15 minute read
COMMON SENSE
VOICE OF THE AMERICAN ACADEMY OF EMERGENCY MEDICINE VOLUME 27, ISSUE 2 MARCH/APRIL 2020
Does AAEM Advocacy Resonate with Residents? Page 23
President’s Message: It’s Enough...
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From the Editor’s Desk: A Thick Skin 6 11 2020 AAEM Board of Directors Election Candidate Statements
Young Physicians Section:
43 Tips for Advancing Your Practice in the New Year
AAEM/RSA Editor: Own Your Worth
>> Leaders are made, they are not born. They are made by hard effort, which is the price which all of us must pay to achieve any goal that is worthwhile.” – Vince Lombardi We are living in these times Where the evil one has come to rob us blind, oh yeah yeah yeah Oh people, we must understand That it’s time to wake up and do what we can, oh yeah yeah yeah it’s enough. – Lenny Kravitz A s, I write my last president’s message, I have been reflecting on the last 27 months. Thank you for the amazing opportunity you gave me to earn your trust and support. My last president’s message will be a call to action. Our specialty is under attack from every possible angle… insurance companies, the threat of advanced practice provider (APP) independent practices, CMGs controlling our practice, congress “fixing” the balanced billing issue, etc. As a specialty, we need for all emergency physicians to get involved. I often hear: “Why should I join an AAEM committee?” “Why should I write and visit my congressional representative?” “Why should I encourage others to join AAEM and get involved?” “Why should I donate to the AAEM PAC?” “I am content, I am happy where I am!” This is the “laissez-faire” attitude that got us where we are at today! Laissez-faire is a French noun meaning “attitude of letting things take their own course, without interfering” We allowed others to make decisions for us, we allowed others to be at the table making decisions for us—not just emergency physicians, but all physicians. In one of my past presidential messages I wrote: “When people are passionate about something, it drives them to become engaged, to learn, to educate, and to want everyone else to listen too. However, most often the reality is that we are “too busy” or have “no time” to take up just another concern in our already busy personal and professional lives. I am deeply passionate about the work AAEM is taking on and my wish is for all of our members to be passionate as well.” But today, it is not an option anymore to just be passionate, it is time to wake up! Time to set aside time for your future! For our patients! This issue was brought home to me last month as I was honored to be the Doctor of the Day in Tallahassee. This happened to be the day when the Florida legislature was considering the issue of granting APPs in Florida independent practice rights. Is it in our patients’ best interest to allow pharmacists and others to prescribe antibiotics? Physicians debate and complain to each other in-person and on social media, but I was the only emergency physician in Tallahassee that spoke to the legislature on this issue on that day. However, many APPs were present and spoke. We need more emergency physicians to be willing to inform legislators on the dangers to the public of allowing such independent practice. It is time to take action. Posting complaints on social media is not effective if that is the only action that we take. People post and repost, giving them a sense of accomplishment. But this is far from enough. Social media is a great platform to get an idea started but unless there is action behind the words, nothing tangible is accomplished. Take, for instance, the Arab Spring — a series of protests that spread across the Islamic world in 2010 in response to an oppressive regime, anti-government for democracy, freedom of election, human rights, economic freedom, to name a few. People used social media to voice their opinion and to show the rest of the world what was happening via social media. But, there would not have been an Arab Spring if people did not also take to the streets, and strike in hope of affecting change. I am not calling for a revolution, but I am calling Today, I will make sure that I renewed my membership. Today, I will encourage my colleagues to join AAEM. Today, I am giving a shift a year to the Political Action Committee. Today, I will get involved and join a committee. Today is the day that I will contact my representative. Today is the day that I will take action. Let your words be followed by actions that help bring about change. My last president’s message will be a call to action.
>> medical staff bylaws, weekend call, or the other myriads of aggravations which can be thrown at a physician who is on their third spouse and facing huge college tuition bills or whatever malfunction is derailing their life. The tired emergency physician seems to them to be a perfect target for their misguided rage. In these instances, having a “thick skin” is
useful if you avoid internalizing this unjustified and misdirected anger. Taking those same negative feelings into your wellness bucket will eventually cause a leak. This of course is easier said than done and does not excuse the physician at the other end of the phone for their behavior. Individuals are responsible for their behavior and we need to do what we reasonably can do to correct this negative and wellness-killing behavior. Whether religious or not, the wisdom of the Serenity Prayer is something to consider. “Grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.” – Reinhold Niebuhr AMERICAN THEOLOGIAN A n essential skill for the wellness of any emergency physician is the ability to cordially and professionally interact with the doctors in person or on the other end of the phone whom we contact for admissions, consults, and follow-up. This skill is difficult to teach, but is essential for success from both a professional standing and wellness point-of-view. Each hospital staff has difficult and sometimes nasty consultants. Sadly, this is part of the terrain of emergency medicine and each of us needs to develop a path and strategy to be able to interact with the most difficult of consultants. Like almost all emergency physicians, I enjoy reading Dr. Ed Leap’s column in Emergency Medicine News. I personally think he is able to most closely articulate the trials and tribulations of the average “pit doc” in an entertaining way so that important issues can be reflected upon while still maintaining some humor. His November column, “The 26-Year Intern,” speaks to the issue of our professional interactions with our consultants in his usual insightful and humorous way, and I encourage you to read or reread it and think about what he is saying. Each of us can immediately identify with all of the scenarios he relates in his column. Your own response to each of these scenarios is tempered by the individuals involved and where you are in your emergency medicine career and your own level of wellness. Personally, I am close to thirty years into my emergency medicine career, but can still easily relate to his 26-year intern idea when I speak to some fellow or new attending on the phone who does not know me and feels entitled to treat me like an intern. We all know attendings who seem to obtain pleasure by torturing the poor ER doc on the phone. What is one to do? Your ability to prevent negative feelings after one of these painful encounters will play a significant role in your ability to have a successful career and is a useful marker for your longevity in emergency medicine. How should we deal with these sometimes unpleasant, and at times demeaning, interactions? The title of this article reveals many emergency physicians’ main coping mechanism in this regard. A thick skin is a very useful tool. We all realize that many of our consultant’s angry or condescending statements really have nothing to do with us. These doctors are often just inappropriately directing their angry at us as a coping mechanism for their own frustration with what is going on in their own career or personal life. Maybe their dog died or simply the fact that they are a tired middleaged surgeon with five elective cases in the morning having to come in at 3:00am
for a less than pleasant case is simply overwhelming them. Their sleep deprived fog when you wake them up leads them to say things that are inappropriate and simply stupid. We did not ask the uninsured chronic pain patient to present to the ER at 2:00am. We are not responsible for EMTALA, YOUR ABILITY TO PREVENT NEGATIVE FEELINGS
ABILITY TO HAVE A SUCCESSFUL CAREER AND IS A USEFUL MARKER FOR YOUR LONGEVITY IN EMERGENCY MEDICINE. BECOMING FRIENDLY WITH THEM CAN LEAD TO MUTUAL RESPECT AND AN INCREASED WILLINGNESS ON THEIR PART TO HELP YOU IN
THE EMERGENCY DEPARTMENT WHEN YOU NEED IT.
Now that 2020 is off to a running start, it is time to set yourself up for success. While the winter months can be grueling, taking the time now to improve your practice and develop good habits will pay off for the rest of the year, and years to come. Better than joining a new gym that you’ll stop going to by the time summer rolls around, here are three ways to optimize your practice that will translate into a successful career and strong personal health.
Mentorship
Mentorship is an important part of career development and is significant in all stages of your career. Both the mentor and mentee gain from the relationship in different ways. 1 Take the time now to find a mentor, and if you do have one, set goals and expectations for the year to come.
Don’t know where to start? A mentor may be a more senior physician in your department, but can also be from a different specialty or from an entirely different field. The goal is to gain alternate views, expose yourself to different opportunities, and help you develop skills and knowledge to advance your career. You can seek career guidance from your mentor, ask for help with professional development or personal and professional problem-solving, as well as utilize your mentor for support and advice. This isn’t just a placebo either; research shows that those that are part of a mentor/mentee relationship have more career satisfaction and productivity than those without one. Beneficial mentorship is an active process for both participants and it will be an investment of time and effort, but ultimately everyone involved will reap the benefits.
Education The medical field is constantly evolving. With our wide scope of practice, it is vital that we continue to learn and stay up-to-date as the literature changes and our knowledge of disease processes expands. After residency, without dedicated conference time or education time in your schedule, it can be difficult to find opportunities to read between shifts, family time, and other activities. One solution is to utilize the free open access movement (FOAM), which has expanded the resources at our fingertips with high quality blogs and podcasts free to all. There are many resources available, so it is important to choose one that meets your educational needs and works with your study habits. 2 Here are some highquality options to make sure you are accessing the best content.
For those with especially hectic schedules, there are tons of great podcasts each featuring a variety of topics that can be listened to on the go or to enjoy during some down time. An easy trick is to keep your podcasts together with a podcast app that automatically downloads new episodes and keeps them organized in one central location. Also, stay current on the latest journal articles with apps such as QxMD that can give you access to journal articles that are specialty specific or subscribe to blogs that curate content for you and often they will send it straight to your inbox. Develop a system for lifelong learning and with the help of FOAM, you can find the resources that work for your learning style and educational needs.
Wellness
Nearly half of all physicians report burnout, with emergency physicians reporting higher levels of burnout compared to other specialties. 3 As emergency physicians, we often have high workloads, stressful work environments, and irregular sleep schedules – all while juggling personal responsibilities. Burnout affects everyone differently and at different times, but personal wellness should be on every physician’s mind. Burnout is defined as a syndrome characterized by high emotional exhaustion, depersonalization, and a low sense of personal accomplishments. 4 Burnout not only has personal consequences for the physician, but it can adversely affect quality of care with studies showing increased risk for patient safety incidents, reduced patient satisfaction, and poorer communication between patients and physicians.
While many different aspects of the health environment (health culture, health organizations, etc.) need to work together to develop integrated ways to prevent and reduce burnout, there are ways YOU can implement wellness measures in your life. Studies have found that resiliency, coping strategies, as well as, strong social support can be protective against burnout. Start 2020 by developing a work-life balance by scheduling regular physical activity and leisure hobbies into your daily routine.
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Human Trafficking: Identification and Treatment Tools for the Emergency Physician Maryam Hockley, MD MPH; Erin Hartnett, BS BA; and Gregory Jasani, MD
Human trafficking (HT) affects over 21 million people worldwide¹, with 600,000-800,000 persons being trafficked annually across international borders, approximately half of whom are younger than 18 years old.² Closer to home, roughly 18,000-20,000 trafficking victims are brought into the United States every year, and this number does not count victims already within our borders.³ Its victims are not confined to a certain age, race, gender, sexual orientation, or socioeconomic level, and it is this level of pervasiveness that makes signs of HT difficult to identify. Vulnerable populations include those in the child welfare and juvenile justice systems, runaway and homeless youth, unaccompanied children, American Indians/Alaska Natives, migrant laborers including undocumented workers and temporary workers on visas, foreign national domestic workers in diplomatic homes, those with limited English proficiency and low literacy, disabled peoples, LGBTI, and those in court-ordered substance use programs. 4 The International Labor Office estimates that 44% of all HT victims worldwide had migrated either within or across international borders prior to being put into forced labor.¹ The nature of human trafficking often leads to both physical and emotional harm for the victims, as it relies upon the coercion of a person into such an exploited role. As a result, an article by emDocs estimates that as many as 88% of victims will seek medical care during the time that they are being trafficked, oftentimes in an emergency department. However, their studies have also shown that as few as 5% of emergency medicine providers feel comfortable identifying and treating victims of HT. 5 This unique encounter, however, offers emergency medicine physicians an invaluable opportunity to intervene
in these victims’ lives. Improving this statistic represents a crucial opportunity to increase awareness and understanding of the potential role we can play in these patients’ lives.
As one of the primary contact persons for their health care, it is vitally important for emergency medicine physicians to identify those at a high risk for trafficking and understand the appropriate steps to take to intervene. Physicians Against the Trafficking of Humans (PATH), an organization within the American Medical Women’s Association (AMWA), offers a structured approach to identifying and caring for victims of trafficking called Stand Up to Sex Trafficking: Awareness, Implementation, and Networking (SUSTAIN). 6 From this training, we learn that the first step is to pick up on subtle cues victims may give. Red flags during the history taking can include: high numbers of sexual partners, multiple sexually transmitted infections, prior abuse or self-harm, homelessness, or repeated ER visits with lack of follow-up. Physical exam findings can include: tattoos such as barcodes or other symbols of one’s ownership, scars, gynecologic injuries that seem out of proportion for age or medical history, and lack of prenatal care.² When in the room with your patient, be aware of their social history, including an unclear living situation as well as those that are in the room at the time of the encounter. Never assume an elder is their parent. Ask how they are related to the patient, and if a clear answer is not given, be on alert. Always ask everyone besides the patient to step out so you can speak to your patient privately. This can be a difficult part of the overall encounter, as this individual may insist on staying. Remind yourself that you are the physician and you can control the situation and realize that the patient should not be asked if they
would like this person to stay as they will likely say yes out of fear of retribution. Once in a private setting, it is paramount to this conversation to allow the patient to feel like they have control and that their hospital room is a non-judgmental space. Questions to ask at this stage would be where they live and if they feel safe, and do they work and sleep in the same place. Administering a domestic violence screen would be appropriate, as well as asking outright if they have ever been forced to have sex in return for necessities for living. A crucial aspect to this very sensitive conversation is giving them the space to share as much or as little as they wish, and that includes asking probing questions like “Do you feel up to telling me what happened?” or “It would be helpful to us if you are willing to tell us what happened, but it is up to you and we understand if it is too difficult to talk about it,” as these statements shift the control back to the patient and reaffirms their autonomy.
