal services available to small businesses but we need to improve ease of access to these programs. My office is open to help all small business owners in my district in this difficult time and beyond.
Dr. Moreno: One of the ways in which the physician’s commitment to put the patient first can be protected is to ensure that we have the right to due process so that our employment cannot be terminated when we raise concerns about patient safety in the emergency department. Emergency physicians who often are forced to waive their due process rights in their employment contracts have been fired during the COVID pandemic for fighting for adequate PPE and standing up for patients and other emergency personnel. Would you support legislation, such as H.R. 6910 introduced last Congress by Representative Raul Ruiz, which would provide critical protections for emergency physicians to advocate for their patients?
Rep. Carter: I am a proud and strong supporter of unions and the right to organize in general, in large part because of the worker protections they provide. I do think all workers should have full due process rights and I look forward to finding ways to improve protections for all workers throughout my time in Congress. I would be happy to consider the bill further and to sit down with my colleague Dr. Raul Ruiz to learn more.
Dr. Moreno: Congressman Carter, I want to thank you for taking the time to talk with us about issues that are important to emergency physicians and to lawmakers. I am looking forward to seeing you when we come to Washington, D.C., for our AAEM Advocacy Day on October 19 and to possibly visiting your office on October 20. Collaboration between doctors and lawmakers will go a long way to protecting the health of the public, so thank you for collaborating with us on this interview and going forward.
Representative Troy A. Carter, Sr. Bio
The Honorable Troy A. Carter, Sr. is serving in his first term as the Congressman from Louisiana’s 2nd Congressional District, encompassing most of New Orleans East & West Bank, Jefferson Parish, and River Parishes including St Charles, St. James, St John the Baptist, Ascension, Assumption, Iberville, as well as portions of East Baton Rouge and West Baton Rouge Parish.
Congressman Carter currently serves on two House Committees, the Transportation and Infrastructure Committee, one of the largest committees in Congress that has jurisdiction over all modes of transportation, and the Small Business Committee, which has direct oversight and consideration over all matters affecting America’s backbone, small businesses.
The youngest of six children, Congressman Carter was raised in Algiers. He is a product of Orleans Parish Public Schools and went on to graduate from Xavier University, earning a Bachelor of Arts in Political Science and Business Administration. Additionally, Congressman Carter earned his MBA graduating Summa Cum Laude from Holy Cross University.
Soon after graduating from Xavier University, Congressman Carter served for six years as the Executive Assistant to Mayor Sidney Barthelemy. In 1991, Congressman Carter became the first African American to be elected to the Louisiana House of Representatives from the 102nd District in Algiers, where he served as the youngest ever floor leader representing the City of New Orleans.
In 1994, Congressman Carter was elected to the New Orleans City Council, representing District ‘C’, which includes Algiers, and the historic French Quarter, again becoming the first African American elected to the position. After a hiatus from public office, Congressman Carter was elected to the State Senate for Louisiana’s 7th District, where he served as the Senate Minority Leader for the Democratic Caucus. During his time as a Legislator, Congressman Carter authored and co-sponsored hundreds of bills.
As a Louisiana Legislator, Congressman Carter championed large-scale infrastructure projects, economic development, and efforts to decrease homelessness drastically. He has also worked as a staunch advocate for criminal justice reform, women’s health care, and civil rights and equality on behalf of the LGBTQI community. As Congressman, he actively continues his work to address the issues above and several others, including COVID-19 relief for individuals and small businesses, environmental justice reform, and reducing student debt.
Congressman Carter is a proud husband to wife, Brigadier General Andreé Navarro-Carter of the United States Army, and father to sons Troy Jr. and Joshua. They live on the Westbank of New Orleans, where Congressman Carter was born and raised.
The Honorable Congressman Troy A. Carter, Sr. has enjoyed a series of historic firsts including:
- 1st African American elected to the Louisiana State House from District 102
- 1st African American elected to the New Orleans City Council representing District C
- 1st African American elected to the Louisiana State Senate from District 7
- 1st Congressman elected to Louisiana’s 2nd Congressional District from the Westbank
- 1st Congressman whose spouse is a General Officer in the United States Army
An Interview with Representative Mark Green, MD
Issue: July/August 2021
Author: Lisa A. Moreno, MD MS MSCR FAAEM FIFEM
Welcome to the second installment of our new Common Sense column, designed to help you get to know your legislators, understand the legislative process and how you can influence it, and strengthen the Academy’s relationship with our lawmakers for the purpose of improving the working conditions of physicians and the health care of the nation. This issue, we interview Congressman Dr. Mark Green (R-TN). Rep. Green is an emergency physician and has recently introduced health related legislation pertinent to emergency medicine. His brief bio and text of the legislation follows this article.
Dr. Moreno: As emergency physicians, we see trends in public health and the impact of public policy faster and more frequently than any other specialty. So, it’s natural for us to be involved in public health and public policy. But, you chose to make public policy your primary focus and the primary way in which you serve our patients. How did you make that decision?
Rep. Dr. Green: When I was a practicing physician, I ran an emergency medicine management company. We wanted to see the delivery of care improve. I recognized there were serious flaws in the way that government impacted health care and I realized that I could have an impact there. I saw this as an opportunity to better serve both physicians and patients on a larger scale.
One of the ways I made an impact was early in my career, while I was still a Tennessee State Senator. I passed a bill that required the insurance companies to get physician input when pre-approval for medical procedures was necessary. I believe that if an insurance company is going to say “no,” then a medical professional must be involved, and it should preferably be an MD. This bill impacted 6.9 million people in the State of Tennessee. That is 6.9 million people who did not have a non-medical administrative person denying their procedure, resulting in delayed care while the patient and the doctor file a request for a review of the denial.
Dr. Moreno: What do you think are the three most critical legislative issues facing emergency medicine today?
Rep. Dr. Green: Telemedicine: We used to say in the military that certain elements are combat multipliers. Telemedicine can be a massive combat multiplier for EM. It can streamline the ED processes, and reduce backups. The use of telemedicine can enhance the impact of the physician intervention while decompressing the ED. It eliminates the need for a patient to have transportation to the ED and would certainly decrease the unnecessary use of EMS transport. It is a practical way of giving universal access for patients to the most highly skilled member of the ED health care team, the emergency physician, at a much, much lower cost than an ED visit. The physician would then be able to call in a prescription, send an ambulance, or get the patient an appointment with primary care or the appropriate specialist in the appropriate time frame.
Rural EM: I am very concerned about critical access hospitals and the possibility that many of them may close. CMS has a 35-mile regulation that says that Medicare will only reimburse if the off-campus clinic is within 35 miles of the main campus hospital. Now, we know as emergency docs that many of our patients across the country live a lot more than 35 miles from a main campus hospital. We know the mantras that “time is muscle” and “time is brain,” and so it is critical that rural patients have access to urgent and emergent care when they have a potentially time critical chief complaint. Every patient deserves access to a physician competent to assess the patient for their chief complaint, start the appropriate intervention, stabilize the patient, and move them to definitive care if this is indicated. If critical access clinics and centers are not reimbursed, they will not be able to afford to stay open, and then all the patients who are served by these institutions could find themselves on a four or five hour ambulance ride to the nearest emergency department. And as we know, patients who are not stabilized prior to transport to definitive care have far worse outcomes.
Something else that people fail to realize when discussing rural health is that critical access hospitals and clinics provide jobs in their communities. So, not only are they providing life- and limb-saving medical interventions and keeping doctors and nurses living in rural communities, but they are also providing jobs for housekeepers, pharmacists, pharmacy assistants, radiology technicians, transporters, security officers, clerical staff, and many others. Protecting these patients and these communities is an overlooked area and one that I champion, so much so that I have introduced two bills, the Rural ER Access Act and the Rural Healthcare Access Act, which is co-sponsored by Rep. Bennie Thompson (D-MS).
Overregulation: Balance billing is an example of this. The intent of the framers of the Constitution did not include overregulation by government. Physician practice, like everything else in our society, should be dependent on the supply/ demand curve. We need to make sure that insurance agencies don’t hinder patient care. We know that the government pays below market value for health care. Insurers keep us in business. The Government should not be involved in this relationship.
Dr. Moreno: At AAEM, we are very aware of the impact of corporate practice on our lives and the lives of our patients. Profit is valued over what is best for the patient and over physician wellness. Patients per hour is valued over quality of care. We are encouraged towards suboptimal practices in order to get high patient satisfaction scores. How do you see the role of lawmakers in protecting the sanctity of the doctor-patient relationship and returning medical decision making into the hands and minds of those most qualified to do this: physician specialists?
Rep. Dr. Green: Lawmakers can do a lot, especially at the state level. In fact, we did a lot in Tennessee. States should run their own programs, because at the state level, the doctors know what the issues are for their communities and the state lawmakers are in touch with what their constituents want. The corporate practice of medicine is damaging to medicine. First and foremost, it drives up the cost of health care. It involves many more people than need to be involved in the delivery of care. We need to put physicians back into decision-making roles, specifically regarding admissions. If you are looking at a patient, and you are laying hands on a patient, and you are a licensed physician, then you know what the appropriate disposition for the patient should be better than some non-medical person in an office somewhere.
Dr. Moreno: Why are states better-placed to make decisions?
Rep. Dr. Green: I am at heart a Constitutionalist, and I believe that what the Constitution says should be followed. According to the Constitution, health care is not a federal issue. The 10th Amendment clearly says that if it is not in the Constitution, then it is within the power of the states to make decisions. (Author’s Note: For those of you who, like me, need a refresher on 8th grade Civics class, here is what the Tenth Amendment says: The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people.) The federal government has
overreached in many areas, not just health care. Sometimes, they do not say exactly what an entity needs to do, but they will say that if you want specific federal money, then you have to comply with specific standards. That is not what the founders wanted; they wanted the power spread out among the different branches and levels of government, a system which better serves the people. One of the intents of the framers was to avoid tyranny. By decreasing the concentration of power, by sharing it among the branches of government and the levels of government (federal, state, and local), tyranny is avoided. The government closest to the people should be making decisions for the people in their states. I know my constituents in Tennessee want this level of autonomy, and I suspect most Americans share this view.
Dr. Moreno: Many lobbyists and citizens come to you to advance their agendas. Some of these contacts are impactful and change the way a lawmaker votes or what bills he introduces or supports. Some of these contacts make no impact on the lawmaker at all. What qualities in a person or in their approach cause you to sit up and listen?
Rep. Dr. Green: You have to take it at face value that lobbyists will pitch their positions well. I expect them to have done the research and to come prepared to discuss the issue they are lobbying for. What I really like to see is someone lobbying who has done what they are lobbying for. So, a physician lobbying for health care is someone I would listen to because they have practiced in the health care field. I think of lobbyists like drug reps, they are the detail people. They bring the details to us. I also always ask every lobbyist who comes to me: tell me the argument of the person on the other side; the opponent. If they can do that, then the lobbyist is honest, and they know the policy issue front and back. It gives them credibility. It goes without saying, but they also need to be articulate and able to sell their argument.
Dr. Moreno: What are some of the things that lobbyists or constituents do that make it less likely that their message will have an impact?
Rep. Dr. Green: Don’t threaten legislators. Some lobbyists will come in and say, if you don’t support this, then we are going to do this. This is not a collaborative stance. Our job as legislators is to represent the needs of our people, to adhere to Constitutional law, and to improve the lives of our constituents. We aren’t swayed by threats. Making threats is not a way to gain respect.
Dr. Moreno: Do you have a closing message for emergency physicians practicing in today’s health care environment?
Rep. Dr. Green: Our goal as medical professionals should be to change people’s lives. That nine-year-old child who comes in with a broken leg should leave wanting to become a doctor. We have that power to change people’s lives, and we should seize it.
Rep. Dr. Green Bio
Congressman Mark Green first took the oath of office to represent the 7th District of Tennessee in Congress on January 3, 2019. It is the exact oath he first took as a cadet, on the historic Plain at West Point more than thirty years earlier. As a successful business leader, decorated combat veteran, ER physician, and former Tennessee State Senator, Green is uniquely equipped to represent the people of his district.
The son of a hardworking father and loving mother, Congressman Mark Green grew up on a dirt road in Mississippi. He came to Tennessee in his last assignment in the Army as the flight surgeon for the premier special operations aviation regiment. As a Night Stalker, Green deployed to both Iraq and Afghanistan in the War on Terror. His most memorable mission was the capture of Saddam Hussein. During the mission, he interrogated Hussein for six hours. The encounter is detailed in a book Green authored, A Night With Saddam. Congressman Green was awarded the Bronze Star, the Air Medal with V Device for Valor, among many others.
After his service in the Army, Green founded an emergency department staffing company that grew to over $200 million in annual revenue. The company provided staffing to 52 hospitals across 11 states. He also founded two medical clinics that provide free healthcare to under-served populations in Memphis and Clarksville as well as numerous medical mission trips throughout the world.
Green was elected to the Tennessee State Senate in 2012, where he distinguished himself as a conservative leader that fought for freedom and smaller government for all Tennesseans. His many legislative accomplishments include the repeal of the Hall Income Tax and the passage of the Tennessee Teacher Bill of Rights. He won the National Federation of Independent Businesses’ Guardian of Small Business award and the Latinos for Tennessee’s Legislator of the Year award, among many other recognitions.
In Congress, Green has worked tirelessly on behalf of people of Tennessee’s 7th District. He serves on the House Armed Services Committee, House Foreign Affairs Committee, and the Select Committee on the Coronavirus Crisis. In addition, Green serves as Ranking Member of the House Foreign Affairs Subcommittee on the Western Hemisphere, Civilian Security, Migration, and International Economic Policy.
Green has sponsored 24 pieces of legislation and cosponsored 168 pieces of legislation over issues facing the people of Tennessee. From strengthening rural healthcare, to holding China accountable, to supporting Gold Star families and bringing American businesses back home, Congressman Green’s well-rounded background in business, healthcare, and the military has made him distinctly qualified to address such issues.
Congressman Green’s experience building a successful healthcare company equips him to take on wasteful spending and over-regulation from Washington. He introduced the Balanced Budget Amendment to the Constitution that requires Congress to pass a balanced budget and stick to it.
His 24 years of service—between the Academy, active duty Army and Army Reserves—have impressed upon him the need for a well-cared for military family. Green made veteran families a priority during his time in the Tennessee State Senate, and has continued to do so during his time in Congress. His first bill introduced in the House was the Protecting Gold Star Spouses Act that allows for spouses to continue receiving benefits during government shutdowns. He introduced another bill for Gold Star families, the Protecting Gold Star Children Act, which places children receiving benefits in the appropriate tax bracket.
Green has also worked to improve resources for the mental and physical health of veterans. He introduced the Spiritual Readiness amendment to the NDAA to address spiking numbers of veteran suicides. In addition, he led the bipartisan fight to include provisions for veterans subjected to toxic exposure while serving at the K2 Air Base in Uzbekistan during the War on Terror. In January of 2021, the President signed an Executive Order modeled after Rep. Green’s bipartisan K2 Veterans Toxic Exposure Accountability Act that requests the Secretary of Defense recognize Uzbekistan as a combat zone for purposes of medical care. This action represents a crucial step toward recognition of K2 veterans’ severe and deadly service-connected illnesses.
His time serving in the Armed Forces also made him aware of the need for strong American leadership internationally and the threat China poses to this generation. Green has introduced 5 bills to hold China accountable: The Our Money in China Transparency Act, the Bring American Companies Home Act, the Protecting Federal Networks Act, the Secure Our Systems Against China’s Tactics Act, and the China Technology Transfer Control Act. He also introduced a resolution demanding China’s repayment of sovereign debt held by American families.
As a physician, Green recognizes life begins at conception and firmly advocates for the unborn. He introduced the Born-Alive Survivors Protection Act that requires medical attention for infants born during abortions. Green also brings the unique perspective of doctor, healthcare administrator, and cancer survivor to the issues surrounding rural healthcare in America. He introduced the bipartisan Rural Health Care Access Act and the Rural ER Access Act to cut regulation and improve emergency medical care in rural hospitals.
Congressman Green has won multiple awards for his work in Congress, including the American Freedom Fund’s Legislator of the Year Award for his work to empower veterans and the Guardian of Small Business award from the National Federation of Independent Business (NFIB). Green received a perfect A+ rating from the Susan B. Anthony List for his pro-life voting record. He also received the impressive distinction of being unanimously voted President of the Republican freshman class in the House of Representatives.
Green resides in Clarksville, Tenn., with his wife, Camilla. They are the proud parents of two grown children
HB 2622: An Interview with Amish Mahendra Shah, MD MPH FAAEM
Issue: May/June 2021
Authors: Amish Mahendra Shah, MD MPH FAAEM and Lisa A. Moreno, MD MS MSCR FAAEM FIFEM – President, AAEM
Dr. Amish Shah is an emergency physician (EP) and an elected member of the Arizona House of Representatives. Dr. Shah graduated from Northwestern University with both his Bachelor’s and his Medical Doctorate degrees and went on to complete an MPH at University of California, Berkeley. He did his emergency medicine residency at Lincoln Medical and Mental Health Center in the Bronx and a fellowship in Sports Medicine at the University of Arizona, Tucson. His run for the Arizona State House grew out of concerns that arose from his experiences as a practicing EP, and his work in the legislature has focused on health and education. Most recently, Rep. Dr. Shah introduced HB 2622, which has been ratified by both Houses of the Arizona legislature and signed into law by Arizona Governor Doug Ducey. A copy of the bill and Rep. Dr. Shah’s bio sketch appear at the end of this article. I recently had the privilege of interviewing Dr. Shah on his groundbreaking, and AAEM hopes, precedent-setting, legislation.
LM: Dr. Shah, would you share the context and a summary of the substance of your recently passed bill, HB 2622?
AS: Prior to my bill, Arizona had a law on the books to prevent retaliation by health care institutions against health care professionals, but that law was outdated. It was written in 2003, and since then, the marketplace has substantially changed. Now, the health care marketplace is, in many regions of the country, dominated by corporate medical groups (CMGs). Even in areas where the CMGs do not dominate the health care marketplace, they are nonetheless significantly impactful. As you know, Dr. Moreno, CMGs have contractual relationships with health care institutions and as part of these contracts, the CMG provides physician services, in some cases for more than just the ED. Those services might include radiology, anesthesiology, critical care, hospitalist services, and inpatient psychiatry, to name a few. If the health care institution has an issue with a physician, the institution does not have to fire the physician because they do not employ the physician. Instead, they voice their complaint to the CMG, which in turn, will terminate the physician or keep the physician off the schedule. Similarly, if a physician voices a concern about staffing, patient safety, or a particular policy of the CMG or the hospital that the physician believes is not in the best interest of patient care, the CMG can retaliate by terminating the physician or failing to put him or her on the schedule.
HB 2622 says that neither the health care institution nor the CMG can retaliate. A retaliatory action is not limited to termination but includes any adverse action, including taking a physician off the schedule. This bill is inclusive of all health care professionals and is not limited to physicians. My goal was to empower all health care professionals to be able to act with integrity around issues of patient safety and excellence in patient care without fear of retaliation.
LM: What prompted you to write this bill?
AS: Two things: First, a friend who is an EP was in the ED and noticed a patient safety concern: a non-medical person was watching the nursing station telemetry monitors. The EP went to the administration and expressed the above concerns. The hospital administrator then talked to the third-party staffing company and informed them that the hospital did not want that physician on the schedule anymore because that physician was “causing trouble.” The staffing company took the doctor off the schedule, and the physician contacted me to share the story. Then, you invited me to speak at AAEM Advocacy Day 2019 in Washington DC. You asked me to speak about the physician’s role in public policy making. While I was there, I learned a lot about the work that AAEM does to protect physicians who are unjustly terminated for speaking up about patient safety and workplace fairness. I met Dr. Wanda Cruz from Florida, who shared her story about being terminated after reporting to her hospital administration that inadequate physician staffing had contributed to long waiting times and a poor outcome for one of her patients. I realized that retaliation against health care personnel, specifically emergency physicians, was far more common than I had previously been aware of, and I decided to act.
I put forth a bill that allows physicians to address patient safety concerns. It also brings awareness to the public that these practices are in place. In the case of my friend’s situation, how would a patient know that they were being monitored by a non-medical person who was not trained to read a cardiac monitor? There are certain things that only the physician working in the ED would be aware of. The bill empowers these physicians to speak up about situations that only they could possibly be aware of by virtue of their work and education. And as I said, this bill is for all physicians, not just EPs, and for all health care professionals. As we know well, situations may arise that only nurses, or only respiratory therapists may be aware, and that have the potential to endanger patients or negatively impact their care.
LM: I’m genuinely happy to hear that AAEM had a role in prompting you to create this bill. It is important to us that our work makes legislators aware of the problems that exist so that legislators can work with us to enhance patient safety and workplace fairness.
AS: I have always believed that physicians have a responsibility in influencing and creating health policy, and this was a great opportunity to demonstrate the importance of such a collaboration.
LM: So, talk to me a little bit about how exactly the process works. Now that the bill has been passed in Arizona, how would an Arizona physician go about registering a concern so that she would be protected by this new law?
AS: To be protected by this law, the health care professional would make a report to the health care institution’s administration about the patient safety issue of concern. This law only protects you if you go to administration first. The new law says you have to give the institution an opportunity to respond and address the report. The law would not protect someone who posts a grievance directly onto social media or another public forum. Every institution must maintain a reporting system, and the health care professional has to use the institution’s reporting system.
LM: Okay, but what would happen if the health care professional went to a regulatory agency first, before they go to the hospital’s administration? Would they still be protected?
AS: Well, there is already a process in place for that. Regulatory agencies have what are called “whistleblower” policies that allow for anonymous reporting by any concerned person. As legislators, we need to be aware of existing federal and state legislation and avoid duplication of existing laws. But we also look at existing laws and consider whether they need to be updated to respond to circumstances that have changed over time. This was the case with my bill.
LM: There are those who would say that your bill does not go far enough. You protect health care professionals against retaliation, but you don’t, for example, spell out severe penalties for the institutions that do retaliate.
AS: (Laughs) There is a lot of statecraft that goes into writing and introducing a bill. What good would a bill do for anyone if it has no possibility of being passed into law? So in most cases, you want the bill that you drop to be reasonable, to be introduced in a way that will not unnecessarily create opposition. You can’t alienate or antagonize others without cause. You have to realize that there are powerful lobbies out there. Most organizations have lobbyists, and they spend considerable time and money protecting their interests.
One of the things I do prior to introducing a bill is called “the stakeholder process.” The legislator needs to make phone calls and have meetings with any entity that is a stakeholder with regards to the issue that we are planning to legislate. It’s important to give everyone a chance to work on a mutual solution. This is what other legislators will expect to have happened. Next, I try to get their buy-in. In this case, I explained to them that penalizing someone who is essentially a whistleblower, someone who is speaking up for the protection of the patient population, is not a good look. They won’t look good in the public eye.
LM: So, did this get buy-in from the health care institutions?
AS: Mostly yes. In undertaking the stakeholder process, you get the broader picture. Like I said, you want to craft a bill that will pass so that it can actually do some good for your constituents. So, I ask them outright, look, is this a bill that you would oppose, and if so, why? They responded that they were okay with the idea as long as I made a couple of technical changes to the bill language. The health care institutions didn’t want liability if a third-party did the firing on their own. So, I tweaked the bill to factor that in and avoid unintended consequences. I appreciated that they worked with me in good faith. With some bills, we won’t reach an agreement during the stakeholder process, and so then we would have to battle it out in committee and on the floor for the votes.
LM: And is this stakeholder process a mandatory process for lawmakers?
AS: Involving all the stakeholders is doing due diligence. It’s not mandatory, but it is likely expected from fellow lawmakers.
LM: And once you have done your due diligence and gone through the stakeholder process, you craft your proposed legislation and then you introduce it?
AS: You can, but as I said, you want a bill that has a high likelihood of being passed into law. So, you want to get other legislators to join as co-sponsors and you want to look for bi-partisan support. So, you approach your colleagues and you point out why the proposal is valuable to constituents, why it is necessary, why it will protect the public. And you let them know that it is not unnecessarily antagonistic to other stakeholders.
LM: I never realized how complicated this process is! And it takes a lot of skill. One just imagines that if you’re doing the right thing, a bill should be passed, but there is clearly a lot more involved in creating a bill that WILL pass. And it seems clear to me now that there can be a lot of value in speaking to the stakeholders. I would not have thought about the liability that a health care institution may be at risk for, even if a third-party entity is retaliating against the physician who speaks up.
AS: You learn a lot as a lawmaker, just as you learn a lot as a physician.
LM: Since we’re talking about learning, can you just walk us through the process for a bill to become a law?
AS: Sure. After the stakeholder process, crafting the bill, getting co-sponsors (including hopefully bi-partisan support), the bill goes to the committee of the relevant chamber. Once it passes committee, it is presented to the floor of the chamber in which it originated. After a vote in that chamber, then it moves to the appropriate committee of the other chamber, and then to the floor of that chamber. Finally, it goes to the Governor, who can either sign it into law or veto it. A veto by the governor can be overruled with a 2/3 vote of the legislators.
LM: I’ve learned a lot today, and this interview has reinforced my commitment to the mission of AAEM and our work to champion the EP so that the EP can do the right thing for the emergency patient. You have also reinforced my belief that physicians, and emergency physicians in particular, have a critical responsibility in advocating for the needs of our patients. I know this is part of what fueled your commitment to run for office.
AS: Absolutely. The things I’ve learned practicing emergency medicine have only reinforced my personal commitment to improve the health of our patient population through education and legislation. It is an honor for me to serve my patients and my constituency both as an emergency physician and a lawmaker.
LM: Thank you for taking the time to meet with me today and to educate us on the complex process of creating legislation and the specifics of HB 2622. AAEM hopes that the protections afforded to health care professionals in Arizona will soon be extended to many other states in the nation, and even to the entire country as a federal law. I want to thank you for all that you do to serve the citizens of Arizona and your fellow physicians. We are proud to have you as a member of AAEM!
AS: You’re very welcome. I’m proud to stand up for my profession and my specialty.
Respect: A Driver of Empathy and Equity
Issue: March/April 2021
Authors: Shanna S. Strauss, MSc MS4; Megan Healy, MD FAAEM; and Sara Urquhart, MA RN
In 1967, Arethra Franklin created “Respect,” a song that not only stayed at the top of the charts for months, but also became a civil rights anthem (Brown, 2018). Respect was central to creating equality in the 1960s and it is just as important today as we strive to create health equity for our patients. This important end cannot be achieved without fair work environments for clinicians.
In many ways, we have seen how public admiration doesn’t translate to workplace respect. On one hand physicians are admired as health care heroes by the public, on the other hand some are also being retaliated against for speaking out about lack of PPE during a pandemic (Carville et al., 2020). Physicians are not immune to the experiences of dehumanization, devaluation, and exploitation in the workplace. These are commonly experienced as unfair employment contracts, punitive policies, and incentives that drive us away from the bedside and our patients.
Is there a connection between the systems eroding the physician-patient relationship and our patients’ health outcomes?
- Hostile work environments contribute to burnout and high physician attrition rates (Nunez-Smith et al., 2009).
- Physician attrition affects patient care. Not only does it limit clinical research but it also sequesters funds for hiring that could be invested in employee satisfaction and patient outcomes (Meurer et al., 2013).
- Burnout is not only expensive for physicians and employers; it is also contributing to the significant rise in physician suicide. “Burnout has widespread consequences, including poor quality of care, increased medical errors, patient and provider dissatisfaction, and attrition from medical practice, exacerbating the shortage and maldistribution of EPs” (Stehman et al., 2019).
- As physicians become more burned out, their self-reported empathy levels decline (Wolfshohl et al., 2019).
In the pioneering article “Reframing Clinician Distress,” (Dean et al., 2019) the authors argued that moral injury lies at the heart of physician burnout. Moral injury “describes the challenge of simultaneously knowing what care patients need but being unable to provide it due to constraints that are beyond our control.” Medicine at large is ill equipped to address the main social determinants of our patients' health outcomes, especially those drivers that impact the most marginalized patients.
Many of our patients experience the direct effects of criminalized poverty (Yungman, 2019) and institutionalized classism (Scambler, 2019). These social factors are foundational to the health inequities contributing to our patients presenting illness. To compound the problem, most medical centers do not have robust systems in place to address issues like homelessness, food insecurity, and violence.
At minimum, emergency physicians need to be empowered to speak out about issues that impact patient safety. Work environments that lack transparency, threaten physician autonomy, or place profit above patient care are unsafe. In challenging work environments like these, physicians face substantial barriers to providing equitable care.
We must also recognize that our patients experience independent hardships when they seek treatment in the emergency department. Just as we AAEM members scrutinize the systems and cultures that threaten our ability to practice good medicine, we must also turn a critical eye to the systems and culture that disempower our patients. Part of the answer to addressing these inequities lies in the same core value: respect. Often patient mistreatment is institutionalized and disproportionately affects patients based on their socioeconomic status, their racial categorization, sexual identity, mental health conditions, and/or addiction. We must look beyond individual patient encounters to the systems, policies and incentives that propagate injustice.
Stigma is one byproduct of medical culture we must closely examine. It is particularly challenging to prevent the stigmatization of people who experience social factors with chronic and less visible stressors. For example, when a patient is obese because they are underemployed and living in a food desert they cannot afford or access unprocessed foods. Too often, this obese patient is stigmatized by their weight, as their weight becomes an easy means of judging their value. The patient becomes the object of blame, rather than the system that failed them. Research has shown negative provider attitudes impact quality of care and outcomes for obese patients (Phelan et al., 2015).
Likewise, when we see patients who are unemployed presenting with mental health crises, how often are we attributing their unemployment to their mental health instead of their crisis as a result of unfair employment practices? This will be increasingly important to recognize as we continue to address the downstream impact of the pandemic.
“Unemployment has been linked with a number of psychological disorders, particularly anxiety, depression, and substance abuse; dangerous behaviors including suicide and violence toward family members or others also correlate with unemployment. These associations hold true not only in surveys of those already unemployed but also in studies that follow one or several individuals with no psychological difficulties into a period of unemployment.” (LexisNexis, 2009 There are similar impacts on psychological health in the underemployed (LaMontagne, 2017).
46% of Americans are experiencing underemployment (PayScale, 2018). At the end of 2020 the United States unemployment rate was at 6.7 percent (Bureau of Labor Statistics, U.S. Department of Labor, 2020). These two statistics highlight that unemployment doesn’t quite capture all of the stressors our patients face.
We do not need to live our patients’ experiences to be able to express empathy. We as physicians inherently understand the importance of respect and feel the repercussions when it is lacking. When we are able to find solidarity with our patients, it connects us to our common humanity.
Simple actions rooted in respect move us closer to empathy and equity in healthcare. When we recognize where we are attributing blame or reinforcing the stigmatization of our patients because of their social factors, we are taking steps towards ending healthcare disparities. When we advocate for our own fair workplace environments, we are taking steps towards increasing our agency. Our ability to advocate for patients is central to addressing health care disparities. By uplifting our patients' voices and valuing their lived experiences as important contributors to their health, we strengthen our platform for creating better health outcomes. There is hope in respect. Through solidarity and respect, we increase our power to implement solutions.
- Brown, D. L. (2018, August 16). How Aretha Franklin’s ‘Respect’ became an anthem for civil rights and feminism. The Washington Post. Retrieved December 26, 2020, from https://www.washingtonpost.com/news/retropolis/wp/2018/08/14/how-aretha-franklins-respect-became-an-anthem-for-civil-rights-and-feminism/
- Bureau of Labor Statistics, U.S. Department of Labor. (2020, December 4). THEEMPLOYMENTSITUATION —NOVEMBER 2020. News Release, USDL-20-2184, 1-42. https://www.bls.gov/news.release/pdf/empsit.pdf
- Carville, O., Court, E., & Brown, K. (2020, March 31). Hospitals Tell Doctors They’ll Be Fired If They Speak Out About Lack of Gear. Bloomberg. Retrieved December 26, 2020, from https://www.bloomberg.com/news/articles/2020-03-31/hospitals-tell-doctors-they-ll-be-fired-if-they-talk-to-press
- Dean, W., Talbot, S., & Dean, A. (2019, September). Reframing Clinician Distress: Moral Injury Not Burnout. Federal Practitioner, 36(9), 400-402. PubMed. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6752815/
- LaMontagne, M. A. (2017). Underemployment and mental health: comparing fixed-effects and random-effects regression approaches in an Australian working population cohort. Occupational and Environmental Medicine, 74, 344-350. https://oem.bmj.com/content/74/5/344
- LexisNexis. (2009, June 25). Workers' Compensation: The Psychological Impact of Unemployment. LexisNexis Occupational Injury & Illness. https://www.lexisnexis.com/legalnewsroom/workers-compensation/b/workers-compensation-law-blog/posts/the-psychological-impact-of-unemployment
- Meurer, W., Sozener, C., Xu, Z., Frederiksen, S., Kade, A., Olgren, M., Vieder, S., Kalbfleish, J., & Scott, P. (2013). The Impact of Emergency Physician Turnover on Planning for Prospective Clinical Trials (14th ed., Vol. 1). West J Emerg Med. 10.5811/westjem.2011.8.6798
- Nunez-Smith, M., Pilgrim, N., Wynia, M., Sesai, M., Bright, C., Krumholz, H., & Bradley, E. (2009, November 19). Health care workplace discrimination and physician turnover. J Natl Med Assoc, 101(12), 1274–1282. PubMed. 10.1016/s0027-9684(15)31139-1
- PayScale. (2018). The Underemployment Big Picture. PayScale. https://www.payscale.com/data-packages/underemployment/
- Phelan, S. M., Burgess, D. J., Yeazel, M. W., Hellerstedt, W. L., Griffin, J. M., & Van Ryn, M. (2015, April). Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obes Rev, 16(4), 319-326. PubMed. 10.1111/obr.12266
- Scambler, G. (2019, July 05). Sociology, Social Class, Health Inequalities, and the Avoidance of “Classism”. Frontiers in Sociology, 4, 56. 10.3389/fsoc.2019.00056
- Stehman, C. R., Testo, Z., Gershaw, R. S., & Kellogg, A. R. (2019, April 23). Burnout, Drop Out, Suicide: Physician Loss in Emergency Medicine, Part I. West J Emerg Med, 20(3), 485–494. PubMed. 10.5811/westjem.2019.4.40970
- Wolfshohl, J. A., Bradley, K., Bell, C., Bell, S., Hodges, C., Knowles, H., Chaudhari, B. R., Kirby, R., Kline, J. A., & Wang, H. (2019, July 11). Association Between Empathy and Burnout Among Emergency Medicine Physicians. J Clin Med Res, 11(7), 532-538. PubMed. 10.14740/jocmr3878
- Yungman, J. (2019, January/February). The Criminalization of Poverty. GPSolo, 36(1). https://www.americanbar.org/groups/gpsolo/publications/gp_solo/2019/january-february/criminalization-poverty/
Who Will Be Their Advocate? A Commentary on Facing Illness Alone.
Issue: January/February 2021 - Ahead of Print!
Committee Report: Ethics
Author: Jennifer Gemmill, MD FAAEM
I am a terrible patient. I will refuse medicines prescribed to me. I will pick up my heavy 2-year-old just hours after delivering my newborn while the L&D nurses give me the evil eye. I will remove my own loop recorder in my bathroom at home instead of having it taken out by my unknowing cardiologist (it’s amazing how useful leftover lidocaine and eyebrow tweezers can be). If you are my physician for any reason, I will be a handful. However, I will also be my strongest advocate.
As a practicing emergency physician, I have the tools, knowledge, and experience to know what questions to ask as it pertains to my own personal care. I understand the risks of procedures, what complications to look for, and how to mentally and physically prepare for what a medicine or intervention will do to my body. Most of our patients do not possess these skills. They rely on us to appropriately explain what we’re doing to them and why. Our patients trust us to ensure their safety and we are tasked with making sure they understand the care we’re providing them. But what if they don’t? What if they are altered, unconscious, too sick to know what is happening to them? Who do we, as providers, turn to for consent or discussion of options, or basic medical information? Family. We rely on the patients’ family members to provide basic yet invaluable information about their history, their wishes, their clinical course when the patients cannot speak for themselves. We rely on family to help us convince the patient that the intervention we’re suggesting is needed, necessary. We rely on the family to help ensure that the patient takes their medicine, supports their smoking cessation, keeps wearing their oxygen masks, avoids eating hamburgers every day. Family support is crucial to medical practice and clinical improvement, both in the home and in the hospital. When faced with my first intubation as a patient, my mother sat at my bedside, grilling the anesthesiologist. She asked him questions that I frankly, despite my having intubated thousands of patients in my career, was just too nervous to ask. I knew everything that could go wrong. Knew exactly what would happen when he gave me the Versed then wheeled me to the OR. But in that moment, all I could think about was how hungry I was and whether or not he’d accidentally chip my tooth with the blade. I needed her there to help me be a regular patient, not a doctor. When the anesthesiologist left the room, she said to me, “I like him.” I immediately felt calmer. I took my Versed obediently then closed my eyes as they rolled me away.
As COVID cases hit their first peak in my hometown, my administration chose to stop allowing visitors into the hospital, both in the ED and on the inpatient floors. I understood the logic of this choice at the time. Fewer people in the building meant fewer chances of accidental transmission and spread of the virus. What was unforeseen, however, was the dramatic impact that would have on our patients. I found myself working up many patients on which I had no information at all: no prior medical history, no knowledge of their primary physician, medication use, or allergies. This not only made my job even more difficult but it added time, extraneous testing, and additional cost to the patient’s visit. That’s to say nothing about the friction it caused for my front-end staff. Families being turned away, sometimes with the needed assistance of our security staff, upset that they could not stay with their spouse, their mother, their sister, or their helpless elderly relative. I watched a 65-year-old man with Alzheimer’s tear up because he couldn’t remember the name of his doctor and told me to ask his wife. I frantically resuscitated a man with hypotension and bradycardia for multiple hours with no effect, only to discover later that he had intentionally overdosed on his blood pressure meds. We were lucky that his spouse called us in the ED to read the suicide note. I cried over the phone with the daughter of a man brought in by EMS alive, only to “code” a short time later. I pronounced his time of death, then had to tell her she couldn’t see her father again because he died of COVID. There are few times in my career thus far that I’ve felt uncomfortable doing my job. This was one of those times. Not allowing this daughter to see her dead father felt wrong. Ethically, morally, and physically wrong. No one should have to say goodbye to their loved ones at the door and wonder if they will ever see them again.
The Coronavirus pandemic has changed the way we practice medicine. It has changed the way we interact and socialize, at work and at home. COVID will continue to impact our lives inside and outside the hospital until we have a way to either prevent it, or eradicate it. But there are some things that no virus or other infectious disease will ever be able to change. And that is the strength that we pull from our family and friends in times of despair and joy. We need our families around us during this time, and so do our patients. As providers, we will continue to provide the best care within our capabilities, but we need the assistance and advocacy of our patient’s family and loved ones. We need to have them to be present, safely, at the bedside to speak for the patient when the patient cannot, to encourage the recovery of each patient and to support us as providers as we battle this disease and all the others.
I am a terrible patient, but having my mom at the bedside makes be a better one. Family presence makes us stronger. Our patients need this extra strength.
Update from the Government and National Affairs Committee
Issue: November/December 2020
Author: Kevin H. Beier, MD FAAEM
With fall upon us and the year so far consumed with the stress of the novel coronavirus, many of us would be willing to take a mulligan for 2020. We all hope for a better next year and a vaccine. Nevertheless, the leadership of AAEM continues to fight for the Academy's membership at both the federal and state levels. We remain active on several important issues, including peer review/due process, balance/surprise billing, and independent/unsupervised practice by PAs and NPs.
Academy leaders and other selected AAEM members typically visit Washington, D.C. at least once a year, to sit down with Members of Congress and staff, as well as executive branch regulators, to discuss issues important to emergency physicians and our patients. Due to SARS-CoV-19, our visit on September 15, 2020 was virtual instead of actual. During these many virtual visits we shared our insights on the pandemic and the other issues mentioned above with Members on both sides of the aisle.
We accomplished a number of things, including securing additional support for federal legislation (HR 6910) to guarantee due process rights for emergency physicians. This is one of AAEM's highest legislative priorities and one we have been pushing for several years. Medical staff due process rights are critical to emergency physicians, and afford us the protection from arbitrary and unfair treatment we need to be strong advocates for our patients. We also continued to educate legislators and staffers on solutions to the balance/surprise billing problem, emphasizing the importance of protecting patients rather than the insurance industry, while making sure rural hospitals and independent physician groups aren't wiped out in the process. A memorable highlight of these virtual visits was a Zoom meeting with eight Members of Congress hosted by Rep. Raul Ruiz (D-CA), an emergency physician and a champion of our specialty. We also had a great conversation with Rep. Mark Green (R-TN), the House's other emergency physician. Our final meeting of the day was with Dr. Ronny Jackson, a Texas emergency physician who will soon join Drs. Ruiz and Green in Congress. While it was certainly a unique experience to do these visits virtually, the Academy felt it was important to convey our message to Congress even while the Capitol remained closed to the public. We were excited by the level of engagement we saw from the Members and senior staff we met with, and it was a highly productive day of virtual meetings.
On a state legislative note, Dr. Maria Paone and the EM Workforce Committee have been very active on the independent/unsupervised PA and NP practice issue, which the Academy views as a threat to patient welfare and safety. We are monitoring the activity of these bills and intervening on the state level when appropriate. The Academy encourages all its members to be active at the state level and to become familiar with your state representative and senator. Another great way to become engaged at the state level is join your state medical association. The expense is well worth it and many states have very engaged and active medical associations. And join your AAEM state chapter division if you have one!
Don't forget to vote on or before November 3. Keep safe, and if you have any questions on legislative or regulatory issues, AAEM's Government and National Affairs Committee is always ready to help.
Kevin Beier, MD, FAAEM
University of Tennessee
Emergency Medicine Residency Program, Murfreesboro
What's With All These Position Statements?
Issue: September/October 2020
Author: Jonathan S. Jones, MD FAAEM
You have likely noticed many recent position statements from the Academy. Some of these statements have been written by AAEM, while some are written by other organizations and endorsed by AAEM.
All of the Academy's position statements are published online at: www.aaem.org/resources/statements
There are several different types of statements, just click the corresponding links. AAEM has always held transparency in high regard as this is why you will always find all of the statements we have ever issued, openly published and accessible to everyone (members and non-members alike). If we feel strongly enough to issue a statement, then we won't ever try to hide it.
Dates of passage or endorsement can also be found. Due to the rapidly changing clinical and political environment, the last several months have seen a dramatic increase in the number of published and endorsed statements.
Given multiple recent questions as to why the Academy is releasing so many position statements, as well as several inquiries as to the content of the statements, on behalf of the board, I want to explain the process and answer some questions which the board has received.
How does AAEM decide what issues to address and what positions to take?
Issues are frequently presented by board members or officers. However, any AAEM member is welcome to bring any issue to the board. Other times, different medical organizations write a statement and ask AAEM to endorse it.
Decisions to publish or endorse a position statement are made by either the AAEM Board of Directors or the Executive Committee depending on the nature of the statement and timeliness of a reply. The Executive Committee is composed of the President, President-Elect, Immediate Past Present, Secretary-Treasurer, and Past-President's Council Representative. It is much quicker for the Executive Committee to discuss issues and so for timeliness sake, some statements are published or endorsed by with only the approval of the Executive Committee as per AAEM bylaws.
Regardless of who approves the statement, we always look at AAEM's mission statement and values in determining our stance. As all of our members, AAEM board members and officers have diverse viewpoints on many issues. Some would likely be described as liberal while others conservative. Some are likely democrats while others republicans and I know for a fact that one is proudly libertarian. However, while we have our own personal values and beliefs and do use these to determine the best course of action, when acting on behalf of AAEM, we strive to only consider the values of the Academy.
Why does the board not ask members how they feel prior to issuing a position statement?
The Academy is proud of its democratic principles and election process. However, just as the U.S. government is not a direct democracy, neither is AAEM. AAEM is a representative democracy. Each member has an equal vote in determining the leaders of the Academy. Those leaders are then entrusted with directing and managing the Academy in the best interest of all members. We function much like the U.S. government. Actually, we function much better with a singular focus. We debate and compromise and I assure you that no statement or position ever approved without genuine discussion.
However, it would be impractical and very nearly impossible to survey membership on every issue. Finally, it would be unclear how a membership survey should impact the decision to issue a statement as likely no issue, save our core mission, would garner unanimous member support.
All members are encouraged to communicate their thoughts to any AAEM board member, staff member, or other leader. Anyone may be contacted through firstname.lastname@example.org. Due to spam, etc. no member's, including no board member's, contact information is published online, but staff will quickly provide any board member's contact information once membership is verified.
But some of the recent position statements seem too political. Do they really have anything to do with emergency medicine?
The board feels that every position statement directly impacts emergency medicine. Otherwise we would not issue a statement. I will briefly discuss two recent statements which generated questions.
AAEM issued a joint position statement against a federal regulation which excludes transgender status from the legal definition of sex discrimination. It separately eliminated certain requirements for language translation as well as requirements for care of patients with a history of termination of pregnancy.
AAEM also issued a joint statement on the death of George Floyd
Why should AAEM get involved in race, police matters, transgender status, abortion, and foreign languages? Simply, AAEM is not getting involved in these issues as a whole. We view the federal regulation and racial inequalities in regards to our mission statement. The first line of AAEM's mission statement is: Every individual should have unencumbered access to quality emergency care provided by a specialist in emergency medicine.
The board knows that American’s and Academy member’s views differ on these issues and we respect that. The board neither supports nor opposes transgender issues in general, but we do support unencumbered access to emergency care for transgender patients. In our view, the federal regulation eliminated that access. We do not know exactly what happened in the situation with George Floyd and we are not calling for charges against the officers involved. However, we know that health disparities exist. We want every one of every race and every gender to feel welcome in the emergency department. Every individual should have unencumbered access to quality emergency care. It's really that simple.
I, our president, Dr. Lisa Moreno, and all board members welcome follow-up questions, comments, and any conversation. Common Sense encourages letters to the editor. Or contact any board member directly. AAEM is strong because of our diverse opinions coupled with our singular focus as the Champion of the Emergency Physician.
Promoting Social Connection during COVID-19
Special Issue: AAEM Tales of COVID-19
Author: Al'ai Alvarez, MD FAAEM; Dr. Aneesha Dhargalkar, MD FAAEM; Carole Levy, MD MPH FAAEM; and Robert Lam, MD FAAEM
The COVID-19 pandemic has led to the implementation of social distancing, which has led to a decreased patient volume from non-COVID-19 related complaints. Along with canceled hospital elective surgeries and other major sources of revenue for the hospital, many emergency departments (ED) across the country, outside of New York City, the major hub of the pandemic in the United States, have implemented reduced staffing. Furthermore, some physicians are not working due to increased health risks, adding to the decreasing frequency of clinicians interacting with each other at work. We simply are not seeing each other in person as much as we used to. In-person department meetings have also been rapidly converted into remote meetings, further exacerbating this loss of physical contact among clinicians in the workplace.
With all the emotions that come with dealing with this global pandemic – fear, anxiety, grief, frustrations, and a clear sense of lack of control – physical distancing and the feelings of isolation add to the moral distress that clinicians experience.
Left unaddressed, the literature suggests loneliness and isolation in medicine lead to decreased productivity, burnout, depression, and other mental health disorders, physician suicide and is even a risk factor for death.1-5 Loneliness and social network size have even been linked to immune response as well as greater psychological stress, poorer sleep, and elevations in circulating levels of cortisol.6 A promising study of isolated senior citizens demonstrated that the use of SkypeTM for video chat had half the probability of depressive symptoms.7 Another study showed that an emotional connectedness similarly to in-person interactions could be achieved with video chat.8
In the time of social distancing, embracing technology as a tool to use with traditional strategies may promote teamwork, build community, and optimize use of positive psychology to enhance social connection.
We propose the following ways of combating isolation during the physical distancing restrictions of the COVID-19 pandemic:
Reinforce Purpose and Meaning
- Celebrate together with colleagues when COVID patients recover and when they are discharged from the hospital.
- Utilize journaling. Keep a log of each shift along with the thoughts and emotions of the day.
- Be detectives for random acts of kindness. Pause and recognize whenever you see goodness happening around you.
Support and Improve Clinician Team
- Send funny memes or words of encouragement. Be careful about patient information when messaging a group via a personal mobile. ContextTM is a HIPAA compliant app that you can use via cell phone or computer for chats.
- Virtual cocktail hours can be beneficial for those who normally enjoy reveling in a post-work beverage with their friend or coworkers.
- Playing online games as a group can be a nice way to socialize from a distance. Host an online game night, dance party, or escape room experience.
- Jackbox (https://www.jackboxgames.com) has a variety of games and you can make a trivia quiz for the group.
- Crowd Purr (https://www.crowdpurr.com/live-crowd-trivia.html)
- Mario Kart tour can be played multiplayer (https://mariokarttour.com/en-US).
- Animal Crossing can be played multiplayer (https://www.nintendo.com/games/detail/animal-crossing-new-horizons-switch).
- Lead with optimism.
- As physicians, we are the team leader and we set the tone for the work environment. How we show up for work ultimately affects how the day will go for the entire team. Inspire.
- Lead with appreciation and gratitude.
- Highlight aspects of our work so that you can show appreciation and gratitude to your team and your leaders.
- Continue to celebrate life events and other things that reinforce the cohesiveness of the team.
- Make time for a formal or informal debrief at the end of each shift.
- Check-in with your colleagues.
- Consider using a modified three good things platform.
- Focus on the positive things that happened during the shift.
- Send postcards. There’s something uplifting about receiving a personal note from someone in the mail.
Encourage Connection to our Shared Humanity
- Create a wall of post-it notes or memes in the break room or office space with encouraging messages or funny memes.
- Post notes of encouragement from the community.
- Bring in photos from home to post on the walls of the break room or office of the family, including fur babies. Include pictures from past social events.
- Pin photos of yourself to your PPE suit to humanize you to your staff and patients.
- Exercise and encourage self-compassion – treat yourself like you would treat a treasured friend.
- Do the 36 Questions with friends.
- With a group, have each friend respond to the question, then go on to the next one.
Personal Improvement / Professional Development
- Start a book club to create a shared narrative. Make it an excuse to meet monthly.
- Start a virtual journal club or work on ABEM MOC articles together
- Create an online band; rehearse songs together. Here's a beautiful example from Italy
Helping Others Has a Double Beneficial Effect
Reaching out to others right now will not only help others but it helps the helper: Helping others increases happiness and our own well-being.
- Give blood if you are able. Convalescent plasma programs for clinicians that recover from COVID-19 can be a life-saving gift.
- Be a battle buddy. A battle buddy is a fellow peer and colleague. The goal is to have two clinicians partner together to support one another.
- Organize a PPE drive. Here is an example of medical students participating in #PPEdrive.
Our work in the ED, and medicine, in general, can be isolating with or without the COVID-19 pandemic. With social distancing, we can continue to physically isolate ourselves, while maintaining social connections. You can start now. Take a moment to reach out to someone. Go ahead. Text a friend and share a moment of gratitude.
- Heinrich, Liesl M., and Eleonora Gullone. "The clinical significance of loneliness: A literature review." Clinical psychology review 26.6 (2006): 695-718.
- )Cacioppo, John T., et al. "Loneliness as a specific risk factor for depressive symptoms: cross-sectional and longitudinal analyses." Psychology and aging 21.1 (2006): 140
- Stravynski, Ariel, and Richard Boyer. "Loneliness in relation to suicide ideation and parasuicide: A population-wide study." Suicide and life-threatening behavior 31.1 (2001): 32-40.
- Seppala, Emma, and Marissa King. "Burnout at work isn’t just about exhaustion. It’s also about loneliness." Harvard Business Review 29 (2017).
- Holt-Lunstad, Julianne, et al. "Loneliness and social isolation as risk factors for mortality: a meta-analytic review." Perspectives on psychological science 10.2 (2015): 227-237.
- Pressman, Sarah D., et al. "Loneliness, social network size, and immune response to influenza vaccination in college freshmen." Health Psychology 24.3 (2005): 297.
- Teo, Alan R., Sheila Markwardt, and Ladson Hinton. "Using Skype to beat the blues: Longitudinal data from a national representative sample." The American Journal of Geriatric Psychiatry 27.3 (2019): 254-262.
- Sherman, Lauren E., Minas Michikyan, and Patricia M. Greenfield. "The effects of text, audio, video, and in-person communication on bonding between friends." Cyberpsychology: Journal of psychosocial research on cyberspace 7.2 (2013).
- University of Washington Department of Science of Social Connection http://depts.washington.edu/uwcssc/content/staying-connected-during-covid-19
- Staying connected — at a distance (University of Washington News) https://www.washington.edu/news/2020/03/12/staying-connected-at-a-distance
- Why You Shouldn’t Give Up on Virtual Happy Hours (Seattle Met) https://www.seattlemet.com/coronavirus/2020/04/why-you-shouldn-t-give-up-on-virtual-happy-hours
- Peer Support Program Strives to Ease Distress during Pandemic
American Medical Association, April 14, 2020
- 5 Resources Built to Provide Emotional Support In Times of Crisis
- Peer Support Program Strives to Ease Distress during Pandemic
- Peer Support
PeerRxMed - Free peer to peer program for physicians and others working in health care to provide support, connection, and encouragement. https://www.peerrxmed.com
AAEM Tales of COVID-19
AAEM wants you to have a forum to share your thoughts, emotions, opinions, and stories related to the COVID-19 pandemic. Thank you for sharing your ideas with other members so we can get through this crisis together. We will continue to share new stories weekly online and then all stories will appear in the print version of the July/August issue of Common Sense. Submissions are now closed for this special feature.
YPS Photo Collage of Life during COVID-19
Special Issue: AAEM Tales of COVID-19
Author: Danielle Goodrich, MD FAAEM
To help showcase what we are going through during the COVID-19 pandemic, we requested YPS members submit photo representations of their lives during COVID-19. Please explore this photo collage from your Young Physicians Section.
YPS photo collage (PDF)
My Life was Turned Upside Down by a COVID-19 Antibody Test
Special Issue: AAEM Tales of COVID-19
Author: Matthew C. Holden, MD
*As information about COVID-19 testing is rapidly evolving, please excuse data that may not be most up to date at the time of this publication.
I signed in for my shift at the freestanding emergency room I work at and found that in addition to answering the COVID-19 check in questions and getting my temperature taken I would also be getting a finger stick COVID-19 antibody test. I felt fine, had not been ill and had no known recent exposure to a coronavirus patient. I had no cough, sore throat, runny nose, headache, diarrhea, shortness of breath, or body aches. My sense of taste and smell were intact. These questions covered most of the current known symptomatology of the pandemic COVID-19 virus. I knew that there was considerable debate regarding the accuracy of antibody testing and how it should be used but I expected to get a negative antibody test. The two-part test would look for IgM antibodies that develop in the first 7-14 days of the infection. IgG antibodies begin to develop 14 days and peak between 21 and 28 days. They represent the antibodies of the recovery phase of the infection and remain elevated for weeks to months and possibly years. It is unknown whether IgG levels represent immunity to the COVID-19 virus.
Our current best test for active infection is not antibody testing but by real time reverse transcriptase polymerase chain reaction (PCR) test. PCR testing, although not perfect, is what we use to tell us who is infected now. It is the best screening test to help us with contact tracing and quarantine and treatment recommendations. This test identifies viral RNA beginning on or around day one of clinical illness but can remain positive, from current data, for weeks to months even without symptoms. COVID-19 viral RNA are found in nasal, oral or pulmonary tract secretions. They have more recently also been found in feces and sperm. There are multiple ways of obtaining specimen. The most common method involves inserting a nasal swab deep into the nasopharynx and preserving in either a dry or liquid medium. Turnaround times are variable. Some tests take as little as 15 minutes while others may take up to a week. PCR antigen testing is considered the gold standard for diagnostic purposes even though they have variable specificities and sensitivities. Some may only have 80-85% specificity. Sensitivity and false negative rates are also variable due to variable viral loads at different stages of illness, inadequate specimen collection, or problems with transport media or the lab testing itself.
The goal of antibody testing is to tell us what proportion of the population may have been infected and may possibly be immune to COVID-19 in hopes of reopening America safely, but experience thus far has been inconsistent and unreliable. It is not a good test to identify whether someone is acutely infected. By the time IgG and IgM antibody levels are detected, viral levels may already be decreasing or cleared from the system. As of April 21, the FDA had approved four antibody tests. These are all enzyme linked immunosorbent assay (ELISA) tests which can identify whether antibodies are present. The FDA had also allowed at least 50 non approved, mostly lateral flow immunodiffusion tests to be marketed. These are point of care tests that are supposed to be done on site in doctors’ offices or labs but are also sold online for home use similar to point of care pregnancy tests. They utilize small plastic cartridges where a drop of blood or serum is applied to one end, followed by a reagent that mixes with the blood sample and then diffuses up a strip of paper. Antibodies collect along lines as antibodies are deposited and provide a colorimetric reading when positive. A final control line validates the test. Many of the non-approved tests have 20-30% or less sensitivity, limiting their utility. Some of the best tests still have limited specificities. A positive IgM (acute phase) with a negative IgG (recovering phase) should lead to a patient getting a PCR antigen test to see if they have acute COVID1-9. A positive IgM and positive IgG may represent recovery from COVID-19 if it they are true positives, but they still do not rule out the presence of an active viral infection. One danger is that people with false positives may let down their guard and stop avoiding possible exposure and then actually contract COVID-19. Negative IgM antibody test results suggest absence of active illness but it may actually be negative because the patient is in the early and most infectious stage of infection before they start producing a measurable number of antibodies. Again, only PCR testing may provide an answer.
So, I got my finger stick antibody test at the ER and it was positive for IgM. I discussed the findings with my medical director, and he recommended I get a nasal swab PCR antigen study to send out to a lab. He suggested that even though I had no symptoms that I get another doctor to cover the rest of my shift and go home early to await final PCR test results in 2-3 days. I had very mixed emotions. First, I was excited to think that I may have an asymptomatic case of COVID-19. This would make my life as an emergency physician much easier since I could then evaluate and treat patients who may have COVID-19 without worrying if I was going to become infected. And I wouldn’t have to worry about catching the illness through exposure in the community. This is where we all hope to be in a couple of years as the illness spreads through the population and we eventually get immunized with a vaccine. Just maybe I was very very lucky. But I was also apprehensive that if I went home to quarantine with my wife that I might give her a COVID-19 infection that might make her very ill. Another possibility was that I had caught another common cold coronavirus infection from her that was giving me a cross reactive but false positive test. She had a sinus infection and a sore throat for a couple of weeks and had only recently started some antibiotics when it would not go away. To help resolve the dilemma I was able to bring home an antibody test and give her the finger stick test. If she tested positive we could both relax. I presented the test to her as soon as I got home in hopes of being able to avoid a long explanation about possible bad news. “Good news,” I said. “I got one of those antibody tests for you.”
Then the test was negative, and the questions started. Why did I test positive? What if I have it? How can she remain safe? What does the antibody test mean? Can I get a repeat test somewhere else? Can I go get a nasal swab PCR test with instant results now? How long will we have to wait until we get the test results back from the lab? Can I call the ER tomorrow to see if the results are back and call every day until the results are back? I tried to put myself in her place and be patient and answer every question, every time she asked, in detail. I wore a mask and maintained a healthy separation. I slept in a spare bedroom and tried to stay in a different part of the house. I saw how hard it would be to safely quarantine in the same house with someone infected with COVID-19. As the weekend went on and I continued to feel healthy, I became less hopeful that I had an asymptomatic case. I became more confident that I had a false positive although nothing on the test kit instructions explained what that might be in my case. It was a long, tense weekend. She worried that she might develop COVID-19. I worried about how she might do if she got it. I called for results on Sunday. They were not back. On Monday I got the results phone call from the ER. It was negative. I told my wife I wanted a big hug and a kiss. She said no tongue. We were back to our normal routines in the COVID-19 era.
AAEM Tales of COVID-19
AAEM wants you to have a forum to share your thoughts, emotions, opinions, and stories related to the COVID-19 pandemic. Thank you for sharing your ideas with other members so we can get through this crisis together. We will continue to share new stories weekly online and then all stories will appear in the print version of the July/August issue of Common Sense. Submissions are now closed for this special feature.
The Black Death
Special Issue: AAEM Tales of COVID-19
Author: Jeff Wade, MD FAAEM
“The Black Death, also known as the Great Plague or the Plague, or less commonly the Black Plague, was one of the most devastating pandemics in human history, resulting in the deaths of an estimated 75 to 200 million people in Eurasia and peaking in Europe from 1347 to 1351.”
The plague has been a huge thing in my life. My third year of college I was still pre-veterinary, but starting to be ready to change. I was working for a vet and he wasn’t seemingly happy at his job, and from what I could see the job wasn’t happiness inducing. People call pediatrics and geriatrics, veterinary medicine. Your patients at either extreme of the lifespan are not able to talk to you and tell you what is wrong, nor understand why you are hurting them. And worse, they can have parents/adult children/owners who can be at either extreme: overly helicopter-y and in-your-face about everything or abusive/neglectful assholes. That’s a pretty good argument against veterinary medicine, peds, or geriatrics in my book (literally in my book). And I had just finished a test in my agribusiness/pre-vet major. The test question was: ‘You have just inherited a large quantity of money. You decide to use this money to open a pig farm (EXACTLY what I would do conveniently enough). Please describe in detail how you would setup the farm with room for breeding, food storage, waste disposal, etc.’ Nice.
Then I had my first microbiology class. The teacher read a case report from the Centers for Disease Control’s Morbidity & Mortality Weekly Report (CDC MMWR), a sampling of trending infection or toxic events. The case he read was about a case of modern-day plague. It still exists today, but as people became more used to it after the Black Death & just people’s and bacterial evolution, it is rare and almost only associated with desert rodent exposure anymore.
He described how the bacteria literally fill the blood vessels. And how from getting sick to dying can be as fast as a day or less. They can get the black swollen lymph nodes in the groin & armpits called buboes. This is where the terms Black Death and Bubonic Plague come from. He also talked about how sometimes it can spread to the lungs and become much more easily spread by coughing instead of requiring rat fleas, the typical way of transmission.
This came at THE right time for me. That day I decided to change my major to microbiology and my goal to med school. And I made the right choice. People are much better conversationalists and by virtue of that, much more interesting to work with than animals. As long as you see non-demented/drunk/high adults or older children, you don’t have to torture things that don’t at least understand the reason for the torture. And the adult children/parents/owners issue doesn’t come up.
Since then I have had an interest in the plague. It literally changed the face of Europe. Before the Black Death, Europe was feudal, where the majority of people were essentially the property of the local lord. The tremendous social change initiated by the plague (and other historical trends at the same time), got rid of the feudal system in all but Russia within a 100 years or so. This freeing of the individuals to live where and how they wanted and general mobilization of society was one of the biggest contributors to the Renaissance and modernity in general.
I have found and read several books that deal with the plague since then. One of the best is by the French Nobel winner Camus and called The Plague. It describes a fictionalized version of one of the last modern widespread outbreaks of the plague in North Africa, where Camus was born and grew up. It is a riveting account that includes all the standard stuff you see in an outbreak: dead rats, buboes, mass graves. However, Camus was an Existentialist, meaning he was interested in how people should act in a world where there is not necessarily a God. So the book is also about more than just the rats, it focuses on a group of accidental friends who band together to deal with the situation. Everyone has a crisis of conscience, even the priest. Quite a great book, one of my all-time favorites.
Another is A Journal of the Plague Year by Daniel DeFoe, the writer of Robinson Crusoe. It is about the 1666 London Plague. He was born not long after the plague, so was able to draw on survivors and recent records. It is a purely journalistic account of the plague and gets into the reactions to and management of this overwhelming event. It’s a nice book if you are interested in the plague.
Much later, I found out that Oxford University has summer school for adults who can afford to study in Oxford. We made plans to do that a few years ago after visiting Oxford. When we looked online at the available courses, the one that jumped out at me, was called The Plague. Of course, I took that one. I brought a fake concert T-shirt that I have had for years. It looks like your standard black long-sleeved concert shirt. Except on the front, it has a picture of a rat surrounded by flies and ‘Black Death European Tour 1347-51.’ The back has the ‘concert’ locations. While there, we learned tons about the plague and its societal aftereffects. As this was right after the big Ebola outbreak, it was even more topical. ANY disease, from Ebola to the plague or even the common flu, can mutate overnite and turn drastically more severe and/or more contagious.
We live in a world where when, not if, the next big epidemic comes up, it will be spread worldwide within days.
Get your flu and other shots. And be afraid. Be not so very afraid…
AAEM Tales of COVID-19
AAEM wants you to have a forum to share your thoughts, emotions, opinions, and stories related to the COVID-19 pandemic. Thank you for sharing your ideas with other members so we can get through this crisis together. We will continue to share new stories weekly online and then all stories will appear in the print version of the July/August issue of Common Sense. Submissions are now closed for this special feature.
Should the 12-Hour Shift be of Historical Interest Only?
Special Issue: AAEM Tales of COVID-19
Author: David P. Lisbon, MD FACEP
I listened with sadness and despair as reports of the death of Dr. Lorna M. Been were broadcast. There were a series of interviews with her heartbroken family. The one that sticks with me was that of her sister. I felt she was most able to convey the sense of fatigue and exhaustion that Dr. Breen felt. In her interview she said, “She had 12 hour shifts.”
In my practice life, I’ve worked both 12 and eight-hour shifts. My first position after residency was one where I contracted to work 12, 12-hour shifts. I trained in a residency program that had eight-hour shifts; I made the adjustment. At the time, my community ED saw 27,000 patients a year, we admitted about 21%, and we were a Level II trauma center. The year was 1995 and I was 25 years younger, the internet was dial -up, there were no cell phone cameras and Tintinalli was soft-cover and could be read twice in residency!
As time passed, patient volume, patient acuity, patient admissions, patient psychosocial issues, and my age all increased. As my children later reminded me; I sometimes struggled to not doze off as I read bedtime stories over the years. As I look back and consider the moment we’re in now, a few other things are clear to me. First, humans are not nocturnal, being your best at 4:00am is just not likely. Two, when I think of the close calls with cognitive, diagnostic, or procedural error, they almost uniformly occurred between 3:00am and 7:00am. Third, the recovery time needed after a string of 12-hour ED shifts in a modern busy ED is at least 24 hours.
I had the great honor to be the founding program director for the emergency medicine residency at The University Kansas School of Medicine. I served for 10 years. I used to joke with my residents that I was open to a discussion about any and everything; except, the implementation of 12-hour shifts. I know that the 12-hour shift has its allure in that one works less shifts a month. I am also aware that very low volume emergency departments might have a logistical need to staff with 12-hour or longer shifts.
Notwithstanding the aforementioned realities, I still believe shifts shorter than 12 hours should be our future. My conversations with colleagues and observations over the years lead me to believe that once an ED gets to 40,000 visits and an admit rate of 25%, the 12-hour shift needs to be rethought. Shift length should be evaluated carefully for its effects on ED physicians. Certainly, a number of operational variables can be considered; staffing matrices, trauma center status, chest, and stroke center designation etc., but cognitive and physical workload over a distinct timespan at some point become germane.
As a frontline response to COVID-19, emergency medicine has and will endure a lot. The 12-hour shift had a place when our mission was perhaps more limited, before medical treatments and medical complexity shifted into high gear and before the pathogenic devastation of the coronavirus struck like a tidal wave. When considering coronavirus one might even ask what degree of concentrated time exposure becomes hazardous?
All of us on the frontlines of healthcare, like Dr. Breen will aim to bring the best of ourselves to each shift. It might be time to ask if it is fair and just to expect that best self to be present at hour 11 and 30 minutes into a 12-hour shift.
AAEM Tales of COVID-19
I’m Not Really a Hero
Special Issue: AAEM Tales of COVID-19
Author: Gregory Jasani, MD
When I lived in Washington, DC, I would occasionally travel to Reagan National Airport to welcome Honor Flights to our nation’s capital. Honor Flight is a program dedicated to transporting military veterans to see the memorials of the wars they fought in, at no cost to the veterans. Anyone who has witnessed these events can tell you that they are filled with cheering crowds and lots of flags. It truly is a sight to behold, and it is a fitting tribute to those brave men and women. They are true heroes. Yet, the veterans I met always insisted that they did not deserve the title of hero. “I’m not a hero,” I heard far more times than I can count. I never could understand how they could feel that way.
I understand it now. I am an emergency medicine physician working during the coronavirus pandemic. To many, that makes me a hero. I have been truly touched by the outpouring of support from my friends, family, and even strangers. It has helped enormously during this challenging time. However, let me be clear, I do not consider myself a hero.
To me, a hero is someone who does something to benefit other people, despite the possibility of immense personal risk. Though COVID-19 is a serious disease, I am in my 20s and in good health. While I could get infected with coronavirus, I know my chances of succumbing to it are fairly low. I am also fortunate enough to work at a hospital that has provided us with adequate PPE. My wife even works in the same hospital as I do, so I do not have the added burden of wondering if I’m endangering her health. For me, the risk I have faced during this pandemic has been minimal.
Many health care workers are not as lucky as I am. Some have continued to work despite being at higher risk due to their age or their underlying health problems. Some work at institutions that face shortages of vital PPE. Some have had to sequester themselves away from their families for long periods of time, just to keep their loved ones safe. Some have even made the ultimate sacrifice and lost their lives during this pandemic. They strove to preserve the lives of others even at the cost of their own. These are the true heroes of this pandemic. Their sacrifice required courage beyond measure, and they exemplify the very best of the healthcare field. They should be held up for generations to come as the ideal of heroism that we should all aspire to.
I will always have the pride of knowing that I was a doctor during a difficult and perilous time. But I am not a hero. I am just doing my job. It is the same job I did before the pandemic, and I will continue to do it after COVID-19 has faded from the public mind. Many healthcare workers are being asked to face much higher risks and make greater sacrifices than I am. They are the heroes that we should honor and remember.
AAEM Tales of COVID-19
AAEM wants you to have a forum to share your thoughts, emotions, opinions, and stories related to the COVID-19 pandemic. Please consider sharing your ideas with other members so we can get through this crisis together. We will be sharing new stories weekly online and then all stories will appear in the print version of the July/August issue of Common Sense. Submit your story, opinion, artwork, poem, or other work here.
COVID-19 Has Made Emergency Physicians the Default Leaders of Medicine
Special Issue: AAEM Tales of COVID-19
Author: Mohamad Moussa, MD FAAEM
The emergency physician (EP) was flung into the spotlight during this COVID-19 pandemic. Every single day since early March 2020 we have seen our EP colleagues on news channels and websites of all kinds talking about COVID-19. Their calm and collected mannerisms on screens all over the country and world gave people the insight of what an EP is willing to do to help their patients—essentially risk their life for the life of another. What was so inspiring was the homogenous message that all EPs gave their communities no matter what part of the country or world they were in. They served as ambassadors of global health to teach and reinforce proper hand hygiene, social distancing, and stay at home measures. This was all in the background of extreme uncertainty about disease spread and treatment. The ability to lead in such a challenging environment and maintain composure for our patients sets us up as the lead doctors across the globe. And because of this unconditional care in this novel pandemic, that is why I say EPs are the new leaders in Medicine.
I say, EPs are the new leaders of medicine because of our practical nature. People understand EPs because we speak in their terms. No big medical terminology laced with the most recent literature. Rather, we use plain, basic language like stay at home, wear a mask, use social distancing, follow national and state COVID-19 protocols. After all, this is what EPs have been doing for years. We are the blue-collar physicians of our day and we do everything we can to blend in with our community. Many times, you cannot differentiate a patient checking in from an EP walking through for a shift in the main entrance lobby. EPs swimmingly shift between complicated Level One MVC trauma resuscitations and simple sore throat patients and carry on with their day. All the while, taking a bite from a peanut butter and jelly sandwich they packed from home. This versatility of an EP is what also made them shine as physician leaders in this relentless COVID-19 pandemic.
I say, EPs are the new leaders of medicine because we keep the calm in chaos. COVID-19 has brought nothing but uncertainty, anxiety, doubt, fear, and death. While hospital administrators, infection control personnel, and infectious disease physicians developed untested protocols, EPs were still covering the emergency department seamlessly in the midst of constant emergency department zoning changes. The EPs applied what they have learned all along in their training which was to adapt to whatever comes their way. The fluttering that now exists between intubating early or not, anticoagulating or not, and pronating or not did not deter the EPs from doing what was right for their patients in that moment. As many suggestions came through on COVID-19 patient care, the decisiveness of EPs remained keen and directed towards doing what is right for their patients.
I say, EPs are the new leaders of medicine because they make an immediate impact. Patients and family members see the lifesaving heroics that are made in the emergency department the minute they arrive. The eye contact from the EP to the patient’s family member about how serious the situation is forever memorable. There is no setting up appointments for another later visit, no blood draws without immediate results, and no insurance checks before a CT or MRI needs to be done. Patients feel the presence and advocacy of the EPs more than any other physician. Similarly, in front of the news cameras, EPs give calm and hope to people in their homes. We lead by example. We lead by our recycled N95 facial bruises. We lead by our worn and torn gowns and gloves. We lead from the very uncertain frontlines. And that is okay with us.
AAEM Tales of COVID-19
AAEM wants you to have a forum to share your thoughts, emotions, opinions, and stories related to the COVID-19 pandemic. Please consider sharing your ideas with other members so we can get through this crisis together. We will be sharing new stories weekly online and then all stories will appear in the print version of the July/August issue of Common Sense. Submit your story, opinion, artwork, poem, or other work here.
Special Issue: AAEM Tales of COVID-19
Author: Puja Singh
They asked me, “How does the current pandemic situation make you feel as a future emergency medicine doctor taken out of your clinical rotations?” Dehumanized. Anxious. Heartbroken. Anxious about the upcoming residency application cycle, anxious about whether I will be able to do audition rotations at the prestigious institutions I have imagined myself going to for the past three years. Anxious about whether I can take Step 2 in time. But more than this, I feel as though our humanity has been snatched away. My mother, an internist in NYC and a single mom, has been isolated in her room, forced to stay away from my ten-year-old brother because she has been taking care of others’ loved ones. Dehumanized because when we got notice of my maternal grandmother, my Nani, passing away in California I had to stay away from my mom and could not go home to see her in order to abide by proper quarantine guidelines. Dehumanized because when we traveled to California to complete the last rites and rituals for my Nani, we were encaged by N95s. As we bid farewell to our grandmother, our hands could not touch her cold and limp body because of the gloves that lay in between us. Dehumanized because as we cried and grieved, we could not wipe each other’s tears away and hug one another, since we were all that we had left. We were all that we had left; and yet we were still so far from one another. Finally, 14 days after my Nani passed, I hugged my mother, I wiped my aunt’s tears away as they fogged her glasses, I brushed my little cousin’s hair as she sat in front of the mirror and cried, I rubbed my uncles back as he sobbed into his palms, and I squeezed my brother’s hand as he watched my mother’s heart break into a million pieces. I cried alone.
Four weeks ago, when I was pulled from my OB/GYN rotation, little did I know that this life changing event would happen in the midst of this global pandemic. My grandmother was my entire life – she raised me for 10 years by herself with no help whatsoever. She was a mother to me when my own mother couldn’t be after the death of my father, an internal medicine resident himself. She was my rock, my person, and now because of this pandemic I could never say goodbye to her the way I had imagined. I was never ready for this day; yet now there were a million barriers to what I had always wished I could do. We aren’t sure why she passed away, but I was sure that I wanted to help lighten the suffering of other families experiencing similar pain. Before my Nani’s passing, I had spoken to her about my idea of recruiting fellow medical students to conduct family phone calls to update them of their loved one’s status in the hospital since hospital visitation had been halted. She absolutely loved the idea! Since then, I have worked alongside my colleagues to develop an initiative to do this at our hospital and we have now called over forty families for COVID and non-COVID patients. The joy and happiness that this has brought me and my classmates, and hopefully the families with whom we have spoken, is a feeling that is unimaginable! To be able to make even a small difference in someone’s life when I, myself, am grieving is somehow healing me. Is this selfish? Or is this selfless?
My heart will never be put fully back together from the loss I have suffered, but it is somehow, just a little bit full and warm. Bliss. Gratitude. Human.
AAEM Tales of COVID-19
AAEM wants you to have a forum to share your thoughts, emotions, opinions, and stories related to the COVID-19 pandemic. Please consider sharing your ideas with other members so we can get through this crisis together. We will be sharing new stories weekly online and then all stories will appear in the print version of the July/August issue of Common Sense. Submit your story, opinion, artwork, poem, or other work here.
The COVID-19 Experience Outside of the Epicenters
Special Issue: AAEM Tales of COVID-19
Author: Robyn Hitchcock, MD FAAEM
We’ve all read the heartbreaking stories of what’s going on in the epi centers in New York City, the Seattle area, Detroit, etc. Clinicians drowning in their work. Typical ICU care turned on its head because standard management of respiratory failure isn’t working. One day we’re told if they start to crump intubate early because using BiPAP and even nebulizers spreads and aerosolizes the virus putting everyone in the department at risk. The next day they’re telling us don’t intubate until very very late because even ventilating them puts them at risk. Then we’re told use higher lung volumes than you think and less peep and then the next day they switch it. Wait, now we need to try prone ventilation and even rolling your patient regularly to expand and drain different parts of the lung.
Nobody really knows how to manage this because it’s not playing by any typical rules. Everyone’s trying to figure out how to split one ventilator to be able to vent from two to four people because there’s such a shortage. Anesthesia societies and pulmonary societies are coming out against this practice but some places have no choice. Human rights groups are up in arms because some facilities and states with shortages are making age cut-offs, or not treating the mentally retarded as aggressively to save a vent for perhaps a college professor instead. We are hearing tearful pleas from nurses that are working in intensive care with staffing ratios that are inconceivable: 19 patients to one ICU nurse with no relief because their colleagues are getting sick or refusing to come to work because of the dangerous staffing ratios. Orthopedic surgeons, dermatologists, and ophthalmologists who have had their clinics closed are retraining for ICU and ER care to help their overwhelmed colleagues. These are the stories that most people are seeing and read about every day for the past month and more since this COVID pandemic has become real.
But this is not the experience for most of the healthcare workers in this country, and at this time I am working primarily at places that have not yet peaked their use of resources. Right now I’m at a hybrid freestanding ER / urgent care facility in the southwest. Our usual complaint is volume. This facility was designed to see about 75 people a day and over the holidays we were seeing upwards of 150 to 200 and experiencing 5-hour waits routinely, etc. It was exhausting and frustrating for all of us. Things seemed to be settling down in January and February to a reasonable number to handle, typically between in the 120 to 140 a day range sometimes less. Then COVID-19 happened. In early March the very few patients we had coming through, we were able to put in our one negative pressure room, and have full PPE available for staff. I don’t think we had a test yet on site at that point, and we had to call the department of health to even get approval for the very few tests that were available.
In the interim I left to go back home and go to Stanford trying to get a loved one operated on which got canceled because of the pandemic. During this time I fortunately missed when one of these facilities was designated the local testing site and things were pretty chaotic for a while. They moved the elective testing site to a park outside of town so this site is now just seeing sick people again.
I returned to work April 8th. This is right around the time when the New York and California sites were starting to peak and finally flattening their curves, But the smaller communities with delayed onset of symptoms had often not even closed their federal facilities and parks, and certainly were nowhere near their peak. Many states issued a stay home order by mid-March but this state was just coming around to that on April 11th. The facility I’m working at which is always drowning in people, is barely seeing half of their previous volumes. That’s good and it means people are staying home like they’re supposed to. Unfortunately, the side effect of that is we’re seeing heart attacks stay home and not get intervention until it’s too late. I’ve seen abdominal pain stay home and progress from simple diverticulitis, which we can treat with antibiotics, to bowel perforation which needs surgery, a drain, and sometimes a colostomy. There are many, many people that come in with very minor symptoms like a runny nose, watery eyes, mild GI symptoms. The more we read about COVID the more we realize it can present with just about anything. So anyone with shortness of breath and cough, or a fever and just about any other symptom is “rule out COVID.” Many of these we are trying to see in the car and then our outdoor tent to avoid bringing them in to avoid exposing both our patients and our staff. If their vitals are normal and lungs are clear we will generally test them and send them on their way. If they’re sick enough to need more evaluation we bring them into the tent and if they’re really sick we bring them inside.
Again, most of these are going to test COVID negative and you know it, except when they don’t. So you have to don full PPE, we are given one N95 mask and face shield to reuse for the entire day. And then we’re even saving those at home at the end of the day in case they run out or in case our health system figures out how to reprocess them for reuse. We are also assigned one surgical mask a day, which we are supposed to wear all day long. This is actually our more important mask to protect our patients and each other. And it’s the most exhausting one to wear. I’m claustrophobic and struggle with wearing a mask at all for more than a few minutes. The N95 mask makes me absolutely feel like I can’t breathe so I’m stuck with a surgical mask most of the time and just switch to the N95 when I go in a patient room with suggestive symptoms or known COVID. It used to take a week to get the test back, now we’re seeing them generally in 24 to 48 hours, but it’s still not enough time for those of us on the frontlines to rule in or rule out needing PPE. It is really hard to maintain super caution in a high level of suspicion when you know what you’re dealing with is mostly not COVID. The rest of the time I am wearing a simple surgical mask which offers me little or no protection, but will protect my patients and coworkers at least somewhat if I’m an asymptomatic carrier. It would be ideal if they would do the same but some people (co-workers) keep taking their masks off. I would also prefer we mask every patient that came in the door for the same reason, but apparently we don’t have enough to do that so we’re only masking people with symptoms. Well, that works until it doesn’t.
People are thanking us for what we’re doing. We’re just going to work. At these facilities, the acuity isn’t very high and we’re not seeing very sick COVID patients. At least not often. We’re still at least two weeks away from our projected peak in New Mexico. People keep buying us food: lunches from local restaurants roll in with thank you notes. It feels somewhat disingenuous to accept this gift because really we’re working less than we typically do with the volumes being lower and all that. So add guilt to the table as well.
But the human fallout of this experience is very real. I’m extremely careful with hand washing and PPE, but not every one of my patients wears a mask and could be infecting me as I walk into any room. I have to assume I’m an asymptomatic carrier. So I’ve made myself into a leper. At my travel assignment, I will not allow housekeeping in my room until I leave to minimize their exposure. I am obsessive with the six foot social distance compliance. I wear a mask whenever I leave my room to protect others. I won’t go in an elevator if somebody else is in it. I move into clumps of weeds on a walking path to make sure I’m not exposing anyone going for a walk, etc. etc. It’s exhausting. I feel like I’m walking poison and must stay away from other people. This is not a pleasant feeling.
And what’s happening at work? Right now the facility I work at is actually pretty slow with low volume. We have a little too much time to spin and talk about the what ifs. Healthcare workers are being laid off all over the country. NOT just at elective facilities like eye clinics, low acuity doctors offices, outpatient surgery or procedure centers, dermatology and aesthetics, physiatrists and physical therapy, etc. Even ER nurses, yes ER nurses and doctors are being furloughed and/or asked to be take mandatory pay cuts because the volume is down. Much to my surprise many people (patients) actually are trying to stay home as much as they can. So not only are we putting ourselves at risk everyday by going to work, we’re being offered less work. Or less pay to do the same or both. Many are being forced to take less hours than they are contracted for or mandatory pay cuts. And it is strictly forbidden to travel to the areas that need help because then that puts you at risk and you would have to have a two-week quarantine before returning to work which would then put you in violation of your contract.
I understand the hospital administrations have to keep their patient population safe but the catch-22 of so many healthcare workers out of work, yet so many systems desperately needing help and the one not able to go to the other makes my soul cringe. Maybe one good thing that could come out of this, since all of the hard hit areas are offering fast track to licenses, which usually take 6 months or more, would be centralized licensing. The medical licensing community will realize we actually all have the same training and if you are licensed in one state you should be able to be licensed in any state. Medical licensing should be a national thing. It’s ridiculous to have to redo this process for every state you work in, and maybe there will be a push for this to happen but honestly I wouldn’t count on it. It would make too much sense.
I’m lucky so far that many of the facilities that I work at are single coverage, smallish places. You can’t really have less than one doctor on at a time. So far I’ve had all the shifts I need. Right now the places I’m working at haven’t surged and the volumes are down. I haven’t gotten sick and I haven’t brought the virus home to people I care about. Yet.
There’s a lot of talk of reopening the country, And the significant economic fallout of staying home and having things locked down. I wonder how we’re going to measure the toll that this virus is taking on all of us. The covered presentations, hospitalizations, and I see you length of stay as well as deaths are actually fairly easy to measure. But how do you measure everybody with chest pain that stays home or a heart attack that dies at home because they were afraid to come in? How do you measure the abdominal pains that turn into perforation or death because they didn’t come in? For the first time, I’m really understanding why people with what we consider to be minor or non-emergent problems need to feel that it’s safe for them to come in to the emergency department and not be ridiculed… That’s the only way we can ensure that the really sick people come. But they’re not coming or they’re not coming until it’s late. COPD exacerbations almost always have to be admitted or intubated because they delay presentations so long. Many systems have gotten telemedicine up and running or are managing more patients remotely. I hope that’s a change that sticks.
It’s way too early to be able to quantify the fallout from this pandemic, so right now we’re all just logging through the best that we can. I actually feel fortunate that I have a job that I can (and need to) go to outside the home. Nobody knows how long this will last. University of Washington cautiously is suggesting mid-May might be a good time to open the country back up. There are increasing protests about the stay home and social distancing orders. We’re seeing some countries that locked down illness right away like Singapore have huge spikes when they started opening things up again, but we don’t seem to be learning from it.
So I go to work. I wash my hands. I wear a mask, and when indicated full PPE. And just try to take things one day at a time and not think too hard about the what ifs. I truly do feel fortunate to still have full-time employment when so many people are out of work and so many things are closing. Times like these define us. Will it tear us apart, or bring us closer? I feel more connected than ever to my ED colleagues as we get through our shifts and try and keep our spirits up, together.
AAEM Tales of COVID-19
Embracing Femininity in a Pandemic
Special Issue: AAEM Tales of COVID-19
Author: Lauren Maloney, MD NRP FP-C NCEE
When I became an EMT in 2007, I could count on one hand the female paramedics I knew from working in the ER of a community hospital across the street from my high school. Female psych patient transports required a female provider in back, and because of how few women in EMS there were, some days the same paramedic would reappear half a dozen times. Those women were total badasses in my mind – they held their own, were wicked smart, quick with a joke, and could literally pull their own weight.
Later on in college as an 18-year-old female paramedic student in New York City, I quickly realized how naïve I was to the prevailing EMS culture. I was told by a preceptor that “women are supposed to be nurses, and men are supposed to be paramedics, so you might as well just quit medic school right now.” I had a signet ring worn by three generations of women in my family resized to fit on my pinky, as wearing it on my ring finger attracted attention from men who believed I was married and therefore more desirable. I learned how to weightlift so my partners wouldn’t be averse to working with a woman in the pre-powerlift stretcher era. I took up reading automotive magazines and watching local sports so I could make conversation across the daily gender and generational gaps. Most of all, I learned to show no emotion, even after a patient attempted to stab me with a knife enroute to the hospital one afternoon.
I continued to work as a paramedic, graduated as one of the few women in my biomedical engineering class, was accepted to medical school, and spent hundreds of hours becoming a state and nationally certified EMS educator. I earned my flight paramedic board certification which allowed me to take a highly coveted position as a critical care transport paramedic, and went on to become a resident emergency physician, still working shifts as a paramedic until I was granted my own medical license.
As I finish an EMS fellowship and become an EMS Medical Director, I feel like I’m finally in a position that I feel safe enough – respected enough – to show others that it’s okay to not be okay. That it takes more far courage to say, “I need help” than “Yeah, I’m fine.” To say we need a safety net for rough calls and to diffuse the cumulative occupational stress we endure.
This winter I teamed up with a paramedic supervisor and we began to craft a program called the EMS Code Lavender. Code Lavender started in a Hawaiian hospital1 as a way for healthcare providers to recognize and begin to heal from traumatic situations and unexpected deaths. During a Code Lavender, a multidisciplinary team meets staff real-time, and while the team composition varies across institutions, all utilize some sort of lavender aromatherapy for the sense of calm and tranquility it’s believed to bring. To overcome operational challenges unique to EMS, we framed it in two parts: a consistent way to recognize and reach out to staff after acute events and a long-term wellness initiative. We formulated a set of initial criteria for notifying the Code Lavender Team about a call and hoped by making it analogous to using criteria to call a major trauma code, the program would be less threatening and remove the sense of “tattling” on each other. A webpage was created so that all the wellness and mental health resources already available to staff, though rarely known about, were in one location. We printed stickers with a QR code that links to the page for providers to put on the back of their ID badge. Finally, we created a Google Voice number for notifications to go to. We planned to screen the notifications to determine if it was appropriate to reach out to providers via text or phone call, or if a Code Lavender needed to be activated for an immediate in-person response. Our grand plans involved rolling the program out in May during a series of department-wide training days.
Then COVID-19 hit, blowing our seemingly brilliant plans right out of the water. Within a week, we realized we were soon-becoming an epicenter in the COVID-19 outbreak. If there ever was a time to hopefully get buy in about acknowledging and embracing mental health, surely it would be during a pandemic with no realistic end in sight. We sent out an email explaining the program to staff, hurriedly gave out the stickers, and made the notification line live within several days. Much as the medical response to COVID-19 has evolved on a daily basis, the EMS Code Lavender response has evolved as well. In addition to maintaining daily peer contact with providers who are quarantined, we gathered items for care packages and purple teddy bears to give to those under strict isolation precautions. We started weekly happy hours via Zoom as a way for folks to laugh and breath together while enjoying a seltzer or adult beverage of their choice. And we bought a supply of chalk for the therapeutic graffiti of EMS bay sidewalks to create visual reminders of the love, community, and gratitude that surrounds us.
I would like to believe that on some level, helping to spearhead this effort as a woman has made it more inviting and warmer. Channeling what I hope someday to be maternal love, to make it non-threatening and genuine. I admittedly have paused before I hit send on emails to the EMS staff, cringing, wondering about if what I’m writing is too “personal”, or “touchy-feely” or “emotional.” But then I think, so what if it is? Since when did saying, “I care about you as a fellow human” become taboo? I have endured what EMS is like without feelings and femininity, and I know that my EMS reality right now, even in the midst of the worst medical nightmare of my lifetime, is something I am so very proud of.
- Karlamangla S. As health workers deal with mass shootings and fires, more hospitals are looking to help them cope. Los Angeles Times. 01/02/2018, 2018. https://www.latimes.com/local/california/la-me-ln-code-compassion-20180102-htmlstory.html
AAEM Tales of COVID-19
Class of 2020: Match Day during a Pandemic
Special Issue: AAEM Tales of COVID-19
Author: Gloria Felix
I opened my email on March 20, 2020 at 11:59 am: I matched into emergency medicine, at a program that serves my community and one where I used to volunteer when I was a teen. After years of living away from home, I get to come back!! I was overwhelmed with nerves, happiness, and joy.
At 12:15pm, I hear the familiar ringtone from my computer, time for our virtual match day party! My fellow 4th years shared our new destinations and jumped for joy for one another. For the past four years we’ve been each other’s support system, we’ve laughed together, studied together, cried together, and here we are – the day we’ve been dreaming of has arrived. We finally did it! We are going to be physicians serving communities all over the country. We laughed, shared silly stories and jokes with liners of “remember that time” or “O man I never thought I’d make it past class…” but here we are. We made it! After rounds of laughs and trips down memory lane we said our “see you later and stay safe everyone” farewells and signed off.
The screen shifted to black, I sat in front of my computer, and suddenly once the adrenaline started to wear off, I started to feel reality set in. I was going to be an emergency medicine intern at the epicenter of the pandemic. I began to feel fear. Will I be able to keep up? Will I know what to do when a family member sees MD on my ID badge and is asking for help? Will I get my family members sick when I come home? Suddenly the excitement and joy I felt was overshadowed by fear. A list of what if scenarios one after the other were playing in my mind on repeat.
I muted the fear, at least for that day, and tried to focus on spending time with my sister and nieces who I hadn’t seen for months. I sat around the table with them as we cut the fluorescent pink match day cake they had bought for me. My niece continued to sing a happy “match day” song on repeat and for a moment my doubts were silenced.
I woke up the next morning and I felt different. My world had changed overnight. I was no longer waiting for where I would be spending the next four years. I already knew. My contract offer was signed and emailed. My new EM family welcomed me and the intern group chat was already booming with funny emojis and excitement for meeting each other. I started to feel the familiar mixture of excitement and fear.
I reached out to my fellow 4th years and future co-interns and asked, “is it me or are you guys feeling kind of scared?” We all were prepared for the traditional novice feeling of moving from medical student to doctor. We’ve been reassured about it being completely normal and everyone feels that way, but no one would have imagined that the class of 2020 would have to be prepared for being novices in what has been compared to be a warzone, a fight against time, and an uphill battle to find resources to keep patients alive.
My worries were not just my own. My fellow 4th years shared the same concerns, my co-interns flooded the chat with words of encouragement and funny videos to ease the seriousness we are facing, and mentors began to share that although they felt immense joy for me, they also felt concern and wished me to be safe.
In sharing my fears, I began to feel less afraid. I am not alone in being scared. I am not alone in wanting to help but not being sure how to do so.
To my fellow 4th years who are entering or have already entered the frontlines of this pandemic, you’re not alone. The class of 2020 is resilient and we will make it through this together. Our voices and sharing our stories make us stronger and empower us during these uncertain times.
I congratulate all of the incoming interns and seniors who will soon be attendings for your accomplishments. It is a crazy time to join the emergency medicine family, but we are in this together!
Stay safe, stay resilient.
AAEM Tales of COVID-19
The Moral Dilemma of COVID-19
Special Issue: AAEM Tales of COVID-19
Author: Andy Mayer, MD FAAEM — Editor, Common Sense
Certainly, there is only one issue which is dominating all thoughts, prayers, and efforts on our planet right now and it is COVID-19. Hopefully where you are, your life and practice will only be incredibly inconvenienced and that your family, your community, and your hospital will be spared the worst of this pandemic. Many areas may be relatively spared by early social distancing and the shutdown of many aspects of daily life which until last month we took for granted. This crisis has brought to the forefront many ethical and moral dilemmas which our society and world need to face with open eyes and minds. Our medical capabilities in our modern prosperous society are currently been taxed past the breaking point in the hotspots of the COVID-19 pandemic. We need as a profession and as a society to consider the correct response to the complex and difficult decisions which physicians on the frontlines are now making or may eventually be facing where conditions are worse. Even if we manage to make it through this pandemic without running out of ventilators and do not lose too many talented and selfless healthcare professionals there may be a next time.
Sadly, I work in one of the initial hotspots of New Orleans. The citywide healthcare system became inundated within days. The whole medical community has come together to try and work through the new complex daily challenges which we are required to meet each and every day. The process, which we worked out the day before, can be quickly scrapped or modified as we learn or try new things. The idea that a new disease can come out of seemingly nowhere and challenge every treatment concept we have is a humbling experience. When you realize that we truly are wandering in the desert when it comes to what is the best course of action for the dying patient is front of you, it is terrifying but also enlightening. How far are we really removed from the “plaque doctor” of old?
Many of us have quickly been through the protocols of early intubation, late intubation, prone ventilation, CPAP, BiPAP, non-rebreather masks, no non-rebreather masks, viral filters, or whatever in an attempt to figure a path forward. Just walk through an ICU of any COVID filled hospital and you quickly see the reality of this pandemic and the current limitations of the available treatments. The prospect of throwing away much of what we thought we knew in regards to treating critically ill patients can make one question much of what we thought were sound and scientifically based principles. Listening to the various experts proposing yet another way to do things differently for this novel disease is fascinating as the medical community having to throw out, at least partially, our “evidence-based” mindset.
Consider the ethical dilemma of trying a novel ARDS protocol or giving a medicine normally used for malaria or lupus with known serious side effects on only anecdotal evidence. Certainly, the intention of using these techniques or medications by physicians in the trenches seeing their ICU and emergency departments filled with patients struggling to breath and dying all around them is noble and in the finest traditions of medicine. The usual treatments and protocols which we have all learned to use are not working and in an act of desperation a dedicated and caring physician who is putting their very own life on the line is attempting to save the patient in front of them. However, there will always be critics and naysayers who will demand to see the evidence and the trial, which shows the safety and efficacy of what is proposed. Many of these ideas will fail and patients will continue to die. I fear the personal consequences for these innovative physicians down the road when the tired old pundits and plaintiff attorneys come out to denounce the medical experimentation, which went on while they were safely home in self isolation. I certainly think that sovereign immunity should be granted to all physicians in this crisis to allay any fears of later recrimination after the dust settles. AAEM has sent letters to all of the governors of our states asking for relief from the fear of medical malpractice liability during this crisis. Will it be fair to pass judgment on the actions of these same doctors who literally placed themselves in danger to treat these patients knowing that our treatments were untested and were driven by their professionalism and compassion to try novel treatment options, which may or not work?
I certainly know what I believe, but more and more I feel like I am a plaque doctor of old. Dealing with a novel disease which is cutting a swathe thorough my community is humbling to say the least. Our emergency department early in the pandemic tried new methods to try and depressurize the department and hospital. Trying to keep a COVID-free area became almost impossible as despite a patient’s chief complaint, in the end everything became COVID. We started seeing patients via Zoom while they were in triage to help start workups and triage to see who needed the next available bed while preserving our limited personal protection equipment supplies and to try and limit exposure to the providers. The fire marshal allowed us to put army type cots along a long hallway outside of the waiting room to see patients when there was no other available space. The scene was surreal walking past six ambulance stretchers waiting on the wall to see people in pediatric area, which we had also cannibalized for sick adults. I never would have thought that I would order so many ferritin or LDH levels in my career.
The potential of the need to ration care when your department seems to be drowning in COVID can become a pressing thought. This is especially true when your local nursing homes become infested with the virus. At one point, we would have nursing homes calling and stating they were sending five patients at a time. Who to see first? Who would get the bed? Would we have enough ventilators? Who to put on hydroxychloroquine? The crucial question, sadly on the initial presentation on some of these patients, is quickly reviewing the code status and immediately trying to call families to discuss treatment options. On some days, it seemed that our number one consulting service was palliative care. Hopefully this time is past for my emergency department, but please think about these questions now before you are doing this in a time of crisis. Please consider beefing up your medical ethics committee. There was a good article in JAMA related to this issue of the potential liability of the rationing of care (https://jamanetwork.com/journals/jama/fullarticle/2764239).
The reality of the shortage of personal protective equipment (PPE) is another moral dilemma. Can you expect any worker in the hospital from an emergency physician to the poor housekeeper dutifully deep cleaning the COVID rooms to enter these contaminated rooms without proper safety equipment? Can we judge them if they are too scared to work? Should only staff less than sixty who do not have significant comorbidities be asked to see these patients? Should older staff members with these comorbidities be asked not to place themselves at risk? Should pregnant staff members be excused from direct patient care? The questions can be endless and I think the answers will also be drastically different depending on your hospital and your perspective. My hospital was spared the worst of this PPE shortage, except for the fact we were given one N95 mask and told we needed to use it for five days and to wipe off the gowns and reuse them. I am thinking of having my first N95 mask bronzed to have as a memento of this pandemic. Luckily, one of my partners “knew a guy” who owned a contracting company and gave us a small supply of nicer masks, which seemed to fit better. Our hospital system seemed to work miracles and we were able to obtain real respirator masks relatively quickly compared to the stories out of New York.
The other remarkable fact about these COVID profession is truly on the frontlines of a real pandemic and that our work entails real risk makes me feel two paradoxical emotions. One is pride that we are professionals who have taken an oath and are dedicated to trying to save the lives of at times an overwhelming number of critically ill patients with the realization that we are putting ourselves and our coworkers at a potential real personal risk. The conflicting emotion is a sense of humility and insignificance that in our advanced and modern medical system we can be seemingly vanquished by a tiny piece of RNA.
Please reflect on these issues even if you have not been required to face them, as the moral and ethical issues related to COVID are real and significant. Hopefully this pandemic is a generational one, but we can never be sure and should be prepared. I would ask you to consider sharing your thoughts on these or any other COVID issues. Working together as a profession can help us all deal with the stress and uncertainty of our new reality.
AAEM Tales of COVID-19
The Sun Is Rising
Special Issue: AAEM Tales of COVID-19
Author: Monica Anita Gupta
The sun is rising with each shivering step I take.
It’s still dark out, but I see pink creeping into the blue:
spring pastels to match the canary yellow gowns inside.
Cotton candy dreams. A veneer of peace.
A flock of birds welcomes it in, nibbling,
eager for a taste of life,
thirsty for the warmth of sun.
Show me how you fly, you birds.
How, on little nibbles, you get by,
consuming little, yet soaring
long and wide and far and singing,
enthused about the dawn you’re bringing,
with faith in the power of the morning sun.
AAEM Tales of COVID-19
The Role of Quarantined Medical Students
Special Issue: AAEM Tales of COVID-19
Author: Jason Wang, MBS
I had the opportunity to recently travel to Eagle Butte, SD to work with the Indian Health Services Hospital on the Cheyenne River reservation. With limited resources and providers, I was given the opportunity to work closely with patients as a third-year medical student. My attending physician entrusted me with the responsibilities of an intern, inputting orders and creating treatment plans. As a student, I learned the necessity of calling down to the laboratory when I added another request after initial blood collection. I researched society guidelines to learn proper antibiotic dosages. It was a great opportunity to be thrust onto the forefront of emergency medicine, seeing patients, seeing results in real-time, and making clinical decisions accordingly.
This experience also proved to be quite nerve-wracking. On my first day in the ED, I was uncertain that I had put in all the correct orders, constantly double-checking my orders and plans with my attending. I poured over and reread the same articles multiple times to make sure I had memorized the correct duration of treatment for otitis media versus streptococcus pharyngitis. Falling asleep at night became more difficult, as I ruminated about each day’s decisions and whether I had mistakenly over- or under-diagnosed my patients. Fortunately, I was never tasked with the most complicated patients, but I couldn’t shake the worry.
Watching my colleagues and peers being thrust onto the frontlines in New York, Washington, and California, I am both envious and nervous. I trust that our academic preparation and clinical training. I know that we are capable of seeing patients and understanding what diseases may be afflicting them. However, I still worry that we are being thrust into positions for which we may not be ready. What happens if we overreact and place a patient under droplet precautions and unnecessarily waste PPE? What if we don’t recognize a PUI and expose healthcare professionals to the disease?
Our hospitals, and more specifically our emergency rooms, are being overwhelmed. As our healthcare professionals are drowning in this COVID-19 pandemic, I want students to step up to the calling that drew them into healthcare. I also want to caution against reaching out to whatever resources are available, especially if they can be harmful to the system. I know that we are capable, but there is definite training that we will need in order to contribute to emergency rooms. I’m disappointed that clinical rotations were suspended. Even though this was necessary to redirect personnel to direct healthcare, it unintentionally interrupted our training. This lapse has left medical students scrambling to catch up. We have missed a critical opportunity to train medical students in proper triaging skills, or as scribes for overburdened resident and attending physicians. Now, as hospitals are starting to call students back to help, I am hopeful that we will help with this pandemic and hopeful that those who aren’t returning to rotations will be spending this time getting the training to be even more effective once we finally get back into the emergency room.
AAEM Tales of COVID-19
Special Issue: AAEM Tales of COVID-19
Author: Stephanie Benjamin, MA MD
February 29, 2020
Happy Leap Day! Sitting in my backyard, listening to the birds and the wind chimes, pushing aside my ever-growing concerns about COVID-19. I checked my old journals but apparently didn’t write anything on the last leap day. Makes sense – 4 years ago I was in the midst of my intern year of my EM residency. But now, I’m more than halfway through my EMS fellowship, casually house hunting, and chats with my hubby have recently revolved around starting a family.
March 1, 2020
About to head into a nightshift. One of several emails today noted that our N95 masks are now under lock and key behind the nursing station. So many sick people. Washing my hands a lot. Hoping to not get sick…
March 6, 2020
Planted our summer garden! The usual array of squash, tomatoes, eggplants, potatoes and peppers are in, as well as a variety of herbs.
March 9, 2020
People are panicked and freaking out, spreading rumors and gossip on social media. Seems like everyone is worried, but no one is staying home. I can’t stay home, I need (and want) to keep working, but other than my ED shifts, I’m not leaving my house. I don’t want to contribute to the societal burden. Told my 70-year-old parents (who live in Manhattan), and my sister (who has 4 small kids) to hunker down.
March 11, 2020
Trying to order COVID testing is a mess. “Infection control” (not infectious disease, to be clear: infection control folks are NOT doctors) implemented a password restriction on obtaining tests. The password is only given if they (again, NOT doctors) approve the test. One of my patients arrived in respiratory distress, and met all the high-risk criteria and classic symptoms, except for recent travel to China or Italy. Infection control declined my test request. ALL requests for testing last night were declined. A co-worker hacked the system and we covertly ordered the tests anyway. It’s insane. People are going to die as a result of the ineptitude.
March 12, 2020
Between not being able to test patients, the projected number of millions infected and dying, and seeing the empty grocery store shelves, my morning began with a panic attack. I stress-cleaned the house within an inch of its life. Then I moved on to stress-cooking. I made stir-fry with a mix of homegrown and store-bought veggies. I’m calmer now, but still worried about my parents.
March 13, 2020
The constant emails and texts and online meetings are a continual source of stress. Probably should avoid social media for a while, at least until I calm down, and probably after that, too. Reminding myself that there’s nothing else I can do helps. We have plenty of food and water and toiletries and entertainment. But my mind keeps wondering if I’ll get sick. Or my family. Or my husband. It feels as if the world is pressing in on me.
March 14, 2020
The situation continues to evolve (unravel, devolve, dissolve?) into chaos. We’re still limited in the amount of testing we’re allowed to do. I’ve had over 100 emails today about COVID and am trying not to spend my day on the news.
March 15, 2020
9/11 and Katrina put me on the path to disaster medicine. In the past, I couldn’t do anything. I was helpless. Now, I’m an EM/EMS physician. I’m writing and reviewing protocols, and contributing my medical opinion on topics ranging from neb treatments to paramedicine to PPE. I can fight now. I’m not helpless anymore, yet at the same time, I feel as if I’m a pawn being shuffled around at the whim of our psychotic government. Deep breath. It’s been an emotional few days and now it’s late. I should go to bed. Need to be ready for more meetings and more bad news tomorrow.
March 16, 2020
All the bars will close indefinitely at midnight. And no dining-in anymore. At all. How surreal. What a simple thing – going out to eat. I wonder the next time we’ll eat at a restaurant. Months? Years? And I leaned that my city currently has a three week supply of masks. Seems like we’ll run out right at the peak of things. Well, who knows when the peak will be. Everything is speculative. Perhaps people will stay home, and we won’t have a peak? Ha. Yeah right. In the meantime, I’ll keep working on protocols/policies for the county and the city and doing whatever else is needed from me. This is my job. I’m here to help.
March 17, 2020
Things are changing rapidly. Time to read a bit (American Gods, by Neil Gaiman). I’ve taken to avoiding social media before bed. Any wonderful news or any terrible news makes me cry. A cartoon of superheroes looking at an ED doc and saying, “Welcome to the Club,” triggered the waterworks. The Spanish citizens who cheered from their balconies as medical staff returned home from a shift unleashed the dam as well. So far I’m keeping my shit together at work.
March 18, 2020
We had a St. Patrick’s Day online happy hour with our friends last night. Seems like everyone around the country is having similar experiences with anxiety and fear and frustration, but seeing their faces and hearing their voices was a needed reminder that I’m not alone.
March 19, 2020
The deluge is coming. I can feel it. People are on spring break, ignoring social distancing, spreading it around. People are going to die. A lot of them. A million? Less? More? My own odds: almost certain to get infected, unlikely to die. Maybe I already had it and am fine. Need to pace myself at work, not burn out. Need to be ready for the long haul. It feels like I’m in a movie, one where a small group knows what lies ahead, and everyone else in society is voluntarily/volitionally clueless. And then all hell breaks loose. We’re at that point. All hell is about to break loose.
March 20, 2020
Watching The Lord of the Rings. Needed an epic, courageous tale of heroes across the realms banding together, a reminder of hope in dark times, and the triumph of good over evil. I lost it when Pippin said, “I don't want to be in a battle, but waiting on the edge of one I can't escape is even worse.”
March 21, 2020
The thought of starting a family has slipped out of our reach. We can’t. Not now. I worry everyday about my friends that are currently pregnant. I’ve accepted who I am and what my response will be. I will work. I’ve already picked up extra shifts, and signed up to be available for backup for when others cannot work. I will accept the consequences, even if that means getting sick – though of course I will do everything possible to protect myself.
March 23, 2020
Work is terrifying. I wonder if anyone else feels his or her pulse quicken or anxiety flare when donning PPE. I felt the panic. I faced it. I cared for my patients. I don’t see how it’s possible not to get sick. Even with all the hand washing and hand sanitizing and whatnot. We all work in such close quarters.
March 24, 2020
(Remote) meetings all day. All. Day. All about COVID-19. Hospital, regional, city, county, state, and national meetings. As the EMS fellow I’m invited to join all of them, which means I learn all the concerns that everyone has about everything related to this pandemic, from limited PPE to hacking ventilator tubing to keeping EMS safe to nursing homes and prison outbreaks, to the homeless to the lack of any convincing evidence for any effective treatment. The tsunami is about to hit. I hope we’re ready.
March 25, 2020
I range between feeling okay, and abject panic. Yesterday was a rough day. Today so far is better, but if I think too much about the lack of ventilators and the exponential number of cases then I’m sure I’ll panic again. For now, staying home (as usual), and then off to another ED shift tonight.
March 26, 2020
Home from another shift, freshly showered, and disinfected. The skin on my hands, especially my right hand, is cracked and red and burning from all the hand sanitizer. The respiratory cases are increasing. Had a tricky case with one of my interns and even though we stabilized the patient, I’m still rethinking every order and every medication we gave, trying to make sure I didn’t miss something. The admitting physician commented something to the effect that it probably doesn’t matter what we did, because if the patient ends up being COVID positive, they will probably die anyway. Ouch. That doesn’t mean we don’t try! It’s 2:30am, time for bed. I’m hoping to fall asleep and not dream/nightmare about work. Again.
March 26, 2020
Trying to remember what life was like before COVID. I had recently accepted an EM/EMS faculty position at my University. I had been writing and publishing a ton. My husband and I were planning a trip to Italy. My husband and I were planning to start a family. My whole family, all in NY, was planning to visit us here in California.
I’m scraping the barrel for silver linings: We planted a large garden, which is minimizing my husband’s trips to the grocery store. Our recipes have become more creative as ingredients run out. The dogs love that we’re home more. I talk to my family a lot on FaceTime, and so far everyone is still healthy. I thank them every day for heeding my warnings to self-quarantine before NY turned into the cesspool that it is today.
March 27, 2020
PPE is spread thin. I have a single N95 per shift, but way more than 1 potential COVID patient per shift these days. The healthcare system is on the brink of collapse. Perhaps in NY it already has collapsed. Same with the economy. The government is still working against us. My friends and colleagues are getting sick. More every day. Young people are dying. A cardiology fellow died. Someone like me, right on the cusp of completing a dozen years of medical training, dead. I lost it.
March 28, 2020
Going to work feels like playing Russian roulette. I updated my will. Well, technically I didn’t update it, I wrote one. I never had one before. I’m 36-years-old. Having to write a will when you’re still paying off student loans seems unfair, even absurd. I suppose a lot of this is, though. And so much of it was preventable. So much. Help us. Please. Stay home.
March 29, 2020
Sitting in my backyard, listening to the birds and the wind rustling the leaves. It’s been a month. Everything’s changed. One day my hubby and I will revisit our plans to buy a home and start a family. Not anytime soon. My anxiety still occasionally peaks, but overall has numbed to a dull ache. I’d write more but I have to get ready for my next shift. I’ll keep working until I get sick. Until I can’t. And when I get better, I’ll go back to work and keep at it. I’m assuming I’ll recover. I should be okay, right? And perhaps this will all be under control by the summer. Or by next spring. Or perhaps by the next Leap Day.
AAEM Tales of COVID-19
JAFERDs Can Do It
Special Issue: AAEM Tales of COVID-19
Author: Elizabeth Paterek, MD FAAEM
It is the calm before the storm where I practice in Philadelphia (at least it is at the time I’m writing this). New York and Northern New Jersey are already struggling and I fear what’s coming next. We are poised to fight a war without adequate protection or support nationally. I want to believe that we can do it.
AAEM Tales of COVID-19
Does AAEM Advocacy Resonate with Residents?
Issue: March/April 2020
Author: Jonathan S. Jones, MD FAAEM
The Academy recently released a position statement on the replacement of physicians by non-physician providers at urgent care centers in the Edwards-Elmhurst health system. There was some healthy internal debate within the Academy and within the EM Workforce Committee about whether AAEM should speak out about this situation given that it involved urgent care centers as opposed to emergency departments. Do employment decisions at urgent care centers impact EM physicians? Could we have any actual influence over the decision? Do our members care about this? Are there more important things on which to focus?
Ultimately, the Academy decided that this situation was important to us and we published a statement on December 3, 2019 (https://www.aaem.org/current-news/edward-elmhurst-health).
Separately, on December 5, I was visiting the Kingman Regional Medical Center EM Residency Program in Kingman, AZ as part of the Academy’s commitment to visit as many EM residency programs as possible to explain the Academy and mission to residents. I often start my discussion by asking the audience what they know about AAEM. The first response was something along the lines of, “Didn’t AAEM just do something about doctor’s getting replaced by NPs?”
I couldn’t have been happier. (Well I suppose I would be happier if physicians weren’t replaced by non-physicians, but we’re still working on that.) While we have a template for residency presentations, I didn’t really use it at all. What followed was instead, an open, informative, sometimes scary, sometimes inspiring conversation between me, an AAEM representative, and a room full of eager and excited EM residents. It was great.
While our statement on the Edwards-Elmhurst situation may not change the decision that organization has made, it absolutely helped inform residents and Academy members. I am fairly certain that it added a few members to our Academy and even more certain that these members will be engaged and contribute to the future of emergency medicine. For that, I want to thank the EM Workforce Committee members and particularly Evie Marcolini and Julie Vieth for their leadership. Job well done.
Statement of the American Academy of Emergency Medicine (AAEM) on the Edward-Elmhurst Health Firing of Physicians and Replacement with Non-Physician Providers
The American Academy of Emergency Medicine is expressing it concerns over the recent firing of 15 physicians from the urgent care centers operated by Edward-Elmhurst Health in Chicago. The Academy represents board-certified emergency physicians, some of whom practice in urgent care settings, and most of whom receive patients sent from urgent care centers when their medical condition requires a higher level of care. Urgent care centers, while created to serve lower acuity patients, do in fact see a significant number of patients who have serious medical problems. It is well known that even a routine complaint such as a headache may be the harbinger of a life-threatening illness. We therefore are concerned by the report that these physicians were fired in a cost-cutting move by Edward-Elmhurst Health. The AAEM believes that the skills and training of non-physician clinicians requires that they function as part of a physician-led team with immediate, onsite, physician supervision. The AAEM asks that the decision to replace physicians with NPs and PAs be reconsidered. The community served must be informed and deserves a chance to be heard on the removal of these physicians. There are better ways to cut costs of health care delivery than removing the most qualified person who cares for the patient.
Approved: December 3, 2019
My First “Sick” Patient
Issue: January/February 2020
Author: Alexandria Gregory, MD
Everyone knows the most fundamental part of emergency medicine residency is learning how to determine “sick versus not sick,” which is often easier said than done. One night, at the end of my shift, a nurse grabbed me, saying the patient in room six needed a doctor now. The patient was a young asthmatic who had apparently walked into the emergency department minutes earlier, but was now unresponsive, gray, and with an oxygen saturation in the 50s. I had no trouble determining she was sick; as a relatively new intern, the bigger problem was figuring out what to do next. To quote Michael Scott from The Office episode “Stress Relief,” in that moment, “I knew exactly what to do, but in a much more real sense I had no idea what to do.” I knew I needed to focus on the ABCs and I knew what medications the patient needed in terms of asthma management, but in the acuity of that moment, it all jumbled together. I quickly grabbed an attending and we worked through the ABCs together as the proper medications were administered and the patient stabilized.
That patient taught me several important lessons about intern year and residency as a whole:
- You know more than you think you do, but you’re not expected to know everything. Looking back on that case, the first thing that struck me was that the nurses had enough faith in me to see this critically ill patient. Perhaps it was simply because I was the closest physician in proximity, but it still serves as an important reminder that even as an intern, people may look to you to make critical decisions. At the same time, no one expects that you have all the answers—after all, that is the point of residency. Someone should always be available to have your back and you should not be afraid to ask for help when you feel stuck.
- Slow down, even when you feel there is no time to do so. Inevitably, as you start to see critical patients as a beginner, just knowing that the patient needs quick interventions will tempt you to rush. However, the best decisions are usually made when you take a step back and look at the big picture. While taking a moment to think may feel like you are wasting precious time, making the right decision for the patient is usually more important than saving a few seconds.
- Your demeanor can have real impact on patient outcomes. Similar to the above, the way you handle yourself in critical moments is almost as important as the actual decisions you make. While it is natural to be flustered in unfamiliar situations as a new learner, being able to remain calm and compassionate in such scenarios is part of what makes an emergency medicine physician. Medicine, and perhaps emergency medicine especially, is unique in that our day-to-day decisions, even seemingly small ones, have direct impact on people’s lives. Mastering the way you carry yourself as you make such decisions is just important as learning the medicine itself.
- Emergency medicine is a team sport. I have known this for a while, and it is part of why I chose to practice emergency medicine specifically, but cases like this are always a good reminder. When I was asked to see the patient with asthma, I was far from alone. I was surrounded by nurses, medics, respiratory therapists, and multiple attendings who came to assist. Everyone had his or her own role, but at the end of the day, we were all there to save our dying patient. While being a resident can feel isolating and challenging at times, remembering that you are part of a team with a shared goal can go a long way.
Development of a Focused Designation of Clinical Practice in Ultrasound
Authors: Melissa Myers, MD FAAEM and Alexis Salerno, MD
Emergency physicians have been an essential part of the development of Point-of-Care Ultrasound (POCUS). In the 1970s, POCUS started as part of the trauma resuscitation. Since then, emergency physicians have expanded the boundaries of POCUS to evaluate and treat a wide range of medical conditions. As early as 1988, emergency physicians began publishing on the use of bedside ultrasound in the emergency department. Within a few years, in 1991, both the American College of Emergency Physicians (ACEP) and the Society of Academic Emergency Medicine (SAEM) published policy statements regarding the utility of bedside ultrasound in the emergency department.1
Emergency physicians have also led the way in developing curriculum. The first published curriculum in 1994 by Mateer et al has led to multiple well-developed curriculums based in educational research. Today, POCUS is considered an essential skill and was recognized as such in the 2013 Model of the Clinical Practice of Emergency Medicine. Modern emergency medicine residencies include rigorous and extensive training in POCUS with graduates performing a wide array of POCUS skills to diagnosis and treat their patients.
Some emergency physicians choose to pursue ultrasound training beyond that required during residency, by completing an emergency ultrasound fellowship. During one or two year fellowships, these physicians become experts in advanced ultrasound modalities and ultrasound education. The presence of ultrasound fellowship trained faculty at residency sites correlates with a higher number of faculty credentialed to perform ultrasound and may assist with quality assurance for ultrasound performed in the ED.2 Fellowship trained emergency physicians also continue to develop new ways to improve the use of POCUS and to study best practices for use on shift.
The Society for Clinical Ultrasound Fellowships (SCUF) currently lists 50 fellowships, though this list is not exhaustive, and does not include the military programs. Until recently, there has been no established way to recognize physicians who choose to pursue this extra training or to credential these fellowships. While some have chosen to pursue recognition through the exams offered by the American Registry for Diagnostic Medical Sonography or other similar organizations, these exams were not developed by emergency physicians and do not reflect the use of POCUS in the emergency department. As noted by Dr. Gibbons in the May/June 2019 edition of Common Sense, emergency physicians do not need these merit badges to legitimize our training.3
Following an extended debate and vote, members of these fellowships and ultrasound societies nationwide felt that attempting to establish a subspecialty board could have unintended consequences for the practice of POCUS by those who did not choose to pursue a fellowship. The alternative chosen was a “Focused Practice Designation (FPD).”
The FPD, which is approved by the American Board of Medical Specialties, “recognizes physicians who devote a substantial portion of their practice to a specific area of a specialty.”4 This will hope to recognize emergency physicians with expertise in emergency ultrasound beyond the requirements for ABEM certification. It will be a recognition developed by emergency physicians which will be specific to the requirements of our specialty. There will be three pathways to obtain this designation, the fellowship training pathway, the training-plus-practice, and the practice-only pathway.5
In the fellowship training pathway, physicians will complete an Advanced Emergency Medicine Ultrasound (AEMUS) fellowship accredited by the Emergency Ultrasound Fellowship Accreditation Council (EUFAC). The Society of Clinical Ultrasound Fellowships (SCUF) will be charged with the creation of this council. For those who do not know, the current SCUF website helps potential fellows compare various ultrasound fellowships and complete fellowship applications. In the future, the EUFAC will release regulations to obtain fellowship accreditation and a curriculum for the fellows. The curriculum will expand on the basic emergency medicine ultrasound knowledge by including advanced measurements and views. Although the curriculum has not been released yet, potential topics may include muscular tendon assessment, arterial doppler assessment or even cardiac diastology. The curriculum will most likely also cover administrative topics such as billing and workflow solutions.
In the training-plus-practice pathway, physicians must complete an acceptable non-EUFAC accredited fellowship. This pathway will most likely be for recent emergency ultrasound fellows who graduated prior to the date of the first accredited fellowship. The physician must also demonstrate 24 months of AEMUS practice including performing or supervising 300 studies per year and reviewing for quality assurance 500 studies per year. This pathway will only be available to physicians for five years from the date of the first EUFAC-accredited AEMUS fellowship. Those who are considering applying for this pathway, may wish to start logging ultrasound scans and QA’ed studies.
In the practice-only pathway, physicians must demonstrate 36 months of AEMUS practice with 300 performed or supervised studies and 500 reviewed studies. In addition, physicians will have to demonstrate additional knowledge in the area by prior work in leadership administration, publications, or teaching. This pathway will most likely be for more senior faculty that continue to have a strong interest in ultrasound. And just as in the training-plus-practice pathway, this will only be available to physicians for five years from the date of the first EUFAC-accredited AEMUS fellowship.
Physicians who meet the eligibility criteria will also need an appropriate verifier who can confirm the physician has the hand-eye-motor coordination to perform ultrasound tasks. Finally, physicians will be able to take a multiple-choice examination to gain FPD. The first exam is scheduled to be offered in 2022.
Through these pathways, emergency physicians who devoted significant time and attention to practicing point-of-care ultrasound will be able to obtain recognition of their expertise. This exciting development will likely continue to evolve over the next few years as ultrasound societies nationwide work together to develop the exam and fellowship credentialing guidelines. To keep updated on the progress of the AEMUS FPD check out the SCUF website at eusfellowships.com and don’t forget to check out EUS-AAEM newsletter, the POCUS Report.
- Kendall, J. L., Hoffenberg, S. R., & Smith, R. S. (2007). History of emergency and critical care ultrasound: the evolution of a new imaging paradigm. Critical care medicine, 35(5), S126-S130.
- Das, D., Kapoor, M., Brown, C., Ndubuisi, A., & Gupta, S. (2016). Current status of emergency department attending physician ultrasound credentialing and quality assurance in the United States. Critical ultrasound journal, 8(1), 6.
- Gibbons, Ryan. “Emergency Ultrasound Merit Badges...There’s No Need.” Common Sense, May/June 2019.
- Focused Practice Designation. Focused Practice Designation | American Board of Medical Specialties. https://www.abms.org/board-certification/focused-practice-designation/. Accessed August 18, 2019.
- Advanced EM Ultrasonography. American Board of Emergency Medicine. https://www.abem.org/public/become-certified/focused-practice-designation/advanced-em-ultrasonography. Accessed August 18, 2019.
Queuing Patients in the Emergency Department: Can It Work?
Issue: September/October 2019
Authors: Andrea Blome, MD
What is queuing theory?
Queuing theory originated more than a century ago from the study of telephone delays and congestion. A simple queue is defined by a stream of arriving customers or tasks that are handled by a server. The goal of queuing models is to eliminate the disparity between the demand for service and the capacity to meet that demand. The concept is used in many service industries to strategize how to improve efficiency.1 For instance, a grocery store that struggles with long lines for check-out could add an express lane for customers with smaller amounts of items to reduce waiting time overall. In addition, call centers for customer service have used technology to improve caller wait times with the ‘virtual queue,’ which keeps the caller in line, but calls the customer back when the agent is free.2
How does it work in the ED?
In the emergency department (ED), decreasing patient wait times is vital. Increased wait times lead to delayed diagnosis, poor patient satisfaction, and increased morbidity and mortality. The ED can be simplified to a ‘multiple server, single phase’ queue, in which patients wait in one line (the waiting room) for servers, including the triage nurse, the bedside nurse, and the physician.3
In health care, queuing calculations are generally based on patient arrival rate, service rate (time for exam, tests, treatment), and the number of servers (number of providers and ancillary staff).4 Most models use the Poisson arrival process, which assumes patients arrive according to a random process. Arrival and service times can vary based on the time of day, the season, etc.1
In the ED queue, interventions should focus on either reducing the server utilization or reducing variation. To reduce server utilization, the rate of service can be increased, with the goal of identifying wasteful elements and reducing or eliminating them. To reduce variation in service, the alignment of the staffing should first match demand before adding additional servers to the system. By predicting the average distribution of patient arrivals by hour, the staffing model can be adjusted to have more servers during high demand times.1 To reduce variation, the variation in arrival and/or the variation in service should be decreased. Reducing variation in arrivals can be difficult, as not much can be done to impact the timing of emergencies. Variation in service is usually related to issues of process, layout, supplies, equipment, and supporting services. For instance, a laceration repair might take longer if supplies are not readily available and stocked in the room where the procedure is being done. Even small adjustments to these issues can reduce service variation.1
Figure 1: Opportunities to Reduce Variation5
Can it work?
Queuing theory can be used to predict the effect of patient arrivals, treatment time, and ED boarding on the patients who leave without being seen (LWBS). One institution used a queuing model to analyze the ED flow model currently in place and found that a queuing model was able to predict the variation in patients who LWBS.6
Lehigh Valley Health Network in Pennsylvania took the theory one step further. The institution used a queuing model to identify that the ED was understaffed during peak hours and overstaffed during non-peak hours. After aligning resource capacity with hourly demand, the hospital saw a reduction of length of stay by 20% and reduced walk-out rates by 58%.5
Figure 2: How to Implement Queuing in the Emergency Department
ED’s are complex, especially in large, academic teaching hospitals. Relying solely on averages to determine forecasts can certainly affect the model. Accounting for residents and medical students in the formula can also impact predicted outcomes. However, queuing models can and should be considered in ED’s in order to improve efficiency and decrease wait times.
1 Crane, Jody, and Noon, Chuck. “The Definitive Guide to Emergency Department Operational Improvement.” CRC Press, 2011, (119-145).
2 Kulbyte, Toma. “5 ways to manage (and reduce) your customer service queues.” November, 2018. https://www.superoffice.com/blog/customer-service-queues/.
3 “Introduction to Queuing Theory.” What is Six Sigma? https://www.whatissixsigma.net/queueing-theory-introduction/.
4 Chowdhury, Naser, et al. “Using Queuing Theory to Reduce Wait, Stay in Emergency Department.” Sept 2018. https://www.physicianleaders.org/news/queuing-theory-reducing-wait-stay.
5 Hu, Xia, et al. “Applying queueing theory to the study of emergency department operations: a survey and a discussion of comparable simulation studies.” Intl. Trans. in Op. Res. 25 (2018) 7–49 DOI: 10.1111/itor.12400.
6 Wiler, JL, et al. “An emergency department patient flow model based on queueing theory principles.” Acad Emerg Med. 2013 Sep;20(9):939-46. doi: 10.1111/acem.12215.
A Sad But True Story
Issue: July/August 2019
Authors: Andy Mayer, MD FAAEM
The issue of the appropriate role of advanced practice providers (APPs) in our emergency departments has been recently analyzed by a task force of AAEM and a new position statement has been approved. AAEM recently published this position statement and AAEM and this editor also submitted contributions to other emergency medicine publications (EM News, April, 2019) related to this issue. Common Sense has recently been contacted by a member of AAEM related to the impact of the increasing use and role of mid-levels in our emergency departments.
This member has recently been told by the new contract management company which took over her hospital’s emergency department staffing contract that there would no longer be any shifts available for her and the other part-time physicians, as the company would be bringing in midlevel providers to take these shifts. Common Sense thought an interview with her would be a good way for our members to understand the risks to our practices by the expanded use of midlevels. Will we be replaced by Doctors of Nursing Practice (DNPs)?
Andy Mayer, MD FAAEM
Editor, Common Sense
Dr. Mayer: So, please tell us a little about yourself, where you went to school, your path to emergency medicine and training.
MEMBER: I am an emergency physician in Louisiana. I went to LSU Medical School in New Orleans, and originally wanted to be a pediatrician. During my third year of pediatric residency, I did a rotation in a pediatric ED and loved it. It was then that I decided to do EM. My initial plan was to do Peds EM, but when I did a second residency in emergency medicine, I found out that I really like adults too!
Dr. Mayer: How did you end up in in practice in Louisiana?
MEMBER: I am from Louisiana and I decided to stay home to be around my family after residency. My first real job was with my current hospital system, and have been with them for around 15 years (other than a brief time at another local hospital to help them start their pediatric ED).
Dr. Mayer: Tell us about the group you joined and the working conditions.
MEMBER: The physician group here has been great to be a part of for many years. It really has been a family-type of atmosphere. We have over 30 ED physicians, and have been providing good care in our region. In fact, we are the only hospital in our area with all board certified emergency physicians working in our emergency departments. I went to parttime work when my daughter was in kindergarten, and she is in 4th grade now. I was an older mom, and wanted to enjoy being a mom. I could be flexible and work more when there was a need and could work less when needed less. Interestingly as a side note, part-time work has been advocated as one avenue to help physician burnout, and I agree. Being part-time has helped me enjoy work more.
Dr. Mayer: Your group sounded great and a place many of us would have been proud to work with. Please tell us what happened? How did the changes to your group by the new contract holder affect you and the other board certified emergency physicians working there?
MEMBER: The hospital was in the process of rolling out a new contract for the ED physicians. In fact, I had just signed the new contract two weeks before that day in August when we were told on a group text that an outside contract management group would be taking over our contract effective November 1. We were blindsided. It was a surprise even to the directors. The corporate management group said that the pay would not change significantly. They gave the staff information on new changes in March.
One change they planned on implementing was to bring on advanced practice providers. Board certified emergency physician hours would be decreased to make room for these midlevel providers. I was told that this was because the labor cost for these midlevel providers was cheaper. This meant that the part-time doctors would no longer be needed as their shifts would be filled with the midlevels, and many of the full-time doctors would have their hours cut. We were all board certified emergency physicians, most with 19+ years of experience. One has been a loyal ED doctor in our system for almost 40 years. Many of us are doctor moms (who work full-time at home, too). Others are also employed at our VA hospital and supplement their income for their families with part-time shifts at our hospital. No more work for us in the hospital system we have been serving for years. We will not be needed, as non-doctors will be replacing us on the schedule.
My residency advisor, who is now one of the administrators at the CMG, had to tell me in April (ironically the day after Doctor’s Day) that there will not be any more shifts for me or the other part-time doctors when the APPs will be implemented. I told her that it stinks. She said it was business. So emergency medicine is just down to business now. How will patient care suffer? I do understand the business part, but replacing doctors with non-doctors is not right. Also, the physicians who remain with the system will be required to work with APPs. It would be different if you have
a midlevel provider in an office setting, where you can hire and train them to work as you do. However, in the ED there are so many different doctors
to work with and different individual approaches to patient care. The ED doc has no voice in whom to hire or who they will work with on shift. They can be required to work with them even if they would have treated a patient differently, and this opens the physician up to more risk of litigation. True point, there are now malpractice lawsuits where this has happened and the doctor was sued — and lost.
Dr. Mayer: Where are you working now?
MEMBER: I still love emergency medicine. I am blessed to be in a field where I can work on a part-time basis. I have been working some at our
VA and in rural emergency departments lately. The work is good, and I have time to talk and visit with my patients. For Doctor’s Day, the rural hospital gave all the docs a nice engraved mug with candy. (I was told that even the pharmacists were involved in helping with the Doctor’s Day gifts!) That is definitely a different experience. Yes, there is a physician shortage in the rural areas. Part of the solution was to have midlevel providers in these areas. Weren’t they originally started as an entity to help doctors, not to replace them? Ironically, they are taking my job in the city, and now I drive out to the rural areas to work.
Dr. Mayer: Tell us what you are looking for and what message you have for your fellow emergency physicians in this changing work environment.
MEMBER: Please know that there are many advanced practice providers who I think are excellent — and they can be of great assistance to doctors in many fields. However, I do not think they should take the place of a board certified physician in the ED just because they are less expensive labor. Less expensive does not always equal similar quality. Would construction companies stop using steel to make buildings because it is too expensive? They might use aluminum because it is cheaper, and looks the same, but there will be detrimental long-term effects.
I have contacted ACEP and AAEM — it would be great if our societies could work together on this issue. Do board certified emergency physicians want full independent practice for advanced practice providers at the risk of making ourselves obsolete and diminishing patient care? If we can be replaced by a nurse with an online degree what message would that send to the medical students and emergency medicine residents who are spending years and huge sums of money to reach the goal of board certification? Does this mean that our training is not that important during medical school and residency? Do the number of hours required to become a midlevel compare in any way to the sacrifices required to become an actual emergency physician? The depth of knowledge is not the same. The recent exponential rise of online NP programs with their clinical hours of shadowing doctors should not replace the years of clinical training and experience of a physician, but it has. They use our education and board certification and dilute its value. How can I recommend to my pre-med niece to be an emergency physician, when we are so easily replaceable? Also, how could it be recommended to be ABEM board certified, to jump through all of the hoops we have to, like MOC, when someone who has DONE NONE OF THIS can take your job?
My message to our ED docs is this — we need to be proactive with our contracts because our jobs and patient care are at stake. We might talk to our anesthesia colleagues, as they have been working against full independent practice of their APPs/CRNAs for years before us. We need for the public to be aware of this shift in medical care so they can have a voice in who treats them in the ED. We could refuse to cosign charts of patients we have not been consulted on, or chart a disclaimer that the patient was not independently evaluated by the MD while they were in the ED. We need for ACEP and AAEM to help speak for physicians who are afraid to do so on this issue for fear of job loss. The contract management groups have become too powerful, but we also need to realize this is not just a CMG problem. It is also going on in academic centers, hospital based departments, and smaller partnership groups. We also need to become more business oriented, maybe depending less on CMGs and more on working together with administration to form our own groups. I understand that it is a business, but our patients should be the first priority. In a post from April, Dr. Edwin Leap talked about things we can do as physicians to improve our situation and satisfaction. He said, “I hope that over time we can push back, steadily, against bad ideas. ...To start by calling them out in the light so that physicians aren’t bullied into thinking that they’re alone, or that they’re complainers. Shine the light on the demons and they scatter. And look smaller than we thought when we stand together.”
In Louisiana, we love our Saints football. To use a football analogy, we don’t need another blown call while those with the power to change things look away and say “It’s not my problem.” This is a blown call for patient care in the ED. Our founding EM physicians fought hard to make our specialty separate and valuable for patients in emergency situations, not to give our specialty away to the lowest bidder. Job security is a thing of the past.
The really sad truth of this whole story is the courage it took for this emergency physician to come forward to share her story. When did we subjugate the
practice of medicine to corporate management groups and hospital administrators? There are many emergency physicians who have been adversely affected by the increasing role of mid-levels working in our nation’s emergency departments. AAEM cares about this issue and wants to hear your story. AAEM has created a form where you can submit ways the increasing role of advanced practice providers has affected you. We want to hear your stories and we understand if you want to be anonymous. The fear of retribution by CMG’s and the like is sadly a real and increasingly oppressive force in modern emergency medicine. AAEM wants to clarify the role of mid-levels in our emergency departments and support the practice of emergency medicine led and controlled by board certified emergency physicians. Please submit a concern or send a letter or comment to the editor. Submit a concern here: https://www.aaem.org/get-involved/committees/committee-groups/em-workforce.
— Andy Mayer, MD FAAEM
Editor, Common Sense
Getting Off the Ground: Developing an ED Patient and Family Advocacy Council to Improve Patient Experience
Issue: May/June 2019
Authors: Jonathan D. Sonis, MD; Maryfran Hughes, RN MSN NE-BC; Cassie Kraus; Robin Lipkis-Orlando, RN MS NE-BC; Linda Kane, MSW LCSW; Benjamin White, MD FAAEM
Patient experience continues to be a growing area of focus for hospital and emergency department (ED) leaders across the United States.1, 2 Despite this, existing avenues of obtaining accurate data regarding the most critical drivers of ED patient experience are limited and, importantly, largely missing the perspective of patients and family members themselves.3 While many U.S. EDs employ a postvisit survey tool (i.e., Press Ganey, Healthstream, QDM, and others), survey data may be limited by poor response rates, non-response bias, and restricted by the scope of the responses reported.4
To address the critical need for patient and family member input in improving patient experience, Patient and Family Advocacy Councils (PFACs), which include both invited patients and family members and selected staff, have been employed at the hospital and specialty level with increasing frequency over the past decade. In early 2018, recognizing a void of the patient’s voice in our own ED patient experience improvement efforts, we set out to create the first-ever ED PFAC at Massachusetts General Hospital.
Planning and Staff Recruitment
The first step in developing the ED PFAC was ensuring that stakeholders from all branches of the department’s leadership were supportive of the concept and would be willing to devote time and resources to the project. Early on, the ED Nursing Director, ED Clinical Director, and Executive Director all recognized the value in forming such a council and agreed to participate. Given the need for experience with PFAC formation, we also reached out to and gained the support of the director of our hospital’s Office of Patient Advocacy (OPA), who provided not only invaluable expertise and support, but also a source of potential participants.
To create balance within the group, it was decided that the PFAC would be co-chaired by a nurse (ED Nursing Director) and a physician (ED Administrative Fellow) with plans to also include a representative from ED Administration (Administrative Manager for Quality and Process Improvement) and the OPA (Advocacy Representative), as well as the ED Clinical Director.
Patient and Family Recruitment
Based on recommendations from the OPA, we sought to have an approximate one-to-one ratio of patients and family participants to staff participants in our PFAC. Therefore, five patient and family participants were sought out. Three participants were identified by the OPA as they had expressed interest in joining a PFAC and had experienced several episodes of care in the ED. Another two participants were identified directly by the PFAC co-chairs through communication following ED visits. Finally, a sixth patient participant who had already expressed long-term interest in supporting ED patient experience improvement efforts was asked to join the group. All participants were interviewed prior to being selected to participate on the council.
First Meeting Logistics
An initial meeting was scheduled for January 2019 after consulting the schedules of each participant. The agenda for the initial PFAC meeting was developed by the co-chairs with assistance and feedback from the OPA with the goal of introducing all participants and providing a general “lay of the land” of the major challenges facing our ED as well as existing solutions. This included a brief explanation of the PFAC’s development and the importance of patient and family perspective in improving ED patient experience followed by participant introductions, a brief summary of ED statistics and a demonstration of previous and current patient experience improvement efforts. While a formal agenda was utilized, extensive discussion among participants occurred throughout the meeting.
A key challenge throughout the planning and recruitment process was ensuring that the resulting group was diverse and as representative as possible of the population served by our ED. In particular, we found it more difficult to recruit younger participants than retirees, who often expressed increased time flexibility compared to their working counterparts. Ongoing recruitment efforts will focus particularly on underrepresented groups.
An additional challenge revolved around management of the meeting itself. Because all participants were eager to share their experiences and personal interests, some group members were more vocal throughout, at times making it challenging for others’ voices to be expressed. Moving forward, each meeting will begin with a summary of meeting expectations, including adhering to time limits and avoiding interruption.
Lastly, maintaining momentum and enthusiasm throughout the PFAC group will continue to be a challenge, both for patient and family participants and for staff. We plan to schedule meetings quarterly for the first year in order to continue to build momentum, with the option of decreasing frequency to three times annually in the second year.
While it is too early to determine whether the formation of the ED PFAC will lead to quantitative improvement in ED patient experience, initial feedback has been universally positive, with patients, family members, staff, and departmental leadership enthusiastic about the promise of gaining the patient and family member perspective in our ongoing patient experience efforts. Despite the challenges in providing excellence in patient experience in the ED, this relatively low-effort, low-resource project has the potential to bring significant and longstanding improvement for our patients and their families.6-8
1. Emergency Department Patient Experiences with Care (EDPEC) Survey. Accessed via: https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/CAHPS/ed.html, January 2019.
2. HCAHPS Hospital Consumer Assessment of Healthcare Providers and Systems. Accessed via: http://www.hcahpsonline.org/, January 2019.
3. Working with patient and families as advisors (Implementation Handbook). Agency for Healthcare Research and Quality. Accessed via: https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy1/Strat1_Implement_Hndbook_508_v2.pdf, January 2019.
4. Tyser AR et al. Evidence of non-response bias in the Press-Ganey patient satisfaction survey. BMC Health Serv Res. 2016 Aug 4;16.
5. Massachusetts General Hospital 2017-18 Patient and Family Advisory Council Annual Report. Accessed via: https://www.massgeneral.org/patientadvisorycouncils/assets/pdf/2017-18-massgeneral-pfac-annualreport.pdf, January 2019.
6. Welch SJ. Twenty years of patient satisfaction research applied to the emergency department: a qualitative review. Am J Med Qual. 2010;25(1):64-72.
7. Pines JM, Iyer S, Disbot M, Hollander JE, Shofer FS, Datner EM. The effect of emergency department crowding on patient satisfaction for admitted patients. Acad Emerg Med. 2008;15(9):825-831.
8. Taylor C, Benger JR. Patient satisfaction in emergency medicine. Emerg Med J. 2004;21(5):528-532.
Why Did AAEM Take a Stand Against APP Independent Practice?
Physician members of the American Academy of Emergency Medicine have voiced concerns about the use of advanced practice providers (APPs) in the emergency department and their push for independent practice without the supervision or even availability of a physician. The task force spent hours discussing the issues, comparing the education of physician assistants, nurse practitioners, and board-certified emergency physicians, speaking to physicians about their concerns, and examining the literature. (J Emerg Med 2004;26:279; Acad Emerg Med 2002;9:1452; J Emerg Med 1999;17:427; Acad Emerg Med 1998;5:247; Ann Emerg Med 1992;21:528.)
Most emergency physicians have worked with APPs and appreciate that they are talented clinicians who improve emergency department flow, efficiency, and quality of care under the guidance of the emergency physician-led team. Many emergency physicians are aware of situations that place APPs in clinical environments that are beyond their capabilities, level of training, and even scope of practice. This is not the quality of care our emergency patients deserve.
There is a vast difference in the clinical training of APPs compared with EPs. Some APP training programs require only 500 hours of unregulated, supervised clinical experience before graduating, while physicians must complete approximately 4,000 hours of clinical experience during medical school and an additional 8500 hours of highly regulated and supervised training as an emergency medicine resident before entering independent clinical practice. (J Emerg Med 2015;48:474.)
APPs do have a valuable role in many emergency departments, but their skills should be used as part of a team led by an ABEM/AOBEM emergency physician. APPs as members of that team should fill a role clearly defined by the emergency physicians in that department which professionally stimulates the APP and results in quality care. The cost of employment is lower for APPs than for EPs. As increasing patient volume drives increased need for coverage, the potential for increased profits grows if APPs replace EPs. The delivery of safe, expert physician-led care to every patient must be the primary factor when making staffing decisions, not profit.
The physicians staffing an emergency department are best capable of determining the needs of their department. Physicians should not be told by management that they must use APPs who have been hired for them. Rather, they should decide how many APPs they need and hire only those candidates who have the expertise and personality to mesh well with the culture of their emergency department team.
We are aware of situations where EPs are expected to supervise three, four, or even five APPs while simultaneously seeing patients primarily. The reality of those situations is often that the EP has only a cursory knowledge of the patients that the APP sees and little or no time to evaluate those patients independently. If defined patients and scenarios are deemed safe for the patient to be seen by the APP with the supervising physician providing only guidance and backup, then a bill should not be sent in the physician’s name. We support meaningful patient care by the physicians who are billing for it and transparency to patients. A signature in medicine implies that the signatory attests to the accuracy of the document. Without direct evaluation of the patient, how can one know the accuracy of the document?
Emergency medicine residency is a time for physicians to learn how to practice their profession. Residents should be trained by those who practice the profession in which they are seeking board certification. In a situation where APPs are practicing alongside EM residents, it is imperative to establish processes so that the training of the EM residents is not compromised. Residents need to complete a certain number of procedures to become competent. Attaining these skills should be a priority, and the residents should be the first priority to perform a procedure to become independently skilled.
It is challenging, if not impossible, for a patient to determine the role of all the people with whom they interact in the emergency department. Patients can easily be misled by non-physicians using the term doctor. They should not be expected to understand the difference between an MD or DO and a DNP or DScPAS (doctorate of science in PA studies). Patients deserve full transparency about who is caring for them, and non-physician clinicians must truthfully represent their level of training.
Throughout its history, AAEM has consistently asserted that ABEM/AOBEM certification is essential. The academy has also spoken against emergency departments staffed by non-ABEM/AOBEM physicians. Supporting the independent practice of APPs in our emergency departments is inconsistent with these core values. If APP independent practice is tolerated, a logical profit-driven next step is staffing entire emergency departments with APPs and even developing staffing companies to provide that coverage.
Our specialty owes its identity to our founders who demonstrated that the skills required to manage an emergency department expertly were unique in the house of medicine. They struggled to establish the specialty of emergency medicine and define the training required to become a specialist in emergency medicine. The independent practice of APPs has the potential to undermine all the efforts of those men and women who created the specialty of emergency medicine.
©2019 Wolters Kluwer Health, Inc. This article first appeared in Emergency Medicine News, and is reprinted with permission. www.em-news.com.
Highlights for Scientific Assembly 2019
Don’t Miss the Keynote Speaker
We could not be more excited for Scientific Assembly 2019 in Las Vegas. Don’t gamble on missing any of the opportunities to meet with your colleagues
from across the country and hear some of the latest scientific material from your favorite speakers and some exciting new talent. Our ,keynote speaker this year, Matthew Wetschler, MD will share his perspective on life and career. Matthew is an emergency physician, artist, and former professional athlete who drowned and suffered ten minutes of cardiac arrest. Even though he has sustained right-sided weakness, he has developed his artistic talents, and works to explore our relationship with limits, edges, and the space beyond. We are looking forward to his message.
Come Early: Pre-Conference Opportunities
Our pre-conference sessions will include the ever-popular ultrasound, resuscitation, ECG, and LLSA reviews, as well as Medication Assisted Treatment (MAT) waiver training and a session on military hemorrhage control. New this year will be a Written Board Review Boot Camp, for those of you taking the ABEM exam in April, and AAEM will jointly provide a teaching program with the Teaching CoOp, for those of you looking to brush up your teaching and presentation skills.
Back by Popular Demand
This year — back by popular demand — we will double the number of highly popular hands-on small group sessions. Our plenary speakers will cover the latest knowledge on cardiology, sepsis, trauma, resuscitation, critical care, and neurology. Also by popular demand, we will have the Airway Storytelling session, hosted by the unstoppable Billy Mallon. There will be many other events to participate in, such as Open Mic, Resident and Student Research Competition, WestJEM Competition and the RSA sessions. The Wellness Committee has some fun plans, including a new attendee welcome and a coffee crawl for you early risers.
New Panel: Patient as Educator
On Tuesday, the AAEM Scientific Assembly Subcommittee is delighted to announce a pilot format featuring patients as the educators in a session entitled: “Oncology Patient Perspective Panel.” In some diseases, there is no better way to learn about “best practice” than to hear from the patients themselves and see the emergency department (ED) encounter through their eyes. In this session, Dr. Jack Perkins (FAAEM) will serve as the moderator, and the panel will consist of oncologist Dr. Jennifer Vaughn, her patient Mr. Ben Bane, and the wife of her late patient Mr. Jason Price. Both Mr. Bane and Mr. Price spent dozens of hours in the ED with neutropenic fever, various chemotherapy complications, and other oncology related issues. Mr. Bane and Mrs. Susan Price will discuss details of their ED encounters in terms of what went smoothly, as well as opportunities for improvement. Dr. Vaughn will provide insight and expertise in a discussion of optimal collaboration between the emergency medicine provider and the patient’s oncologist.
This session will introduce a new “patient as the educator” format for educational sessions that may be utilized for future scientific assemblies. We will cover best practice in evaluation of neutropenic fever, optimal ways to initiate goals of care or end of life discussions, and the critical importance of collaboration with the patient’s oncologist regardless of the perceived severity of the presenting complaint. Please come to hear this engaging panel where the patients will give us their perspective. We guarantee it will be insightful and valuable.
Because we will be in Las Vegas, you will also have easy access to flights, and the opportunity to take in a show or maybe even practice your card shark skills. Don’t play the odds — join us for some of the best emergency medicine education and a great time!
Tattered Tarp or New Roof: Who Gets Included in Disaster Recovery?
In the bend of the south Texas coast, a community comes together to reflect on a year gone by since many lost everything. We danced in the streets, honored one another’s hardships and congratulated each other’s resilience, and I reflect on my own experience.
The last move my husband and I made before evacuating with our toddler and seven month- old was to throw an anchor from our sailboat, sitting on its trailer, in the front yard, a hundred feet from the water’s edge. “Maybe that will keep her from surfing into the neighbor’s second story living room,” my husband half-heartedly joked as he climbed into our small RV, wet from the first bands of the storm blowing ashore. At 5:30am, we left our home, driving in 20-minute shifts, exhausted from a day and a night of increasingly frantic preparation. Less than 12 hours later, the eye-wall of Hurricane Harvey made landfall directly on our small hometown of Rockport, Texas.
We returned to “The Charm of the Texas Coast” two days after the storm. Half of the structures were damaged beyond repair, the electrical grid was a tangle of wires and snapped poles, there was no running water, and overnight there was a new homeless population. The nearest hospital was destroyed and the majority of doctors’ offices closed due to damage. Rockport (Aransas County), Texas, was already designated a Medically Underserved Area. Like so many coastal communities, it is a glaring example of wealth inequality and social stratification; vacation homes and trailer homes. The storm’s destruction exacerbated an already failing safety net of health care and left our vulnerable population struggling with added mental and physical stress, financial devastation, and decreased access to primary care resources. It was obvious that the community needed a local medical response. After a short and self-guided course on legal protections for volunteer medical professionals in disaster zones, approval from the city Emergency Manager, and crucial support, both on the ground and remote, from a small group of graduates of the Latin American School of Medicine, I founded the Rockport Strong Mobile Medical Unit (RSMMU). For four months, RSMMU served as a pop-up urgent care clinic, staffed with volunteer physicians, nurses, and community health workers, operating out of the same RV in which my family had evacuated. Working alongside Emergency Management and FEMA, we provided free medical attention to over 400 patients.
Our team conducted a survey analysis to determine some characteristics of the population seeking our services. Some of the more important questions we asked our patients were if they had a primary care provider (61.5% reported they did not) and if they had health insurance (68% said no). And to the question, “Do you use the ED as your primary care provider?” 34% said they did. Of note, 74% of patients reported negative effects of the storm on their physical and/or mental health. The stories of the people represented in these figures were just as disconcerting: “I lost everything. I didn’t qualify for assistance. I don’t have a spare dollar to my name. My house is molding. I can’t afford my prescriptions.”
A year later, tattered blue tarps fail to cover the holes in roofs spaced throughout the community. Whose roof, though? Well, this is a diversity and inclusion column, so I bet you can guess. First, let’s talk about disaster vulnerability and how social conditions and location lend to the potential for greater harm to some social groups during a disaster and in the immediate aftermath. Social class factors force the poor to live in substandard housing, often located in physically vulnerable areas such as flood zones and in proximity to industrial sites, and reduce the ability to undertake loss-reduction measures (boarding windows, stockpiling supplies). In the U.S., race and ethnicity are strongly correlated with social class and are also associated with increased vulnerability to disaster.1
In the intermediate phase of disaster recovery, the same differential presents itself. Research conducted in the months following Hurricane Harvey found that the population affected differs by geography, race/ethnicity, and income, the largest impact felt by Blacks, Hispanics, and those with a self-reported income <100% FPL.2 Loss of income and employment disruption had a larger effect on Hispanic, Black, and lower-income residents. Among those with home damage, low-income, Black and Hispanic residents were less likely to have had insurance. Blacks and low-income residents also reported in higher percentages that they were not getting the help they needed. Language barriers arose as a contributing factor to sluggish recovery. Three in ten individuals answering a survey in Spanish reported that it was very or somewhat difficult to find information in Spanish regarding recovery assistance. The study also conveyed that undocumented migrants are particularly vulnerable to the effects of natural disasters, in part out of fear of exposing themselves or family member’s immigration status, and in another part due to ineligibility for benefits.
Now let’s look at long-term recovery and what has recently come to light. A study published in August (2018) concludes that wealth inequality increases along the lines of race, education, and home ownership in counties badly hit by natural disasters.3 In areas with at least $10 billion in damages, Black, Hispanic, and Asian communities saw their wealth decrease by an amount between $10,000 and $29,000, while white communities increased their wealth by an average of $126,000. The study suggests that the money follows the higher levels of reinvestment via infrastructure improvements and low-interest loans after a disaster occurs, as more privileged residents gain access to new resources. Meanwhile, low-income and non-property owners are more likely to experience financial strain from losing one’s job, moving, paying higher rents due to housing shortages, and depleting savings trying to compensate. Contrary to an often repeated myth, this data does not support the idea of disasters being “great equalizers.” It does however bring attention to the fact that for some people the resources which flow into disaster zones can be a silver lining to a universally bad situation. I witnessed this in Rockport as it became a temporary boomtown for construction contractors, clean-up crews, and donation sites across town. The issue is that the silver doesn’t seem to be making it into all folk’s pockets, especially for people of color.
What can we do? Disasters are great disruptors, and where there is disruption, there is room for innovation. After Hurricane Mitch slammed Honduras in 1998, Cuba responded by founding an international medical school, The Latin American School of Medicine (Escuela Latinoamericana de Medicina), designed to train doctors from lesser developed countries, mostly people of color, who would return to their medically underserved area when they graduate so that these communities would be healthier and more prepared for disasters in the future. This plan obviously took a very long view of disaster response, as the first graduates would have returned home some seven years after Mitch made landfall. It’s an example of a long-term disaster response that promotes inclusion and diversity in terms of both the medical profession and access to health care. The free mobile clinic in Rockport was a much= smaller and shorter-term response, but was still a successful innovation that brought resources to a medically underserved disaster zone. It is a model that can easily be recreated when the need presents.
The scientific community warns us that our warming planet will make high-magnitude weather events like hurricanes Katrina, Harvey, and Maria more frequent over the coming years. What does this mean for the health of communities of color exposed to these forces of destruction? Unfortunately, if disaster recovery maintains the pattern of reinforcing gaps in wealth along racial lines and the strong correlation between socio-economic status and individual health is also maintained, it’s likely that the health of communities of color will disproportionately suffer. While the issues are systemic, there are roles that individual physicians can take to immediately address some of the social determinants of health at play in post-disaster communities. Here are three suggestions:
- Set up a free clinic or volunteer to staff if one is already operating.
- Consider in-kind donations of medical equipment.
- Get involved with Emergency Management and advocate for the funding of programs that will improve access to health care (a community health center, for example).
Innovate. We need to change the trajectory of who gets to recovery from a disaster. The resilience and diversity of our communities depend on it.
1. Tierney, Kathleen. (2006). Social inequality, hazards, and disasters. On Risk and Disaster: Lessons from Hurricane Katrina. 109-128.
2. Hamel, L. et al. (2017). An Early Assessment of Hurricane Harvey’s Impact on Vulnerable Texans in the Gulf Coast Region: Their Voices and Priorities to Inform Rebuilding Efforts. Kaiser Family Foundation and Episcopal Health Foundation. http://www.episcopalhealth.org/files/7315/1240/4311/An_Early_Assessment_of_Hurricane_Harveys_Impact.pdf
3. Junia Howell, James R Elliott. (2018). Damages Done: The Longitudinal Impacts of Natural Hazards on Wealth Inequality in the United States, Social Problems, spy016, https://doi.org/10.1093/socpro/spy016
Highlights of AAEM's Legal Advocacy for Emergency Physicians
In the 25 years since AAEM’s founding, the Academy has been very active in advocacy and legal efforts on behalf of individual emergency physicians and independent groups. AAEM continues to be the only emergency medicine (EM) professional society ever to take legal action against contract management groups (CMGs) in defense of emergency physicians. The Academy’s willingness to put the interests of individual emergency physicians over corporate interests has had a major impact on our specialty.
Corporate Practice of Medicine
Catholic Healthcare West (CHW) and Emergency Physician Medical Group (EPMG)
In 1997, CHW, one of the largest hospital chains in the country, announced the purchase of EPMG, a privately held emergency medicine (EM) group. For the first time, a large hospital system had taken over a large EM group, converting hundreds of private practice emergency physicians into hospital employees. The $36 million purchase price was to be recouped by CHW from revenue taken from the professional fees of those emergency physicians. EPMG’s principal owners earned millions of dollars on the sale, and were then given jobs in the new CHW managed services organization, Meriten, which was essentially a contract management group. All current EPMG physicians — staffing eight of the 37 CHW hospitals — immediately became part of Meriten. Even more concerning, the independent emergency physician groups staffing the 29 CHW hospitals that were not part of EPMG were to be forced under the control of Meriten, which planned to take a 28% fee from its emergency physicians’ fees for expenses and profit.
With 29 contracts at risk, the regional implications were profound. AAEM also recognized national implications, as every large hospital system would see the opportunity to control and profit from their emergency physicians. After AAEM wrote letters of concern to the board of CHW, CHW in turn threatened AAEM. Undeterred and with AAEM’s help, the practicing emergency physicians of CHW organized into the Affiliated Catholic Healthcare Physicians (ACHP). With the support of AAEM, ACHP — along with the California Chapter of AAEM and the California Medical Association (CMA) — filed a lawsuit alleging violations of corporate practice of medicine (CPOM) and fee-splitting laws. The CMA recognized both the threat to emergency physician autonomy and the wider threat, as Meriten would also be positioned to control other hospital-based specialists. ACEP was asked to participate in these actions but declined, saying it was a private business matter.
The amicus curiae (friend of the court) brief filed by AAEM in this case can be found here.
After initial court hearings seemed to go against it, CHW sold EPMG back to its original owners, who then reorganized EPMG into a fairer, independent, physician-owned group. If CHW had been successful in this endeavor it would have opened the door to other hospital chains taking over emergency physician groups large and small, dipping into emergency physicians’ professional fees as a new source of revenue, and dramatically reducing the number of private EM groups. AAEM, at the time a fledgling organization, was the only EM society willing to stand with the ACHP physicians. This stand changed the course of EM in California. In the aftermath of this failed attempted takeover of EM, the chief medical officer (CMO) and chief executive officer (CEO) of CHW both resigned.
Mount Diablo Hospital (MDH), California Emergency Physicians (CEP), and TeamHealth
In 2003, Quantum Health, a subsidiary of TeamHealth, the second largest EM contract management group (CMG) in the United States, lost its contract at Mount Diablo Hospital in Concord, California to CEP. Three of the emergency physicians there wanted to continue working at MDH, where they had each been on staff for years. One was even a former Medical Staff President. In response, Quantum Health filed suit against these doctors, seeking damages from them for their supposed role in the loss of the contract. The emergency physicians went to ACEP for help and were told, as in the CHW matter, that it was a private business matter. They then came to AAEM and were provided advice, support, and legal assistance. The doctors joined AAEM in a counter-suit against TeamHealth, alleging that TeamHealth was using corporate subsidiaries to hide its violation of California’s prohibition on the corporate practice of medicine (CPOM). AAEM sought a declaratory judgment, requesting that all ED staffing contracts held by TeamHealth subsidiaries in California be voided, in light of California’s CPOM laws. This counter-suit was the first legal action ever taken against a CMG by an EM professional society.
All parties reached a settlement whereby TeamHealth dropped its lawsuits against the emergency physicians, who were able to continue working at MDH, and AAEM dropped its lawsuit against TeamHealth for violating California CPOM laws. In 2005, AAEM assisted in similar cases in Rhode Island and Indiana, also with favorable outcomes.
A copy of the AAEM counter-suit can be found here.
Read the full story from Emergency Medicine News here.
CMGs and Malpractice Coverage
In 2003, PhyAmerica, one of the largest CMGs, went bankrupt. In 2004, Sterling Healthcare, another large contract management group, purchased PhyAmerica’s bankrupt assets, including its ED contracts. PhyAmerica then told its emergency physicians that their self-insured medical malpractice/legal defense fund had been exhausted. 200 PhyAmerica emergency physicians who had already been sued were told they no longer had malpractice coverage, and must pay all attorney fees and legal judgments out of their own pockets. And of course, PhyAmerica emergency physicians had no malpractice coverage for future suits. In response, AAEM organized a Working Group from among the affected emergency physicians, handled logistics, and offered free legal counsel. The Academy also filed an amicus curiae brief before the Baltimore Bankruptcy Court.
In April of 2005 a court order guaranteeing the protection of the physicians’ personal assets was handed down. AAEM also negotiated with Sterling Healthcare for partial reimbursement of the emergency physicians’ legal costs.
Corporate Practice of Medicine
Emergency Physicians Professional Association (EPPA) and EmCare
In 2004, EmCare, the largest emergency medicine CMG, acquired the contract at Methodist Hospital in St. Louis Park, Minnesota. EPPA, a private democratic group serving the hospital since 1969, was not even told the contract was up for bid until after the contract was awarded to EmCare. No request for proposals was issued. EPPA’s physicians initially reached out to ACEP for support through its state chapter, but were told this was not allowed by national ACEP. EPPA then asked AAEM for help. AAEM Past President, Dr. Robert McNamara flew to Minnesota and met with nearly 100 emergency physicians. The Academy offered legal counsel, went to the hospital on EPPA’s behalf, and filed complaints with the state attorney general and Board of Medicine. In December of 2004, AAEM and EPPA jointly filed suit against EmCare for violating CPOM and fee-splitting laws, and filed suit against the hospital for breach of contract. A copy of the suit can be found here.
Three weeks later, Methodist Hospital terminated its relationship with EmCare and re-contracted with EPPA. EPPA continues to serve Methodist Hospital and several other local hospitals. AAEM then sent a letter to every hospital administrator in the state of Minnesota, informing them of this matter and sending the message that AAEM is watching what they do with their EDs. This action had a chilling effect on the desire of layperson-owned CMGs to move into Minnesota, and they have been unable to establish a significant foothold in that state.
Read more from EM News.
The Fight Against Alternate Boards
The American Board of Physician Specialties (ABPS) began approaching state medical boards seeking formal recognition beginning in the early 2000’s. State boards do not generally control what specialties different physicians may practice, but several state boards limit how physicians may describe their specialization, typically in the form of advertising. The ABPS describes itself as “… the official multi-specialty board certifying body of the American Association of Physician Specialists (AAPS).” It offers certification in 20 different specialties, but review of its website reveals that the majority of its diplomats are certified in a single specialty: Emergency Medicine. Their designation is “Board of Certification in Emergency Medicine” (BCEM).
AAEM believes that “A specialist in emergency medicine is a physician who has achieved, through personal dedication and sacrifice, certification by either the American Board of Emergency Medicine (ABEM) or the American Osteopathic Board of Emergency Medicine (AOBEM).” The fundamental problem with the BCEM process is that it does not require formal ACGME accredited Emergency Medicine training. Rather, an applicant can qualify after completing one of a large number of alternative specialty training programs or even one of 14 EM fellowships, harkening back to the ABEM and AOBEM “Practice Track ” provisions that closed in the late 1980’s. State board recognition of BCEM allows these physicians to misleadingly represent themselves as EM specialists.
In 2002, AAPS certified physicians were approved by the Florida Board of Medicine for such advertising. In 2010, similar recognition was granted in Texas. However, AAEM has been a staunch opponent of back-door paths to proclaim “board certification” outside the ABEM/AOBEM process.
AAEM played a key role in successful efforts in Oklahoma, North Carolina, Utah opposing AAPS’s attempts to gain similar status in these states. AAEM member Dr. Howard Roemer, was awarded AAEM’s James Keaney Award for his key role in convincing the Oklahoma State Legislature to reject AAPS’s proposal. AAEM remains the only EM organization requiring board certification to be a full voting member and a fellow of AAEM.
Read the February 6, 2006 letter to OK Board of Osteopathic Examiners.
Read the AAEM Values Statement, describing EM Specialist.
Restrictive Covenants in Tennessee
In 2005, legislation was introduced to allow restrictive covenants in physician employment contracts in Tennessee. AAEM and its Tennessee chapter strongly opposed these efforts and made this issue a top legislative priority for the next two years. TN-AAEM Board members Dr. David Lawhorn and Dr. Andy Walker testified before the House committee reviewing the bill, and explained to committee members how such non-compete clauses harm both patients in general and emergency physicians in particular.
While TNAAEM was not able to kill the bill entirely, emergency medicine was exempted. Emergency physicians in Tennessee remain free of restrictive covenants to this day.
Read more at EM News.
Corporate Practice of Medicine
TeamHealth and the Memorial Hermann Hospital System (MHHS)
In 2007, MHHS, a large hospital network in Houston, awarded eight emergency department contracts to TeamHealth. Several emergency physicians contacted AAEM for assistance in this matter, including a private group with a 20-year history with MHHS, which was ousted in this move. AAEM and the private group — with AAEM’s financial assistance — filed suit against TeamHealth and MHHS, citing violation of Texas CPOM laws. AAEM felt the case had substantial footing, as the Texas Medical Practice Act prohibits physicians from being employed by lay corporations for the practice of medicine. Additionally, previous Texas case law (Flynn Brothers, Inc. v. First Medical Associates, Dallas 1986) held that lay persons could not profit from an ED contract. AAEM’s efforts were funded through donations to the AAEM Foundation.
Unfortunately, a state district court held that it did not have jurisdiction to hear the case. Despite an amicus curiae brief filed in support of AAEM by the Texas Medical Association, a state appeals court affirmed the district court’s decision. The court of appeals held that AAEM lacked standing to challenge the contract between MHHS and TeamHealth, as well as the contracts between TeamHealth and its emergency physicians. One of the plaintiff physicians actually signed a contract with the TeamHealth subsidiary, but even then the court would not grant a declaratory judgment enforcing the state CPOM laws, holding that private individuals could not enforce the Texas Medical Practice Act. The court did leave open the possibility that physicians could file suit to nullify their contracts with a lay-owned corporation, as such contracts may violate state CPOM laws.
AAEM then appealed to the Texas Supreme Court, which refused to hear the appeal. As a result, neither the Academy nor the plaintiff physicians ever got the chance to argue the merits of their case before a judge or jury, and no judgment on the merits of AAEM’s corporate practice of medicine claim was rendered. AAEM still believes it could win in court on the issue of the corporate practice of emergency medicine in Texas.
Read more from EM News.
Due Process / Whisteblower Case
Dr. Genova versus Banner Health
In January of 2010, emergency physician Dr. Ronald Genova contacted the hospital administrator on-call, the hospital CEO, requesting to implement a “Code Purple” to divert patients to other hospitals, because he believed the ED at North Colorado Medical Center could no longer provide appropriate and timely screening to patients due to excessive crowding. According to the facts alleged in Dr. Genova’s lawsuit, a patient with a GI bleed had already collapsed in the waiting room bathroom while awaiting evaluation and two heart attack patients had just presented to the ED. According to Dr. Genova, the hospital CEO refused the request. Two weeks later, in apparent retaliation, Dr. Genova was removed from ED duties.
Dr. Genova filed a lawsuit noting that his removal from the schedule violated EMTALA whistle-blower protections and the covenant of good faith and fair dealing implied in contracts by Colorado law. The federal District Court dismissed Dr. Genova’s suit, citing that Dr. Genova signed away his right to sue the hospital when his group contracted to provide physician coverage of the ED. Dr. Genova then asked for AAEM’s assistance. In November of 2012, Dr. Genova appealed, and AAEM filed an amicus curiae brief asking the appellate court to overturn the dismissal and have the allegations in the complaint adjudicated on its merits. AAEM argued that the District Court imposed too narrow a reading of EMTALA’s whistle-blower protections. AAEM also argued that a hospital should not be allowed to insist on a waiver of the covenant of good faith and fair dealing, as that implied covenant serves not only to protect the physician but also patients. While the 10th Circuit Court of Appeals favorably discussed the arguments made by AAEM, it ultimately upheld the dismissal. Although AAEM is disappointed with the outcome, this case demonstrates the Academy’s willingness to come to a member’s aid when their practice rights are threatened.
The AAEM amicus curiae brief can be accessed here.
Cross Subsidization, Fee Splitting, CPOM
In 2014, Tenet Health, one of the largest hospital networks in the country, put the contracts out for bid at 11 of its hospitals in California, to replace their emergency medicine, anesthesiology, and hospitalist groups. Many of these groups had served their hospitals and their communities well for decades. Such a change would be highly disruptive to the hundreds of physicians who have learned the systems and processes of their practice over time, and have developed relationships with their hospitals and medical staffs — not to mention the disruption to local nursing staffs, patients, and communities. Most of the hospitalist contracts and some of the anesthesiology contracts included a subsidy from Tenet, while most of the EM contracts generated enough revenue through collected professional fees to be entirely self-supporting and quite profitable.
Tenet solicited several large CMGs seeking a no-subsidy arrangement for all contracts. Essentially, Tenet wanted the profits from the emergency medicine contracts to cover its losses on the hospitalist and anesthesiology contracts. In addition, the emergency medicine practices will serve as a piggy bank to be raided by the CMG and the hospital. Of course, the CMG needs to show a nice profit to its investors too, which is hard to do without the anesthesiology and hospitalist subsidies. So, this also raised concern for future belt-tightening at the affected hospitals: less physician coverage, greater use of NPs and PAs, and lower pay for physicians. Federal fee-splitting laws, enacted to prevent kickbacks and abuse, prohibit the distribution of part of a physician’s professional fee to any entity, in excess of the fair market value of services provided to that physician. When part of a physician’s professional fee is being distributed to a hospital or CMG, the parties involved may be in violation of those laws. If an emergency physician’s professional fees were to go towards subsidizing other hospital-based specialists, or to pad the bottom line of a for-profit corporation, this would appear to be an extreme violation of federal fee-splitting laws. It is also important to recognize that California has some of the strongest corporate practice of medicine (CPOM) laws in the country. These laws, drafted to protect the public due to the potential for abuse when a corporation’s fiduciary duty to its shareholders is in conflict with a physician’s duty to his or her patients, prohibit non-physician, lay corporations from owning or controlling physician practices.
The leaders of several groups affected contacted AAEM and asked for our assistance. AAEM and its California chapter provided advice to the affected groups, sent letters outlining AAEM’s concerns to the relevant hospital leaders, hospital boards, and medical staffs; and engaged in discussions with Tenet Health leadership. AAEM and the affected groups organized a highly effective public relations campaign. AAEM President Dr. Mark Reiter was quoted in many media outlets, noting his concerns that Tenet Health’s proposal was bad for Tenet’s hospitals, bad for its physicians, and bad for its patients. Soon after, Tenet’s leadership informed AAEM that they were no longer considering this course of action, and that the local groups would remain.
Read the September/October 2014 President’s Message: Tenet Wants Emergency Physicians to Subsidize the Rest of the Hospital.
Read the November/December 2014 President’s Message: Tenet Health Update & Opportunities with AAEM.
Fee Splitting, Anti-Kickback, CPOM
Over the past decade, the largest hospital network in the country, Hospital Corporation of America (HCA), entered into a joint venture with EmCare/Envision, the largest CMG in the country. Under this arrangement, via the joint venture, the hospital and the CMG jointly own the emergency physician group and split the profits resultant from the emergency physician professional fees. Although CMGs have profited handsomely from emergency physician professional fees for decades, this was new territory for hospitals. In the past few years, HCA has brought most of its EDs under the joint venture, destroying dozens of independent EM groups. In return for being able to keep working in the same ED, many of these physicians are forced to take significant pay cuts and lose much of their independence and job security. Several other hospitals and CMGs have engaged in similar arrangements on a smaller scale.
Since hospitals and CMGs are typically not physician-owned corporations, having a hospital-CMG joint venture owning or controlling a physician practice may violate corporate practice of medicine laws in many states. In addition, federal fee-splitting laws, drafted to prevent kickbacks and abuse, prohibit any portion of the physician professional fee from being distributed to any entity in excess of the fair market value of any services provided. In addition, there is concern that these arrangements violate federal anti-kickback laws.
AAEM, in conjunction with a prominent law firm, has been actively investigating potentially illegal activities and hopes to enforce any prohibitions on such activity. AAEM has brought its concerns to a variety of federal and state agencies, many of which have voiced significant concerns with the legality of these arrangements and continue to investigate. AAEM has also passed a position statement noting its opposition to these joint venture arrangements and has discussed the issue with the media.
Unfortunately, we have not been successful in shutting these joint ventures down, but we will continue to be the only professional organization that is fighting for its members on this important issue.
Read the May/June 2014 President’s Message: Hospital-Contract Management Group Join Ventures: A Disturbing Trend.
AAEM Physician Group
For years, AAEM has been the strongest advocate in the house of medicine for physicians owning and controlling their own practices. Practices owned by a small subset of their physicians or entirely owned by lay corporations are much more likely to lack transparency, political equity, and financial equity. This can create conditions ripe for exploitation. AAEM has worked hard to promote equitable, democratic, physician-owned practices throughout its existence. Despite AAEM’s efforts, physician-owned practices are under significant threat. Small practices may have difficulty developing and maintaining the infrastructure needed to be successful in the new reality of health care reform, accountable care organizations, and value-based purchasing.
In 2016, the AAEM Physician Group was launched to combine the advantages of small, democratic groups of physician owners, with the economies of scale, expanded services, and clout of large groups. Likewise, the AAEM Physician Group can help minimize the time, resources, and risk to emergency physicians who want to create their own EM group, or to bring the control of their group back to the physicians actually practicing in their ED. AAEM has created a new paradigm whereby smaller EM groups could become part of a national collaborative with access to best-in-class practice management services provided at fair market value. For existing groups, we believe the addition of more professional management will help them maintain their contracts and facilitate possible expansion. Moreover, as part of AAEM, we believe affiliated groups will garner significant legal protection under the existing prohibitions on corporate practice of medicine and fee-splitting. Unlike the Memorial Hermann case mentioned above, AAEM will now have “standing” in any threat to the contract. Likewise, AAEM Physician Group can seek new, high quality ED contracts and then set up and install local, democratic groups at these sites. We developed a set of fairness principles that would be required for participating groups to meet (i.e., financial transparency, reasonable path to partnership, due process, political and financial equity) to ensure that the commitment to a fair environment would be maintained.
The AAEM Physician Group is off to an excellent start. We now have multiple EDs representing hundreds of thousands of patient visits partnering with us as part of the AAEM Physician Group. Each group maintains local ownership and control while being obligated to follow AAEM’s Fairness Principles. If your group is interested in learning more about the AAEM Physician Group, please contact its CMO, Dr. Robert McNamara at email@example.com
Read the September/October 2015 President’s Message: The AAEM Physician Group at: http://www.aaem.org/UserFiles/file/CS_SepOct2015_ President.pdf
As you can see, the Academy has been extremely active in protecting the practice rights and livelihoods of emergency physicians, who often have nowhere else to turn for support in such matters. Many of our advocacy and legal actions have been successful and substantial, with significant benefits to the emergency physicians involved — including saving their jobs. There is still much to do, however, especially in an environment where lay-owned, corporate, contract management groups — which often have a very poor track record regarding restrictive covenants, due process, and other practice rights — control a large proportion of emergency medicine jobs. Your AAEM membership, your active support of its work, your recruitment of new Academy members, and your donations to the AAEM Foundation provide the resources the Academy needs to be a successful advocate for the practicing emergency physician.
The links below are further readings on this matter:
Emergency Medicine at Risk?
You may have heard it said that we really don’t have a health care system, rather a health care mess. I disagree. Our system is actually quite good at doing what it is designed to do. Let me explain by starting with some definitions.
Health care is the prevention, treatment, and management of illness or injury by health professionals.
Physicians deliver health care along with the advance practice providers, nurses, techs, respiratory therapists, physical therapists, etc. that we guide. Hospitals, insurance companies, pharmaceutical companies, pharmacies don’t deliver health care. They may be part of a system within which health care is delivered but they don’t deliver health care. What should their role be? Let’s look at another definition.
According to the Business Dictionary a system is an organized, purposeful structure that consists of interrelated and interdependent elements (components, entities, factors, members, parts etc.). These elements continually influence one another (directly or indirectly) to maintain their activity and the existence of the system, in order to achieve the goal of the system.
If you think of the various entities in our “system” — pharmaceutical companies, hospitals, insurance companies, medical device manufacturers, contract management groups, pharmacies, and a host of others — they are certainly interrelated and continually influence on another to maintain their activity. They just have the wrong goal. Their goal is to make money and as evidence by the fact that we spend around 18% of our GDP on the delivery of health care they are very good at it. The goal should be to support the delivery of health care. Everything these entities do should foster and facilitate the physician-patient relationship. We all know from our various experiences that our system does not support but rather uses and in some cases corrupts the physician-patient relationship. That corruption is the root cause of much of the burnout we observe in our practices, in my opinion. But I digress.
Change is going to happen because the economists and other “experts” believe that the spending is not sustainable. They are probably right but it is a by-product of our system so efforts to control the spending must necessarily change the system. This will be a monumental task simply because there is so much money involved and no one will voluntarily give that up. Those with the best lobbyist have their turf protected. Physicians are very bad about organizing and devoting their time and money to protect their turf, believing the sanctity of the patient physician relationship will protect them. I may be cynical but I think that belief is naive.
I think this poses a very real threat to emergency medicine. It is widely believed that the care delivered in the emergency department is too costly. Efforts to show that it is only a small part of the overall health care spend are important but I believe will not be enough to protect our turf. Strides to defend the prudent layperson standard and prevent post treatment denials of payments such as Anthem has announced, are crucial. I am not sure they will be enough. I believe that someone will figure out how to keep the patients that “don’t need to be there” out of the emergency department. I am not talking about the patients that we can all agree that don’t need to be there — they probably don’t even need a doctor. I think the big challenge is those patients that we see every day that don’t need to be there but we don’t know this until after we see them. Pay attention during your next shift. How many patients can you determine after one or two minutes don’t need to be there? I know that the professional fees are not the problem. The facility fees are typically 5-10 times the professional fees. The hospitals are not going to bring those in line. Anthem and United recognize this and that is why they are retrospectively denying payments.
With challenges comes opportunity. Emergency medicine is a unique specialty we are defined by a patient population (those that present to an emergency department) and not, like most other specialties, defined by an organ system or disease process. We still may be defined by a patient population but within the house of medicine our role has evolved. We are now the specialty that treats almost all patients with undifferentiated acute illness. We are the specialty that puts the puzzle together and makes the diagnosis. Our skill set is crucial. Is it necessarily tied to hospital based emergency departments? Sure, we need some tools to do our job but the decreasing cost of tools no longer necessitates them being in hospitals. The growth of freestanding emergency centers (FSEC) in many areas of the country was fueled by this recognition and may be part of the solution. However, the “cost” of the FSECs are not much less than the hospitals. Urgent care centers largely lack the expertise and equipment to make a big impact.
Emergency medicine needs to understand that change is coming and that it is a particular threat to our specialty. But also recognize that our expertise is crucial and put forth “out of the box” solutions before the “system” defines our role going forward. Our “system” is very good at what it does — make money. If we don’t define the solutions we run the risk of being left out of the money.