July/August2021 Common Sense by American Academy of Emergency Medicine

COMMON SENSE VOICE OF THE AMERICAN ACADEMY OF EMERGENCY MEDICINE VOLUME 28, ISSUE 4 JULY/AUGUST 2021

AAEM21 – The First In-Person Post-Pandemic and Hybrid Emergency Medicine Conference Page 5

President’s Message:

The State of the Academy: It’s GREAT

From the Editor’s Desk:

The New Threat

Diversity, Equity, and Inclusion:

Diversity as a Vehicle for Excellence: Perspectives on a More Inclusive Recruitment Process in Emergency Medicine

Young Physicians:

Fake It ‘Til You Make It?: Recognizing and Combating Imposter Syndrome

AAEM/RSA President’s Message

An Open Letter to the Specialty of Emergency Medicine

Table of Contents TM

Officers President Lisa A. Moreno, MD MS MSCR FIFEM President-Elect Jonathan S. Jones, MD Secretary-Treasurer Robert Frolichstein, MD Immediate Past President David A. Farcy, MD FCCM Past Presidents Council Representative William T. Durkin Jr., MD MBA Board of Directors Phillip Dixon, MD MPH Al O. Giwa, LLB MD MBA MBE L.E. Gomez, MD MBA Robert P. Lam, MD Bruce Lo, MD MBA RDMS Terrence Mulligan, DO MPH Vicki Norton, MD Carol Pak-Teng, MD YPS Director Fred E. Kency, JR., MD AAEM/RSA President Lauren Lamparter, MD Editor, JEM Ex-Officio Board Member Stephen R. Hayden, MD Editor, Common Sense Ex-Officio Board Member Andy Mayer, MD Executive Director Missy Zagroba, CAE Executive Director Emeritus Kay Whalen, MBA CAE

COMMONSENSE

Regular Features President’s Message: The State of the Academy: It’s GREAT...................................................................................3 From the Editor’s Desk: The New Threat..................................................................................................................11 Legislators in the News: An Interview with Representative Mark Green, MD...........................................................14 Foundation Donations...............................................................................................................................................17 PAC Donations.........................................................................................................................................................17 LEAD-EM Donations................................................................................................................................................18 Upcoming Conferences ...........................................................................................................................................18 AAEM Chapter Division Updates: Medicine and Politics...........................................................................................40 AAEM Chapter Division Updates: Tennessee...........................................................................................................42 AAEM/RSA President: An Open Letter to the Specialty of Emergency Medicine.....................................................47 AAEM/RSA Editor: A Reflection on Residency.........................................................................................................51 Resident Journal Review: Adjunctive Therapies in Septic Shock, Part 2: Steroids...................................................53 Medical Student Council Chair’s Message: Medical School Reflections through a #MedTwitter Lens......................56 Board of Directors Meeting Summary: June.............................................................................................................57 Job Bank...................................................................................................................................................................59

Special Articles The Rise and Fall of Medicine..................................................................................................................................24 Social EM & Population Health: Training Future Leaders: Social Emergency Medicine Fellowships........................26 Diversity, Equity, and Inclusion: Diversity as a Vehicle for Excellence: Perspectives on a More Inclusive Recruitment Process in Emergency Medicine...................................................................................................29 Operations Management: Why You Should Do a Fellowship in Administration.........................................................31 Wellness: Verbal Abuse............................................................................................................................................33 Emergency Ultrasound: Ultrasound as My Antidote.................................................................................................37 Women in EM: How to Increase Your Effectiveness in Committee Representation and Leadership.........................38 Young Physicians: Fake It ‘Til You Make It?: Recognizing and Combating Imposter Syndrome...............................43 Young Physicians: Starting Strong: Essential Steps to Making the Right First Impression at Your New Job............45 The Value of Reflection during Residency................................................................................................................50

Updates and Announcements AAEM21 – The First In-Person Post-Pandemic and Hybrid Emergency Medicine Conference...................................6 Meet Your 2021-2022 AAEM Board of Directors......................................................................................................10 The New AAEM Physician Group.............................................................................................................................19 AAEM-LG Spring 2021 President’s Message............................................................................................................20 ABEM News.............................................................................................................................................................22 Critical Care Medicine: 2020-2021: A One Year Summary of the Critical Care Medicine Section............................35 AAEM/RSA ABEM News: Residents Guide to ABEM Certification...........................................................................48

AAEM/RSA Executive Director Madeleine Hanan, MSM Common Sense Editors Mehruba Anwar Parris, MD, Assistant Editor Ryan P. Gibney, MD, Resident Editor Cassidy Davis, Managing Editor Articles appearing in Common Sense are intended for the individual use of AAEM members. Opinions expressed are those of the authors and do not necessarily represent the official views of AAEM or AAEM/RSA. Articles may not be duplicated or distributed without the explicit permission of AAEM. Permission is granted in some instances in the interest of public education. Requests for reprints should be directed to AAEM, 555 East Wells Street, Suite 1100, Milwaukee, WI 53202, Tel: (800) 884-2236, Fax: (414) 276-3349, Email: info@aaem.org AAEM is a non-profit, professional organization. Our mailing list is private.

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Mission Statement

The American Academy of Emergency Medicine (AAEM) is the specialty society of emergency medicine. AAEM is a democratic organization committed to the following principles: 1. Every individual should have unencumbered access to quality emergency care provided by a specialist in emergency medicine. 2. The practice of emergency medicine is best conducted by a specialist in emergency medicine. 3. 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). 4. The personal and professional welfare of the individual specialist in emergency medicine is a primary concern to the AAEM. 5. The Academy supports fair and equitable practice environments necessary to allow the specialist in emergency medicine to deliver the highest quality of patient care. Such an environment includes provisions for due process and the absence of restrictive covenants. 6. The Academy supports residency programs and graduate medical education, which are essential to the continued enrichment of emergency medicine and to ensure a high quallity of care for the patients. 7. The Academy is committed to providing affordable high quality continuing medical education in emergency medicine for its members. 8. The Academy supports the establishment and recognition of emergency medicine internationally as an independent specialty and is committed to its role in the advancement of emergency medicine worldwide.

Membership Information

Fellow and Full Voting Member (FAAEM): $525* (Must be ABEM or AOBEM certified, or have recertified for 25 years or more in EM or Pediatric EM) Associate: $150 (Limited to graduates of an ACGME or AOA approved emergency medicine program within their first year out of residency) or $250 (Limited to graduates of an ACGME or AOA approved emergency medicine program more than one year out of residency) Fellow-in-Training Member: $75 (Must be graduates of an ACGME or AOA approved emergency medicine program and be enrolled in a fellowship) Emeritus Member: $250 (Please visit www.aaem.org for special eligibility criteria) International Member: $150 (Non-voting status) Resident Member: $60 (voting in AAEM/RSA elections only) Transitional Member: $60 (voting in AAEM/RSA elections only) International Resident Member: $30 (voting in AAEM/RSA elections only) Student Member: $40 (voting in AAEM/RSA elections only) International Student Member: $30 (voting in AAEM/RSA elections only) Pay dues online at www.aaem.org or send check or money order to: AAEM, 555 East Wells Street, Suite 1100, Milwaukee, WI 53202 Tel: (800) 884-2236, Fax: (414) 276-3349, Email: info@aaem.org AAEM-0621-147

The State of the Academy: It’s GREAT

AAEM NEWS PRESIDENT’S MESSAGE

Lisa A. Moreno, MD MS MSCR FAAEM FIFEM — President, AAEM

hen you read this, you will have returned, physically or virtually, from what I believe (writing this in early June) is going to be the most fantastic post-isolation reunion of emergency physicians. AAEM will have hosted the first in-person meeting in EM since March 2020. The date change was a calculated risk, consulting with virologists, immunologists, epidemiologists, and government officials on the local, state, and federal levels to assess the likelihood that June would be a safe month to hold a conference. The date change and the decision to go live resulted in a restructuring of the SA planning subcommittee and revamping by the staff of all the plans made earlier, adaptation to a hybrid model that AAEM had never previously used for a conference, and close communication with the CDC and the city of St. Louis. As regulations changed weekly, we changed our implementation plans. But this is who we are: RESILIENT, COLLABORATIVE, ADAPTIVE. These words characterize emergency physicians, and our best qualities are best exemplified by AAEM. The State of the Academy is GREAT! The committees, sections, chapter divisions, and interest groups are the lifeblood of the Academy and our main source of member engagement. You all outperformed and overachieved in the year of COVID. AAEM members did not hibernate; they produced. The Clinical Practice Committee developed two new policy statements: How Should Native Crotalid Envenomation Be Managed in the Emergency Department? and Do patients on Direct Oral Anticoagulants (DOACs) require repeat imaging and a period of observation after a head injury with an initial negative CT? The Diversity, Equity, and Inclusion Committee is hard at work to support the diversification of our membership. They developed a “Bring a Black Physician to SA” campaign,

and have sponsored a few SA events. Plenary Speaker Glenn Singleton spoke on “Courageous Conversations about Race in Emergency Medicine,” a social was held at BBs Jazz, Blues, and Soups, and a cultural tour of the Scott Joplin Historical Site was also held. DEI did a Black History Month Twitter campaign and is beginning work on a grant funded video podcast series, “Physicians of Color who Have Done Great Things.” The first physician you should know whose segment will be filmed at the end of June is Dr. Marcus Martin. The Education Committee took the lead on creating an innovative AAEM21 that

status and published a broad, comprehensive, authoritative white paper on the management of opioid use disorder in the ED. Social Media reviewed current podcast offerings and analytics and offered expertise and support to other committees creating enduring materials. They also created the AAEM Instagram account. Wellness did a Stories from the Pandemic Storytelling Live Event encompassing a global audience including storytellers from Sweden and Turkey, developed the Dr. Lorna Breen Position Statement, and the Interruptions in the ED Position Statement. Palliative Care updated their webpage with COVID-specific resources

“AAEM members did not hibernate; they produced.” upholds the standards of AAEM under difficult and stressful circumstances. They were also responsible for a rapid and complete transition of the Written Board Review Course to a virtual format, which was offered FREE to all AAEM members through Dec 31, 2021. They created and implemented a Virtual Oral Board Course to parallel what ABEM is using. Six cases and two Structured Interviews. By May 5th, they completed six, one day courses and are already started the planning for six courses in the fall. Our new Ethics Committee issued a Principles of Ethics Joint position statement with Geriatrics and Palliative Care as well as a position statement on the ethical physician. The LMS Committee did a needs assessment of our learning community in the pandemic environment and undertook a data analysis of current user practices to guide identification and development of new materials. They developed an application to streamline the new material approval and posting process. This has resulted in a collection of great online CME opportunities for AAEM members. Check them out and think about what your committee, section, chapter division, or IG can create to share with our AAEM community! Pain and Addiction moved from IG to committee

for advance care planning discussions in the ED, established a portal for sharing of pandemic narratives, and makes regular contributions to Common Sense’s Palliative Corner. An ED Observation IG is seeking members. Social EM and Population Health is applying for committee status! They have a great group of members from medical students to senior attendings, have a standing column in Common Sense, and are creating curriculum for the non-profit Foundations of Emergency Medicine on patients experiencing homelessness and patients impacted by gun violence. This curriculum will be utilized by thousands of EM residents in the U.S. and abroad. They are developing a border health research project. Among our sections: Critical Care has a new novel event called the CCMS Salon, which has the reverse structure of a journal club. Each salon covers a single topic with controversial or limited literature with the goal of practical, bedside-oriented conclusions and aids such as a sample protocol. Their goal is to stir the pot! They started a quarterly newsletter with practical practice tips, EM and intensivist perspectives, and even a light-hearted cartoon section. Their inaugural mentor/mentee group

>> COMMON SENSE JULY/AUGUST 2021

AAEM NEWS PRESIDENT’S MESSAGE

is a great success! EMS completed a survey to assess needs of members and are working out an MOU with National Association of EMS Physicians. They have a clinical practice subgroup at work on a paper addressing Ketamine use in the prehospital setting. Emergency Ultrasound developed what has become the legendary ‘Unmute Your Probe’ virtual ultrasound series. They are developing the Ultrasound Skills Verification Program. Women in EM developed mentoring pairs as well as the Poster Pearls Series- A interview CME featuring members who submitted photo competition posters, and the Virtual Mentoring Sessions for Osteopathic Medical Students, focused on assisting IMGs and osteopaths aspiring to EM careers. Young Physicians created “Where are the jobs?” a post-pandemic world webinar event, set up an Instagram account, and revamped their mentor program.

NYAAEM Research Scholarship which is dedicated to support research that combats systemic racism, prejudice, violence, and inequality against people of color within emergency medicine or within their community. This award was given to Dr. Sowmya Sanapala for her work with the Bangladesh community in the Bronx. They put on “EM for IMGs - How to Navigate the Challenges” forum. Tennessee continues to be a top advocacy chapter division, working on balance billing and contributing to the creation of the federal legislation that became law as the No Surprises Act. Members engaged Governor Bill Lee about the importance of masking and promoted it on news media. Texas will hold its first ever chapter division conference this fall with a great line up of speakers. A southeast chapter division is in the works.

“While the world was

binging on Netflix and trying to find things to do, Academy members were hard at work.”

Among our chapters divisions, California hosted the Zoom-based Golden State Symposium, a Medical Student Symposium, and they launched Quarantini, a quarterly event for socializing, discussions, and education. A new Capital Region Chapter Division was launched for members in Virginia, Maryland, and DC. Delaware Valley hosted a successful chapter division conference geared towards the area residents. Great Lakes re-started their newsletter and advocated for changing language in the Minnesota licensure application. India worked with an India-based non-profit to secure resources for the development of EM in that country. Under their all-female board, Louisiana led the defeat of PA and NP independent practice bills and did a Statewide Coordinated Residency Education Day. Lebanon led the country though the Beirut Blast and is holding a strong EM presence despite political and economic upheaval. The Mediterranean Chapter Division is working closely with AAEM leadership to put on another great MEMC in Malta this year. New York awarded the first ever

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During my first year as president, I held 71 meetings with the leaders of chapter divisions, IGs, committees and sections. From these meetings, there were 296 initiatives/ ideas generated. One hundred and two of those initiatives have been completed and 135 are in progress. We issued 21 position and policy statements and letters to government officials on issues impacting our practice environment and the safety of our patients. We gave 15 interviews to news media and made 11 residency visits. We expanded the Leadership Academy to a yearlong program attended by 89 emerging leaders who attended our full day session and two Touch Back Sessions on the Job Market Landscape and Legislation and Advocacy. A Wellness and Social Justice Touch Back will take place in October. Our Leadership Academy attendees are already assuming leadership roles in Academy committees and

sections. We hosted six virtual meetings and three Town Halls on issues urgent and critical to today’s practice of EM. We launched MyAAEM, an online platform where AAEM members can collaborate with other committee members, council members, board members, interest group members, section members, and chapter division members. AAEM continued to represent on coalitions and committees working with ABEM to continue to improve the certification and lifelong learning process, with COOMB to eliminate merit badge requirements, with three ABEM Working Groups, the Sickle Cell Coalition, the ACGME TF on Protected Time, the AMA Rules Committee, National Association of State EMS Officials, and the SAEM Guidelines Committee. Dr. Farcy continues his Critical Care in EM Podcast series, and I appeared in the DEI Shift Podcast episode on LGBTQ Health. Our journal, Journal of Emergency Medicine, has monthly educational podcasts. AAEM/RSA put out a series of podcasts, and WiEM put out the Women’s Wisdom Series. AAEM cosponsored 20 COVIDrelated webinars led by ACMT, while EUS put out the Unmute Your Probe Series and CCMS produced “COVID from the ED to the ICU: Do we have a crystal ball?,” “An Open, Expert Panel Discussion on Palliative Care in the ED and ICU in the Era of COVID,” and “Any Fluid You Can Give, I Can Give Better.” WiEM produced a webinar series and AAEM/RSA put out “Ask Me Anything.”

“We have learned that

we are resilient and strong, and we have also learned that we must care for ourselves and each other.”

While the world was binging on Netflix and trying to find things to do, Academy members were hard at work. We came home from the shifts where we treated and intubated COVID patients, put bacitracin on the open wounds left on our faces by 12 hours in an N-95 and, in isolation from our families and loved ones, created podcasts and webinars to educate and support our colleagues, lobbied legislators to

AAEM NEWS PRESIDENT’S MESSAGE

champion our specialty and our patients, cried over the deaths of the patients and colleagues we could not save, supported residents and students crushed by the shrinking job market and the isolation of the pandemic, did research and published papers on best practices, and attended hundreds of hours of zoom to teach and learn from each other, only to pick ourselves up and face another day or night shift. We have learned that we are resilient and strong, and we have also learned that we must care for ourselves and each other. In

our isolation, we found community. AND WE DID A LOT!! Thank you for being part of a very good year for AAEM. And as you read through the tremendous accomplishments of our AAEM community, take another look and find something new that interests you. We need and want your unique talents and contributions. We are excited by the prospect of another wonderful year, of welcoming new members, of engaging old members, and by all becoming wiser and stronger through the work of our community.

AAEM Antitrust Compliance Plan: As part of AAEM’s antitrust compliance plan, we invite all readers of Common Sense to report any AAEM publication or activity which may restrain trade or limit competition. You may confidentially file a report at info@aaem. org or by calling 800-884-AAEM.

AAEM21 – The First In-Person Post-Pandemic and Hybrid Emergency Medicine Conference Laura J. Bontempo, MD MEd FAAEM; Jack C. Perkins, Jr., MD FAAEM; Julie Vieth, MBChB FAAEM; and George C. Willis, MD FAAEM — Co-Chairs, Scientific Assembly Subcommittee

he 27th Annual AAEM Scientific Assembly in St. Louis was the first post-pandemic conference providing in-person and virtual attendee emergency medicine education. We had 452 registered for the in-person conference in St. Louis and 356 members registered for the virtual conference. Powerhouse plenaries included Drs. Amal Mattu (Cardiology), Al’ai Alvarez (Wellness), Ilene Claudius (Pediatric Agitation), Corey Slovis (EMS), Mimi Lu (Pediatric Updates), and Michael Winters (Resuscitation). Mr. Glenn Singleton joined us for the Diversity and Inclusion plenary. Drs. Nadeem Qureshi and Moiz Qureshi were joined by Dr. Susan Wilcox for a panel discussion on COVID-19. In our keynote presentation, Vice President of Mission at Boston Medical Center (BMC) Dr. Thea James shared the story of how BMC innovated effective new models of care through relationships and strategic

alliances with a wide range of local, state, and national organizations including community agencies, housing advocates, and other organizations to meet the full spectrum of patients’ needs. She gave an inspirational and realistic vision of achieving health equity that communities and institutions can aspire to reach. The COVID plenary panel was especially powerful. Moderated by Dr. Jack Perkins, Drs. Nadeem Qureshi and Moiz Qureshi (father/son) shared the moving and deeply personal story of Nadeem’s COVID infection and prolonged hospitalization including ECMO, alongside Moiz’s journey as a family member and emergency physician during the early days of the pandemic. Dr. Susan Wilcox shared haunting and harrowing experiences and perspectives from the COVID ICU. Another highlight of AAEM21 was the first jointly presented AAEM section talk: Five EM Docs Walk into a Shift Show, organized by Dr. Andrew Phillips. This 90-minute session was part drama and part didactic education. The audience followed Dr. Molly Estes as she navigated a terrible case from the prehospital alert through the dreaded transfer decision, drawing insight from all five AAEM sections (EMS, Emergency Ultrasound, Critical Care, Young Physicians, and Women in EM) to achieve that coveted save.

COMMON SENSE JULY/AUGUST 2021

AAEM21 Recap

A new educational format entitled Meeting of the Minds debuted this year. The inspiration of Dr. Harman Gill, this session engaged four experts in a literature review of two recent studies. “Association of Nonoperative Management Using Antibiotic Therapy vs Laparoscopic Appendectomy with Treatment Success and Disability Days in Children With Uncomplicated Appendicitis” was detailed and debated by Drs. Mimi Lu and Ilene Claudius. Then, a literature review of “Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates with Suspected or Confirmed COVID-19” was reviewed and debated by Drs. Corey Slovis and David Farcy. The ever-popular Breve Dulce tracks, led by Dr. Laura Bontempo continued to be some of the most attended sessions of AAEM21. Both seasoned and new speakers delivered a record number (42) high-yield talks covering everything from anxiety to VP shunt malfunctions.

Dr. George Willis organized engaging post conference sessions that featured the popular recurring hands-on skill training ultrasound courses with a new Skills Verification program. Special thanks to Drs. Eric Chin and Katharine Burns for organizing these courses. Resuscitation, ECG, and LLSA courses were well received. Thank you to Drs. Mike Winters, Amal Mattu, Bill Brady, Richard Shih, and Michael Silverman (respectively) for directing these courses. Attendees were also able to attend a disaster medicine familiarization course to expose attendees with an introduction to the knowledge, skills and abilities necessary to perform medical functions in support of search and rescue teams during a disaster in an austere environment. Special thanks to Drs. Alexandre Migala and Stanley and Craig Hempstead for assisting Dr. Zach Sletten of USAAEM to organize this course.

For the fourth year in a row, Dr. Mak Moayedi organized the interactive Small Group Clinic sessions, which gave attendees hands-on practice in LVAD, ultrasound guided nerve blocks, basic echo, priapism, transvenous pacer, and vertigo maneuver management.

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!

The moderators of each session provided an introduction, direction and engagement for in person and at home audience members. Special thanks go to nearly 30 members who stepped forward to lead a session.

The Open Mic Session was a great success with Dr. Cara Kanter serving as director. The winners were Joshua J. Lynch, DO FAAEM FACEP with “New York MATTERS – A Novel Approach to OUD in the ED’’ and Anne Whitehead, MD FAAEM with “The FAST Exam: You’re Doing It

The 4th Annual Airway at AAEM Storytelling session, was moderated by Dr. Matthew Zuckermann with great attendance and participation and

some heartwarming and thought provoking stories. Thank you Matthew!

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AAEM21 Recap

Wrong.” As winners of this year’s competition, Drs. Lynch and Whitehead are invited to speak at AAEM22 in Baltimore — we look forward to their talks! This year, the AAEM21 social media team engaged the global audience with educational pearls from the Scientific Assembly. The social media team encouraged attendees to follow along and join the conversation by using the hashtag #AAEM21. Attendees new to social media platforms were welcomed to visit the social media bar and learn tips and tricks for how to use social media effectively. Despite the pandemic the second Women in EM Networking Lunch participation exceeded expectations! This year the council presented three new awards for the Women in EM Section. The Joanne Williams Award was awarded to Dr. Lisa A. Moreno, the Young Leader Award was awarded to Dr. Molly K. Estes, and the Gender Diversity Award was awarded to Dr. Megan Healy. A gem of attending Scientific Assembly is the networking opportunities in the hallways, at receptions, and/or near the coffee stations during breaks. In addition, Chapter divisions and sections enjoyed an evening of sharing resources and making connections to advance the outreach in their respective areas. We were excited to welcome a number of guests that participated in the DEI Outreach Program to

attend their first AAEM Scientific Assembly. The Diversity, Equity, and Inclusion Committee organized several activities including an off-site trip to BB’s Jazz, Blues and Soups and a tour of the Scott Joplin Historic Site. We hope that you enjoyed the scientific content, the new modalities of learning and the young up-and-coming speakers 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 Baltimore, Maryland for AAEM22 – April 23-27!

Total Registered for AAEM21: • In-person: 452 • Virtual: 356

808

Total number of exhibitors: 25

Number of sponsors: 13

Number of speakers: 133

Total number of virtual session views: 6,059 Number of competition submissions: 267

Number of impressions on #AAEM21: 10.098 M Tweets about #AAEM21: 1,688 Number of AAEM21 mobile app participants: 588 Catch the Code Participants: 15

Airway at AAEM attendees: 30

Number of WiEM Networking Lunch Participants: 77

Scott Joplin Historical Site Tour Attendees: 31 DEI Reception Attendees: 54 COMMON SENSE JULY/AUGUST 2021

AAEM21 Recap AAEM21 Planning Subcommittee Co-Chairs Laura J. Bontempo, MD MEd FAAEM Jack C. Perkins Jr., MD FAAEM Julie Vieth, MBChB FAAEM George C. Willis, MD FAAEM Advisors Joelle Borhart, MD FAAEM FACEP Christopher I. Doty, MD MAAEM FAAEM Kevin C. Reed, MD FAAEM R. Gentry Wilkerson, MD FAAEM Subcommittee Members Lisa A. Moreno, MD MS MSCR FAAEM FIFEM (AAEM President) Teresa M. Ross, MD FAAEM (Education Committee Chair) David J. Carlberg, MD FAAEM (Education Vice Committee Chair) David A. Farcy, MD FAAEM FCCM (Liaison to the Board) Sara M. Bradley, DO Christopher Colbert, DO FAAEM Molly K. Estes, MD FAAEM FACEP David Fine, MD Harman S. Gill, MD FAAEM Siamak Moayedi, MD FAAEM Breve Dulce Planning Work Group Laura J. Bontempo, MD MEd FAAEM (Lead) David J. Carlberg, MD FAAEM Sarah B. Dubbs, MD FAAEM Rupal Jain, MD Patricia Panakos, MD FAAEM Kathleen M. Stephanos, MD FAAEM Matthew D. Zuckerman, MD FAAEM Competitions Work Group Cara Kanter, MD FAAEM Jessica K. Fujimoto, MD Stephen R. Hayden, MD FAAEM Mark I. Langdorf, MD MHPE FAAEM RDMS Shahram Lotfipour, MD MPH FAAEM Jack C. Perkins Jr., MD FAAEM Bob Zemple, MD FAAEM

2020 AAEM Award Winners Administrator of the Year Peter M.C. DeBlieux, MD FAAEM Amin Kazzi International Emergency Medicine Leadership Haywood Hall III, MD FIFEM David K. Wagner Award Peter G. Anderson, MD FAAEM James Keaney Award Vicki Norton, MD FAAEM Joe Lex Educator of Year Ziad N. Kazzi, MD FAAEM FACMT FAACT Master of AAEM Christopher I. Doty, MD MAAEM FAAEM 2019 Oral Board Speakers Dennis M. Allin, MD FAAEM Sudhir Baliga, MD FAAEM William Scott Boston, MD FAAEM Thomas N. Bottoni, MD Peter J. Buckley, DO Carlton E. Cash, MD MS FAAEM Frank L. Christopher, MD FAAEM Henry A. Curtis, MD FACEP FAAEM Mark W. Donnelly, MD FAAEM Marilyn R. Geninatti, MD CWSP FACC FAAEM William G Gossman, MD FAAEM Monica Johnson, MD FACEP FAAEM Michael H. LeWitt, MD MPH Edmundo Mandac, MD FAAEM Alexandre F. Migala, DO FAAEM Aaron M. Orqvist, MD FAAEM Loice Swisher, MD FAAEM Sabrina Taylor, MD FAAEM Andrej Urumov, MD FAAEM Resident of the Year Haig Aintablian, MD Robert McNamara Award Michael Epter, DO FAAEM Written Board 2019 Course Top Speaker Michael E. Silverman, MD MBA FAAEM FACEP Written Board 2020 Course Top Speaker Laura J. Bontempo, MD MEd FAAEM Young Educator of the Year Molly K. Estes, MD FAAEM FACEP

COMMON SENSE JULY/AUGUST 2021

AAEM21 Recap 2020 AAEM/RSA Award Winners

AAEM21 Competition Winners

Kevin G. Rodgers Program Director of the Year Scott Young, DO FAAEM

AAEM/RSA Breve Dulce Competition 1st Place: Kaitlin Parks, DO 2nd Place: Richard Cunningham, MD 3rd Place: Aaron Kuzel, DO

Program Coordinator of the Year Norma Franco

YPS Research Competition 1st Place: Sean Stuart, DO FAAEM 2nd Place: Faith C. Quenzer, DO 3rd Place: Levi Filler, DO FAAEM 4th Place Runner-Up: Ahmed Bendary, DO

Committee Member of the Year Gregory Jasani, MD Nahal G. Nikroo, MD Medical Student Scholarships Ayesha Ali Thomas Shank

AAEM/RSA and WestJEM Population Health Research Competition 1st Place: Joshua Tiao, MD 2nd Place: Matthew P. Czaja, MPH 3rd Place: Sofia Ruiz-Castaneda

2021 AAEM/RSA Award Winners

AAEM/JEM Resident and Student Research Competition 1st Place: Austin T. Jones, MPHTM 2nd Place: Tyler Lopachin, MD LT MC USN 3rd Place: Mack Sheraton, MD MHA 4th Place Runner-Up: Robert Waller, MD

Kevin G. Rodgers Program Director of the Year Jason C. Wagner, MD FAAEM

Open Mic Competition Joshua J. Lynch, DO FAAEM FACEP Anne Whitehead, MD FAAEM

Faculty Mentor of the Year Brian D. Barbas, MD FAAEM National Medical Student of the Year Lauren Lamparter, MD Program Coordinator of Year Jennifer Owens Regional Faculty Mentor Sally Bogoch, MD FAAEM (Northeast) Adeola Kosoko, MD FAAEM (West) Patricia D. Panakos, MD FAAEM (South) Aaron Quarles, MD MPP (Midwest)

2021 AAEM Award Winners Amin Kazzi International Emergency Medicine Leadership Sagar C. Galwankar, MD FAAEM James Keaney Award Robert P. Lam, MD FAAEM Master of AAEM Steven B. Rosenbaum, MD MAAEM FAAEM Loice A. Swisher, MD MAAEM FAAEM Andy Walker, MD MAAEM FAAEM Joe Lex Educator of Year Evie G. Marcolini, MD FAAEM FACEP FCCM Resident of the Year Resident Physicians at the American University of Beirut

Regional Medical Student of the Year Abraham Akbar (South) Kersti Bellardi (West) Christian Casteel (Midwest) Ava Omidvar (International) Bryan Redmond (Northeast) EMIG of the Year Loyola University Stritch School of Medicine (Midwest) Ochsner Clinical School (International) Committee Member of Year Alexandria (Alex) Gregory, MD Matthew Carvey Joelle Brown Medical Student Scholarship Awards Lachlan Driver Neal Fischer

Young Educator of the Year Mark A. Newberry, DO FAAEM FACEP COMMON SENSE JULY/AUGUST 2021

Meet Your 2021-2022 AAEM Board of Directors AAEM is proud to welcome the newly elected board! To contact the board of directors, email info@aaem.org.

PRESIDENT

PRESIDENT-ELECT

TREASURER

Lisa A. Moreno, MD MS MSCR FAAEM FIFEM

Jonathan S. Jones, MD FAAEM

Robert Frolichstein, MD FAAEM

IMMEDIATE PAST PRESIDENT

PAST PRESIDENTS COUNCIL REPRESENTATIVE

AT-LARGE DIRECTOR

David A. Farcy, MD FAAEM FCC

William T. Durkin, Jr., MD MBA MAAEM FAAEM

Phillip A. Dixon, MD MBA MPH FAAEM CHCQM-PHYADV

AT-LARGE DIRECTOR

Al O. Giwa, LLB MD MBA MBE FAAEM

L.E. Gomez, MD MBA FAAEM

Robert P. Lam, MD FAAEM

AT-LARGE DIRECTOR

Bruce Lo, MD MBA FAAEM RDMS

Terrence Mulligan, DO MPH FAAEM

Vicki Norton, MD FAAEM

AT-LARGE DIRECTOR

YPS DIRECTOR

AAEM/RSA PRESIDENT

Carol Pak-Teng, MD FAAEM

Fred E. Kency, Jr., MD FAAEM

Lauren Lamparter, MD

EDITOR, COMMON SENSE

EDITOR, JEM

EX-OFFICIO BOARD MEMBER Andy Mayer, MD FAAEM

EX-OFFICIO BOARD MEMBER Stephen R. Hayden, MD FAAEM

COMMON SENSE JULY/AUGUST 2021

AAEM NEWS FROM THE EDITOR’S DESK

The New Threat Andy Mayer, MD FAAEM — Editor, Common Sense

ell another Scientific Assembly has concluded in St. Louis. The very fact that it was held at all was a minor miracle with all of the uncertainties and challenges which COVID presented. The discussion and decisions which had to be made to make this meeting happen were significant, but AAEM held a hybrid in-person and virtual meeting and over 400 emergency physicians gathered in St. Louis for the conference. The speakers, as usual, were excellent and seeing old friends and colleagues in real life instead of on Zoom was very gratifying. Certainly, one felt strange standing in a room with a group of people, sitting in an audience, or shaking the hands of old friends. This was all healing and hopeful of a return to more normal times. The feeling seemed to be to try and move forward and to get past the pandemic and the fact that we all sort of lost a year or more of our lives. I doubt there were few of us who have not been personally touched by COVID with the illness of ourselves, family, friends, or colleagues. There were many COVID-related discussions and talks. One was a touching panel of three physicians describing their own personal experiences with COVID for different perspectives. One was as a critically ill patient, one related the impact of being a family member of a sick COVID patient, and the third was related to the stress of being a bedside physician. Their stories were all moving. It was good to hear these stories but it was even more fulfilling were talks about issues unrelated to COVID, and those about the challenges which our profession faces. The mood at the meeting also had a component of anger related to the newest of the serious threats to the profession of emergency medicine. The newest threat is the unprecedented and massive expansion of the number of emergency medicine residencies and residents. AAEM has long spoken out about the dangers of the corporate practice of medicine and the threat of the expansion of the numbers and scope of practice of non-physician practitioners (NPPs) but this newest challenge which must be dealt with and soon. This expansion is now the third pillar of danger to emergency medicine possibly more impactful than corporate management groups (CMGs) or NPPs. You might not think that anger is a positive feeling for a meeting environment, but I think it was in fact very healthy. Typically, when I speak to emergency physicians about the issues facing our profession, there is a sense of frustration and apathy. Anger to the point of actually doing something to positively impact our profession would be much better than sitting idly by as the wolves enter and destroy our profession. AAEM has naturally attracted the unsettled soul who is willing to raise their fist and scream, “I’m not going to take it anymore!” The percentage of politically active members in any organization is typically very low, but to me is much higher in AAEM than in other organized medicine groups. It is great to see a member who is impassioned about an issue and see them transform into an expert and leader of an effort to combat one of the issues which face us. Dr. Debbie Fletcher from Louisiana is such a person this past year and has quickly risen to prominence in the fight against the expanding practice rights of NPPs. She was our leader in the fight in Louisiana which just successfully defeated the latest bill to give expand practice rights to nurse practitioners in Louisiana. This type of emergency physician is what attracted me to the organization and has kept me involved for all of these years. Let’s face it; we cannot all be Bob McNamara but there is strength in numbers and activism. The fact is that what any organization needs are dues paying members which can be represented by the more active members. The organization needs the financial and moral support so that the organization’s message can be heard. However, we need more champions and defenders of our specialty specifically to deal with the looming workforce crisis.

The rise of new residencies is an issue which none of us can ignore. This drastic rise in the number of graduating residents could well have a profound negative effect on our specialty and lead to a drastic decrease in the quality of incoming residents. I certainly would never have predicted it. When I left residency in 1990, a residency trained emergency physician was a rare bird and I could have worked anywhere I wanted. I chose an independent democratic group as I had the ability to choose. That ability to choose has already drastically decreased over the years with the expansion of CMGs. There are many areas where they are the only game in town. The expansion of NPPs has led to fewer emergency physicians being utilized to staff America’s emergency departments and with expanding practice rights for NPPs this cost cutting reality will only worsen. One main reason NPPs were proposed to be used in emergency departments was due to the workforce “shortage” so that they could see easier cases and work in rural areas where few residency trained physicians wanted to go. It is a fallacy that many NPPs want to work alone or at night in rural emergency departments. Dr. Mark Reiter has been one of AAEM’s leaders in learning the hard facts related to the rapid expansion of emergency medicine residencies and what that might mean for all of us. His upcoming article in the Journal of Emergency Medicine is something which you must carefully read and understand. The implications of what is quickly happening must be appreciated and we need to quickly adopt the best options which are available to our profession. I also suggest you look at “The Emergency Medicine Physician Workforce: Projections for 2030” or simply web search the issue and you can quickly understand the problem. A recent YouTube video called “How Can We Save Emergency Medicine” is also worth viewing (www.youtube.com/ watch?v=rfGhX7QHZcA). The facts related to this issue are shocking and each of you needs to be well informed about it.

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AAEM NEWS FROM THE EDITOR’S DESK

Did you know that the number of emergency medicine residencies from 2012 to 2021 have increased from 153 to 276? The number of new first year residents has increased from 1,785 to 2,969. Predictions reveal that there may be an oversupply of up to 40% of new residency graduates by 2030. Imagine the future, if current predictions for 2030 are correct, and what it will mean. Think of the current idealistic and motivated but unsuspecting biology major currently in college. They will work their way through the difficult process of medical education and finish an emergency medicine residency in 2030. These young and ambitious emergency physicians will have an average of $200,000 in debt and discover that no jobs are available. If they are lucky enough to land one what terms do you think the friendly CMG who started their residency will offer them? The expected workforce surplus will lead to abysmal job security, deteriorated practice rights and no ability for any emergency physician to express any concerns or advocate for their patients. Any troublemakers will simply be shown the door and a joyful and desperate emergency physician will be glad to work for less money, worse hours and sign as many NPP charts as needed. Are future emergency physicians predestined to a life of indentured servitude after being created as a pool of cheap labor by CMGs and large hospital systems?

The truth at the newest “enemy at the gates” has been revealed by Dr. Reiter’s research and has led him to conclude that drastic and immediate action is needed to prevent this disaster. His recommendation is simple but painful. He recommends increasing residency standards by requiring a minimum of 3,600 patients at the primary training site per emergency medicine resident. This approach would increase the quality of medical education, as it would allow more clinical and procedural opportunities for each resident. This would produce a 40% reduction in the total number of new residents. It also leaves room for the rational expansion of emergency medicine residency slots as emergency department volumes increase with time. This method will allow for the supply of emergency medicine residents will meets demand. Otherwise, in ten years who would chose to enter an emergency medicine residency? Will we continue to get the best and brightest of each class or are we to be relegated to a different sort of emergency medicine resident? Will emergency medicine be the specialty for physicians who could not match in more desirable types of specialties? Who do you think would voluntarily chose to enter a specialty with such abysmal job opportunities? The AAEM Board of Directors at the Scientific Assembly has endorsed this painful but needed adjustment to the number of emergency medicine residency positions. Below is the position statement recently released by AAEM. AAEM

will certainly be criticized by CMGs and other groups who have a financial interest in producing cheap labor. All interested emergency medicine organizations need to step up and support this initiative. There is no time if we are to save the quality of future emergency medicine residents and their professional futures. Every emergency physician needs to enter this fight.

References 1. Reiter M, Wen LS, Allen BW. “The Emergency Medicine Workforce: Profile and Projections.” The Journal of Emergency Medicine, vol. 50, issue 4, April 2016, P690-693. https://doi. org/10.1016/j.jemermed.2015.09.022 2. Reiter M, Allen BW. “The Emergency Medicine Workforce: Shortage Resolving, Future Surplus Expected.” The Journal of Emergency Medicine, vol. 58, issue 2, February 2020, P198-202. https://doi.org/10.1016/j. jemermed.2020.01.004 3. Reiter M, Allen BW. “The Emergency Medicine Residency Programs - Achieving a Balanced Workforce.” Submitted for publication. Draft available upon request. 4. EM Physician Workforce of the Future; Taskforce Report Overview. ACEP.org. 5. Percentage Change in Number of First Year ACGME Residents and Fellows by Specialty—2020 and 2018 report. AAMC and American Medical Association. National GME Census in GME Track® (Aug. 13, 2020).

You can also read An Open Letter the Specialty of Emergency Medicine from the AAEM Resident and Student Association (AAEM/RSA) on page 45.

In an effort to keep our members connected, Common Sense began a column of member updates submitted by our members. We ask you to submit brief updates related to your career. We will also publish the unfortunate news of the passing of current or former members. Visit the Common Sense website to learn more and submit your updates for publication! www.aaem.org/resources/publications/common-sense

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AAEM NEWS FROM THE EDITOR’S DESK

AAEM Position Statement: Raising Emergency Medicine Residency Standards Introduction AAEM has received much feedback from our members regarding concerns that the rapid proliferation in the number of emergency medicine resident positions, and increased utilization of non-physician practitioners at emergency department training sites has negatively impacted the quality of emergency medicine resident education. .

Position Statement AAEM suggests the ACGME Emergency Medicine Residency Review Committee take action to raise emergency medicine training and quality standards by setting a minimum number of patients at the primary site emergency department per resident and setting a maximum percentage

of emergency department patients seen by non-physician practitioners (NPPs). Specifically, AAEM advocates for the implementation of a standard of one resident per 3,600 patient volume at the primary residency training site and a maximum of 25% of patients seen by NPPs. Residency programs will be able to devote more resources to each resident and faculty/resident ratios would improve. Emergency medicine residents would benefit from exposure to more emergency patients, resuscitations, and procedures, and would have increased faculty access and supervision. Expected shortages in other medical specialties can be addressed by reallocating excess emergency medicine resident positions. Revised 7/7/2021

Access Your Member Benefits Get Started! Visit the redesigned website: www.aaem.org/membership/benefits Our academic and career-based benefits range from discounts on AAEM educational meetings to free and discounted publications and other resources.

COMMON SENSE JULY/AUGUST 2021

LEGISLATORS IN THE NEWS

An Interview with Representative Mark Green, MD Lisa A. Moreno, MD MS MSCR FAAEM FIFEM — President, AAEM

elcome 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

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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

“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.”

LEGISLATORS IN THE NEWS

“You learn a lot as a lawmaker, just as you learn a lot as a physician.” Access Act, which is co-sponsored by Rep. Bennie Thompson (D-MS). (Editor’s Note: The text of both bills appears at the end of this article.) 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.

COMMON SENSE JULY/AUGUST 2021

LEGISLATORS IN THE NEWS

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.

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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.

AAEM Foundation Contributors – Thank You! Levels of recognition to those who donate to the AAEM Foundation have been established. The information below includes a list of the different levels of contributions. The Foundation would like to thank the individuals below who contributed from 1-1-2021 to 4-1-2021. AAEM established its Foundation for the purposes of (1) studying and providing education relating to the access and availability of emergency medical care and (2) defending the rights of patients to receive such care and emergency physicians to provide such care. The latter purpose may include providing financial support for litigation to further these objectives. The Foundation will limit financial support to cases involving physician practice rights and cases involving a broad public interest. Contributions to the Foundation are tax deductible.

Contributions $250-$499

Kevin Allen, MD FAAEM Kevin S. Barlotta, MD FAAEM William T. Durkin Jr., MD MBA MAAEM FAAEM Albert L. Gest, DO FAAEM Neal Handly, MD FAAEM Alison S. Hayward, MD MPH FAAEM John E. Hunt III, MD FAAEM Fred Earl Kency Jr., MD FAAEM David W. Lawhorn, MD MAAEM FAAEM Bruce E. Lohman, MD FAAEM Andrew P. Mayer, MD FAAEM Edgar McPherson, MD FAAEM Keith D. Stamler, MD FAAEM David T. Williams, DO FAAEM

Contributions $100-$249

Juan F. Acosta, DO MS FAAEM Shannon M. Alwood, MD FAAEM Justin P. Anderson, MD FAAEM Jonathan D. Apfelbaum, MD FAAEM Dusan Barisic, MD FAAEM David Baumgartner, MD MBA FAAEM

Scott Beaudoin, MD FAAEM Jon T. Beezley, DO FAAEM Richard D. Brantner, MD FAAEM Mary Jane Brown, MD FAAEM Anthony J. Callisto, MD FAAEM Steve C. Christos, DO MS FACEP FAAEM Ian Glen Ferguson, DO FAAEM Clifford J. Fields, DO FAAEM Joseph Flynn, DO FAAEM William E. Franklin, DO FAAEM Paul W. Gabriel, MD FAAEM Ugo E. Gallo, MD FAAEM Holly A. Gardner, MD FAAEM Kathryn Getzewich, MD FAAEM Shayne Gue, MD FAAEM Regina Hammock, DO FAAEM Marianne Haughey, MD FAAEM Kathleen Hayward, MD FAAEM Lance H. Hoffman, MD FAAEM Leah Houston Heath A. Jolliff, DO FAAEM David W. Kelton, MD FAAEM Brian Kenny, DO

Chaiya Laoteppitaks, MD FAAEM Jacob Lentz, MD FAAEM Scott Leuchten, DO FAAEM Carole D. Levy, MD MPH FAAEM Donald J. Linder, DO FAAEM Ann Loudermilk, MD FAAEM Karl A. Nibbelink, MD FAAEM Travis Omura, MD FAAEM Isaac Philip, MD Brian R. Potts, MD MBA FAAEM Kevin C. Reed, MD FAAEM Jeffrey A. Rey, MD FAAEM Teresa M. Ross, MD FAAEM Hemali Shah, MD FAAEM Sachin J. Shah, MD FAAEM Jonathan F. Shultz, MD FAAEM Susan Socha, DO FAAEM David R. Steinbruner, MD FAAEM Tito Suero Salvador, MD Brian J. Wieczorek, MD FAAEM Patrick G. Woods, MD FAAEM

Contributions up to $75

Robert Bassett, DO FAAEM Scott Beaudoin, MD FAAEM Monisha Bindra, FAAEM James T. Buchanan Jr., MD FAAEM David C. Crutchfield, MD FAAEM Freya Dittrich, DO FAAEM Timothy J. Durkin, DO FAAEM CAQSM Orlando J. Encarnacion, MD FAAEM Alex Kaplan, MD FAAEM Shireen Khan, MD Julie A. Littwin, DO FAAEM Seth Lotterman, MD FAAEM James Arnold Nichols, MD FAAEM Michelle C. Pesek-McCoy, MD FAAEM Allan Ricardo Preciado Tolano, MD Matt Rudy, MD FAAEM Gholamreza Sadeghipour Roodsari Charles Spencer, III, MD FAAEM James J. Suel, MD FAAEM Dean J. Williams, MD FAAEM Joanne Williams, MD MAAEM FAAEM T. Andrew Windsor, MD RDMS FAAEM

James P. Alva, MD FAAEM

AAEM PAC Contributors – Thank You! AAEM PAC is the political action committee of the American Academy of Emergency Medicine. Through AAEM PAC, the Academy is able to support legislation and effect change on behalf of its members and with consideration to their unique concerns. Our dedicated efforts will help to improve the overall quality of health care in our country and to improve the lot of all emergency physicians. All contributions are voluntary and the suggested amount of contribution is only a suggestion. The amount given by the contributor, or the refusal to give, will not benefit or disadvantage the person being solicited. Levels of recognition to those who donate to the AAEM PAC have been established. The information below includes a list of the different levels of contributions. The PAC would like to thank the individuals below who contributed from 1-1-2021 to 4-1-2021.

Contributions $500-$999

Bao L. Dang William T. Durkin Jr., MD MBA MAAEM FAAEM David A. Farcy, MD FAAEM FCCM Seth Womack, MD FAAEM

Contributions $250-$499

Joseph T. Bleier, MD FAAEM Eric W. Brader, MD FAAEM Albert L. Gest, DO FAAEM Kathryn Getzewich, MD FAAEM Alison S. Hayward, MD MPH FAAEM Jacob Lentz, MD FAAEM Bruce E. Lohman, MD FAAEM Edgar McPherson, MD FAAEM Sameer D. Mistry, MD CPE FAAEM Michael Rosselli, MD FAAEM Marianne Sacasa De Strasberg, MD FAAEM Stewart M. Wente, MD Brian J. Wieczorek, MD FAAEM David T. Williams, DO FAAEM

Contributions $100-$249 Tiffany Alima, MD FAAEM

Kevin Allen, MD FAAEM Justin P. Anderson, MD FAAEM Kevin S. Barlotta, MD FAAEM David Baumgartner, MD MBA FAAEM Scott Beaudoin, MD FAAEM Tomer Begaz, MD FAAEM Elizabeth Bockewitz, MD FAAEM Christine Coleman, MD FAAEM Benjamin P. Davis, MD FAAEM FACEP Peter M.C. DeBlieux, MD FAAEM Orlando J. Encarnacion, MD FAAEM Brandon Faza, MD MBA FAAEM FACEP Deborah M. Fernon, DO FAAEM Clifford J. Fields, DO FAAEM Paul W. Gabriel, MD FAAEM Ugo E. Gallo, MD FAAEM Brendon L. Gelford, MD FAAEM Kimberly K. Getzinger, FAAEM Felipe H. Grimaldo Jr., MD FAAEM Joseph W. Hensley, DO FAAEM Leah Houston Evan Jackson, DO, MPH Heath A. Jolliff, DO FAAEM David W. Kelton, MD FAAEM Eric S. Kenley, MD FAAEM

Shireen Khan, MD Vinicius Knabben, MD Chaiya Laoteppitaks, MD FAAEM Derek L. Marcantel, MD FAAEM Scott P. Marquis, MD FAAEM Cynthia Martinez-Capolino, MD FAAEM Andrew P. Mayer, MD FAAEM Daniel T. McDermott, DO FAAEM Travis Omura, MD FAAEM Steven Parr, DO FAAEM Michelle C. Pesek-McCoy, MD FAAEM Brian R. Potts, MD MBA FAAEM Jeffrey A. Rey, MD FAAEM Teresa M. Ross, MD FAAEM Linda Sanders, MD Sachin J. Shah, MD FAAEM Mark O. Simon, MD FAAEM Marc D. Squillante, DO FAAEM David R. Steinbruner, MD FAAEM Miguel L. Terrazas III, MD FAAEM Larisa M. Traill, MD FAAEM Kurt E. Urban, DO FAAEM Marc B. Ydenberg, MD FAAEM

Alexei Adan, MD Laura Barrera Robert Bassett, DO FAAEM Benjamin Bloom, MD Matthew R. Brewer, MD Michael A. Cecilia, DO Timothy P. Dotzler, DO Timothy J. Durkin, DO FAAEM CAQSM Jake Gold, MD Paulette Gori, MD FAAEM Ziyad Khesbak, MD Ann Loudermilk, MD FAAEM Matthew Mosko Mass, DO Michael S. Oertly, MD FAAEM Ramon J. Pabalan, MD FAAEM Gholamreza Sadeghipour Roodsari Ameer Sharifzadeh, MD Charles Spencer, III, MD FAAEM James J. Suel, MD FAAEM Natasha Trainer James Webley, MD FAAEM Scott Wiesenborn, MD FAAEM

Contributions up to $50

Sean M. Abraham, DO FAAEM

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LEAD-EM Contributors – Thank You! The AAEM Institute for Leadership, Education & Advancement in the Development of Emergency Medicine, Inc. (LEAD-EM) was established after the tragic and unexpected death of AAEM president, Dr. Kevin G. Rodgers. The Kevin G. Rodgers Fund and the Institute will LEAD-EM just like Dr. Rodgers did. The funds will support important projects such as development of leadership qualities, and clinical and operational knowledge of emergency physicians with a view toward improving and advancing the quality of medical care in emergency medicine, and public health, safety and well-being overall. LEADEM would like to thank the individuals below who contributed from 1-1-2021 to 6-15-2021.

Contributions $500-$999

David A. Farcy, MD FAAEM FCCM

Carol Pak-Teng, MD FAAEM Keith D. Stamler, MD FAAEM

Contributions $250-$499

Contributions $100-$249

Dale S. Birenbaum, MD FAAEM Blackbaud Giving Fund Eric W. Brader, MD FAAEM Daniel F. Danzl, MD MAAEM FAAEM Sarah B. Dubbs, MD FAAEM Albert L. Gest, DO FAAEM Sarah Hemming-Meyer, DO FAAEM Fred Earl Kency Jr., MD FAAEM David W. Lawhorn, MD MAAEM FAAEM Andrew P. Mayer, MD FAAEM

Sudhir Baliga, MD FAAEM David Baumgartner, MD MBA FAAEM Ugo E. Gallo, MD FAAEM Regina Hammock, DO FAAEM Alison S. Hayward, MD MPH FAAEM Kathleen Hayward, MD FAAEM Kevin T. Jordan, MD FACEP FAAEM Kailyn Kahre-Sights, MD FAAEM Christopher Kang, MD FAAEM David W. Kelton, MD FAAEM

Ann Loudermilk, MD FAAEM Gerald E. Maloney Jr., DO FAAEM David P. Mason, MD FAAEM FACEP Travis Omura, MD FAAEM Casey Brock Patrick, MD FAAEM Brian R. Potts, MD MBA FAAEM Kevin C. Reed, MD FAAEM Hemali Shah, MD FAAEM Mark O. Simon, MD FAAEM Brian J. Wieczorek, MD FAAEM Marc B. Ydenberg, MD FAAEM

Contributions up to $75

Robert W. Bankov, MD FAAEM FACEP

Robert Bassett, DO FAAEM Richard D. Brantner, MD FAAEM Benjamin P. Davis, MD FAAEM FACEP Joseph Flynn, DO FAAEM Edward T. Grove, MD FAAEM MSPH William R. Hinckley, MD CMTE FAAEM Jacob Lentz, MD FAAEM Seth Lotterman, MD FAAEM Ramon J. Pabalan, MD FAAEM Charles R. Phillips, MD Marc D. Squillante, DO FAAEM David R. Steinbruner, MD FAAEM John K. Wall, MD FAAEM George Robert Woodward, DO FAAEM

Upcoming Conferences: AAEM Directly, Jointly Provided, & Recommended AAEM is featuring the following upcoming conferences and activities for your consideration. For a complete listing of upcoming conferences and other meetings, please visit: www.aaem.org/education/aaem-recommended-conferences-and-activities.

AAEM Conferences August 24, 2021 Oral Board Review Course Virtual www.aaem.org/oral-board-review August 25, 2021 Oral Board Review Course Virtual www.aaem.org/oral-board-review September 21, 2021 Oral Board Review Course Virtual www.aaem.org/oral-board-review September 22, 2021 Oral Board Review Course Virtual www.aaem.org/oral-board-review

COMMON SENSE JULY/AUGUST 2021

10-13 November 2021 XIth Mediterranean Emergency Medicine Congress – MEMC21 St. Julian’s, Malta www.aaem.org/MEMC21 November 30, 2021 Oral Board Review Course Virtual www.aaem.org/oral-board-review December 1, 2021 Oral Board Review Course Virtual www.aaem.org/oral-board-review

Jointly Provided Re-Occurring Monthly Unmute Your Probe - Virtual Ultrasound Course Series Jointly provided by EUS-AAEM Virtual www.aaem.org/eus

September 29, 2021 AAEMLa Residents’ Day and Annual Meeting Jointly provided by AAEMLa Shreveport, LA and livestreamed locally in New Orleans and Baton Rouge www.aaem.org/aaemla October 12, 2021 TAEM Virtual Residents’ Day and Annual Meeting Virtual www.aaem.org/education/events October 25-30, 2021 Emergency Medicine Update Hot Topics Jointly provided by UC-Davis Health Maui, HI www.aaem.org/education/events

AAEM-PG REPORT

The New AAEM Physician Group Mark Reiter, MD MBA MAAEM FAAEM, AAEM-PG CEO and Robert McNamara, MD MAAEM FAAEM, AAEM-PG CMO

“AAEM Physician Group also stands ready to assist aspiring new democratic physician groups to organize themselves and pitch their services to hospital leaders.”

AEM Physician Group (AAEM-PG) seeks to improve the marketplace for emergency physicians and their patients through a national consortium of local, independent, democratic emergency physician groups that adhere to the values of AAEM. Our member groups practice in a setting based on fairness and transparency where each physician is an owner. AAEM believes physician groups comprised of local physician owners provide the highest level of care and are most invested in the long-term success of their hospital partners and community. AAEM-PG provides support to independent democratic emergency physician groups, who retain full ownership of their practices. AAEM Physician Group also stands ready to assist aspiring new democratic physician groups to organize themselves and pitch their services to hospital leaders. Since its inception several years ago, AAEM-PG has been successful in helping to start new democratic group practices and to help manage existing democratic groups. We have received a lot of great feedback and ideas from our existing groups and prospective groups over the past few years. We recently performed an extensive evaluation of AAEM-PG’s offerings and are now excited to “reboot” the new AAEM Physician Group. We will be offering groups additional choices for practice management services with different price ranges and scope of services. In addition to our initial practice management partner, PSR (now part of R1), we have several new partners that can assist with your practice management and revenue cycle management (RCM) needs. We will also be offering the opportunity to join the AAEM Physician Group with your existing practice manager and/or RCM company, for those groups that do not need additional assistance in these areas. We have revamped our fee structure to be more transparent and affordable and have unbundled AAEM-PG fees from practice management fees. Physician groups with total ED volumes of < 25k, 25-75k, and 75k+, will have annual dues of $10k, $20k, and $40k respectively (plus practice management and/or RCM fees from our partner companies, if these services are utilized).

We are launching several additional benefits. Your AAEM-PG membership now includes access to our CMO Dr. Robert McNamara and our CEO Dr. Mark Reiter. In addition, AAEM-PG members can access our new Consultation Service, to interact with many of our accomplished physician leader consultants. We can review any aspects of your group’s governance, operations, financials, strategy, clinical policies, etc. to offer suggestions for improvement and to assist your group with any needs you have identified. We can assist you with negotiating with insurers, vendors, etc. AAEM-PG also remains available to help your group navigate through any potential threats to your group and its hospital contract. We can help your group be as successful as possible while maintaining its integrity. Your AAEM-PG membership also now includes a complimentary booth at AAEM Scientific Assembly, complimentary advertisements in the AAEM Job Bank, discounted rates for locums physicians and placements through our new AAEM Locums Group, complimentary registration at our AAEM Management Conference, and complimentary registration for our AAEM Written Board Review Course. We will be offering networking opportunities for AAEM-PG members. With these new benefits and additional flexibility, we plan to significantly grow the size of the AAEM Physician Group over the next year. Please learn more about AAEM-PG at www.aaempg.com and contact us for more information.

“We can help your group be

as successful as possible while maintaining its integrity.”

COMMON SENSE JULY/AUGUST 2021

AAEM-LG Spring 2021 President’s Message

AAEM-LG REPORT

Robert Mohr, MD FAAEM, Assistant Professor of Emergency Medicine, Penn State Hershey Medical Center — President, AAEM Locum Group

ear Physicians, Hospitals, and Locum Tenens Companies:

The state of the locum tenens market is weak. There is a paucity of jobs, and reimbursement rates are low. As physicians, we don’t know if we are being treated fairly. Meanwhile locum companies and hospitals have difficulty staffing a quality physician for the rates being offered. What remains is a sentiment of mutual distrust. Enter the American Academy of Emergency Medicine Locum Group (AAEM-LG). We exist because we feel matching a physician with a job should be conducted with more dignity than a used car deal. As the AAEM-LG Board of Directors President, I know through honest transparent conversation that all parties can win. Welcome to what I hope is a referendum on how locum tenens is conducted.

“Locums can be a scary place. Negotiating the job shouldn’t be.” To Our Physicians Locum tenens is a lifestyle. From the moonlighting resident, the “pit doc” looking to supplement their income, or the full time traveling physician; locum tenens is a means to freedom and the reclamation of autonomy. Locums can be a scary place. Negotiating the job shouldn’t be. When you are entering a new marketplace it’s hard to know what your worth is or if your altruism and naivete are being exploited. AAEM Locum Group strives to make this conversation one hundred percent transparent by partnering with locum agencies that have met rigorous standards and demonstrate a commitment to integrity. This means you know not only what you are being paid, but also what the agency is billing the facility. You know what your malpractice costs are and whether or not travel and lodging are included without having to deal with nebulous contract language. We also feel that non-restrictive covenants are an important part of a good physician-agency relationship so you will never be considered “presented” by a locum agency without your express written permission that is site and offer specific. Additionally, if you want to work for a client after months of service, a prohibitive buyout clause should not get in the way. We espouse the values of the American Academy of Emergency Medicine and see experts in emergency medicine as more than just a cog in the wheel. All “providers” are not created or trained equally and we recognize the value of a physician that has put in tens of thousands of hours to attain mastery of the practice of emergency care.

To Our Clients Finding a quality physician can be daunting. It’s frustrating to sort through vaguely worded CVs and discern who is qualified and who isn’t. Furthermore, just because a doctor checks the boxes on paper doesn’t mean they are going to show up ready to move your department forward. This is why the AAEM Locum Group seeks to

COMMON SENSE JULY/AUGUST 2021

AAEM-LG Best Practices for Locums Physicians • Transparent negotiation is facilitated by clearly discussing margins with physicians. - Physicians will be privy to what they are being presented at - What the markup is for their placement - What the cost and terms of contract buyout consist of • Buyout provisions - Terms should be clearly stated - Preferentially include a “diminishing buyout” to facilitate permanent placement for longer term contracts • Physician contractors will understand what is paid for by the client, by the locums company, and what will come out of pocket. - Travel costs including hotels, airfare, car rental, mileage reimbursement, and who pays them (if they are included in markup or separate) - The cost of state license and the terms of repayment if this is included - Presence/absence of state income tax • Malpractice - Malpractice company, policy type, and/or the inclusion of tail - Markup (if any) of malpractice policy - The rating of the malpractice company providing coverage - Any requirements to participate in “Patient Compensation Funds” for liability protection and who pays them - Disclosure of Consent to Settle authority - Disclosure of who named insured party is (physician vs agency) • Clearly stated contract cancellation deadlines and guaranteed payment to the physician if contracts are cancelled within 30 days no matter the reason • Reimbursement policy in the event that a client refuses or is unable to pay

AAEM-LG REPORT

“This is why the AAEM Locum Group seeks to work with clients to ensure that qualified doctors who understand the importance of team dynamics are put forward.” • Inclusion of a due process system to resolve conflicts with patient care, administrative conflict, or personal misconduct • Delineation of liability for on-the-job injuries for independent contractor physicians. • Worker’s Comp inclusion/exclusion should be clearly stated • Assignments should be accepted by written agreement only. • Non-compete agreements shall be site specific only and for a term of 1 year or less - Global (non-site specific) non-compete agreements to nationwide groups are unethical - Non-compete agreements do not extend to other clients represented by the same locums company • Expected patient volume should be stated in writing including average patients per hour and range. • Supervision of NPPs should be clearly delineated including requirements to staff charts for patients not seen by or discussed with the physician. • Orientation shall be provided and shall be paid at the physician’s hourly rate. • Physicians will be presented to a facility only after explicit, written permission to a specific singular site. This permission must be renewed in writing every 30 days.

work with clients to ensure that qualified doctors who understand the importance of team dynamics are put forward. We strive to internally vet and maintain high quality physicians that you are proud to have in your department. When adverse outcomes occur, we want to partner with you to ensure that the patient, the physician, and the hospital’s interests are fairly represented and that process improvement and quality control occurs. We feel by disclosing margins both parties actually come out ahead since clients and physicians know and can trust that opportunities are represented fairly. You may think you are paying market standard rates only to find the locums company is recruiting below average “providers” as a result of high markups. This puts morally forward companies ahead and discourages companies that rely on exploitative practices thereby tipping the scales towards those who are conducting honest business. You get great physicians who are happy to be working for you and know what they are walking into. In order to guide both industry and our colleagues in conducting negotiations the AAEM-LG has compiled a list of best practices through which we feel the interests of both parties are fairly represented. The locum tenens market is highly variable for both clinicians and clients, but together we can mutually advance by ensuring that both parties are treated fairly and transparently. I look forward to developing this project and changing the way conversations occur in locum tenens. Very Respectfully, Robert Mohr, MD FAAEM Assistant Professor of Emergency Medicine Penn State Hershey Medical Center President, AAEM Locum Group

COMMON SENSE JULY/AUGUST 2021

ABEM NEWS

MyEMCert: Transforming Continuing Certification to Meet Today’s Emergency Physicians Where They Are

he American Board of Emergency Medicine (ABEM) launched the first three modules of MyEMCert this spring, offering a new way for emergency physicians to stay certified. Physicians have provided overwhelmingly positive responses due to MyEMCert’s convenience, flexibility, and relevance to clinical practice.

MyEMCert was created by emergency physicians, for emergency physicians. ABEM surveyed thousands of physicians and consulted many Emergency Medicine organizations to ensure MyEMCert met the needs of busy physicians. MyEMCert advances ABEM’s mission of upholding the highest standards of patient care, encouraging continuous learning, and improving medical practice, while maintaining convenience for physicians. MyEMCert meets emergency physicians where they are—allowing doctors to answer questions at a time and place of their choosing, including their own homes—instead of requiring a high-stakes exam be incorporated into their busy lives. Emergency physicians no longer need to travel to a testing center to take an exam.

The modules are open book and topic-specific, so physicians do not have to spend time memorizing facts for an exam. If physicians feel the need to prepare, they may wish to study the topic and review the resources provided by ABEM before beginning a module. Learn more about the module content on ABEM’s website (www.abem.org/public/stay-certified/ myemcert/module-content). MyEMCert integrates key clinical advances to ensure new information and practices spread throughout the specialty at a faster rate. Physicians should access the Key Advances synopses (www.abem.org/public/staycertified/myemcert/key-advances) and learning resources prior to starting a module and reference them while completing the module itself.

MyEMCert consists of eight modules that focus on real-world scenarios that emergency physicians often see in daily practice, like trauma and bleeding and thoracorespiratory conditions. The modules are designed to give immediate feedback by providing the correct answers with rationales so that physicians can learn as they go. Physicians must complete four modules every five years to stay certified.

ABEM President-Elect, Marianne Gausche-Hill, MD, shared her perspective on ABEM’s transition to MyEMCert modules. “ABEM is excited to roll out a formative assessment that provides a unique opportunity to engage emergency physicians in a format that is more relevant and flexible.” she said. “Emergency physicians face many demands, and we hope the switch to MyEMCert makes continuing certification more convenient while allowing physicians to learn and stay updated on key advances in the specialty.” ABEM encourages certified physicians to learn more and explore the key benefits of MyEMCert (www.abem.org/public/stay-certified/myemcert) as they are able, and to try it out with the free demo module available on the ABEM portal.

When Do Physcians Need to Take MyEMCert Modules?

Use the ü ABEM Reqs tool to learn when you should plan to take MyEMCert modules.

COMMON SENSE JULY/AUGUST 2021

Exciting opportunities at our growing organization • Adult and Pediatric Emergency Medicine Faculty positions • Medical Director • Vice Chair, Clinical Operations • Vice Chair, Research • Medical Student Clerkship Director

Penn State Health, Hershey PA, is expanding our health system. We offer multiple new positions for exceptional physicians eager to join our dynamic team of EM and PEM faculty treating patients at the only Level I Adult and Level I Pediatrics Trauma Center in Central Pennsylvania. What We’re Offering: • Salaries commensurate with qualifications • Sign-on Bonus • Relocation Assistance • Retirement options, Penn State University Tuition Discount, and so much more! What We’re Seeking: • Emergency Medicine trained physicians with additional training in any of the following: Toxicology, Ultrasound, Geriatric Medicine, Pediatric Emergency Medicine, Research • Completion of an accredited Residency Program. • BE/BC by ABEM or ABOEM

What the Area Offers: We welcome you to a community that emulates the values Milton Hershey instilled in a town that holds his name. Located in a safe family-friendly setting, Hershey, PA, our local neighborhoods boast a reasonable cost of living whether you prefer a more suburban setting or thriving city rich in theater, arts, and culture. Known as the home of the Hershey chocolate bar, Hershey’s community is rich in history and offers an abundant range of outdoor activities, arts, and diverse experiences. We’re conveniently located within a short distance to major cities such as Philadelphia, Pittsburgh, NYC, Baltimore, and Washington DC.

FOR MORE INFORMATION PLEASE CONTACT:

Heather Peffley, PHR FASPR at: hpeffley@pennstatehealth.psu.edu Penn State Health is committed to affirmative action, equal opportunity and the diversity of its workforce. Equal Opportunity Employer – Minorities/Women/Protected Veterans/Disabled.

AAEM NEWS

The Rise and Fall of Medicine Mark Borden, MD FAAEM

enturies ago, doctors had few useful treatments. There were a few things that a doctor could do, but mostly he understood the path of disease, could predict the outcome of a problem, and invoked friendly spirits, creatures such as leaches, and occasionally an herbal remedy to help those that suffered. A doctor could do little, but he could sometimes with accuracy say; “Get your affairs in order; you won’t see the next spring.” As time passed, science began to replace faith in healing. Leaches didn’t cost much, local herbs were available, and healing hands had the time to apply their touch and comfort. Science was a bit more expensive. Medicine, X-ray machines, and hospitals cost money. Fees went from “one chicken,” to a certain amount of money. Drug producing companies went from a covered wagon selling “remedies” to huge commercial enterprises with the most powerful political lobby in the world. As a new system arose, teams began to form. Doctors and their nurses (at first subordinate, then a separate but equal team) formed one team, and in the beginning that team, with its training and knowledge of medicine, duty, and commitment to “the patient first,” and promise to adhere to a higher ethic, was in charge. Lots of time, commitment and intense study is required to thoroughly learn pre-med science, four years of medical school, and learn to apply Internship and residency (3-8 years) the knowledge of medicine. This does not leave much time to master business. Criteria to measure medical qualifications are clear, and used often. Now that lots of money was involved, some businessmen began to “help.” Hospitals that were managed by doctors were at a disadvantage financially, since administration and finance also have a skill set. During this period, doctors and nurses outnumbered administrators, and were considered valuable. It was clear that doctors should be shielded from the financial machine. Doctors should be free to put their patients ahead of financial motivations. Clearly, doctors should not be employed, and good laws were adopted to prevent doctors from being employed by, and therefore subject to, the demands of financially motivated administrators. Every administrator needed a few secretaries, though, and there were new departments that needed to be created. New administrators were needed to manage these new departments. Soon there were more administrators, and other managerial personnel, than doctors and nurses (and other medically trained caregivers). Criteria to measure administrative qualifications are vague and not often used. A previous hospital CEO with whom I worked, for example, had no administrative training, and indeed, no college degree.

“As time passed, science began to replace faith in healing.”

Suddenly, doctors were a “nuisance.” They remembered the old days when they were considered important, and treated with respect, and they acted a little grumpy. Administrators complained that doctors were their “problem,” and stated that if doctors could be employed they would be “better able to control them.” The employment model was debated, and then tried. Sure enough, if a doctor could be terminated simply by not renewing an annual contract, that doctor was more responsive to the demands of an administrator. Some doctors objected to being told which surgeries they could perform, how many patients they needed to see each hour to “make quota,” and which drugs they could (expensive ones) and could not (less expensive though often more proven ones) prescribe, but some just enjoyed “punching the clock” and getting a paycheck without all of that billing hassle and paperwork. At first employment was unusual, then more and more common until in 2019 more doctors were employed by hospitals than independent for the first time in history. Gone are doctor’s lounges...”Why do those doctors need to lounge anyway?” In actuality, that is where doctors met, talked, collaborated, and coordinated care of their patients, while forming relationships with each other, which led to better patient care. Gone are special parking spots for doctors...”Why do those doctors need to park close anyway?” In actuality, coming in again and again all night (instead of 9:00am-5:00pm) makes having a close spot without a long icy parking lot to traverse in the dark, essential. Gone is the time required to conduct a thorough history and physical exam. “I like the doctors that just order a CT scan ($2,000.00) instead of wasting time on a physical exam ($69.00). Maybe

“The bottom line is that the quality of medical care is suffering as the big dollar business model grows and continues to feed upon itself.” 24

COMMON SENSE JULY/AUGUST 2021

AAEM NEWS

“At first employment was unusual, then more and more common until in 2019 more doctors were employed by hospitals than independent for the first time in history.”

the administrator doesn’t know that the CT delivers the equivalent of 500 X-rays worth of radiation, or maybe they just don’t know that X-rays are proven to cause cancer? The bottom line is that the quality of medical care is suffering as the big dollar business model grows and continues to feed upon itself. Will patients notice? No. Will new doctors notice? Maybe. Most doctors these days clock in and clock out without ever seeing a “doctor’s lounge.” Then an administrator had a bright thought. Why bother employing a doctor when I can get a PA or NP for half the price? It doesn’t matter to an administrator that doctors have ten times the education and training, what matters is the price! With the right incentives, a midlevel can see just as many patients per hour.

Another bright idea! Why don’t we make our own doctors? That will help cure this “doctor shortage” and we business folk know the “law of supply and demand,” right? What does the future hold? We have lost control of our destiny, and if we do not regain it, our patients will continue to pay a higher and higher price. Employees unionize. A union can bargain for better working conditions. When I was in residency, such a thought was beneath my dignity. Now it may be required. Can we enact laws preventing employment of physicians? Must we wait until the government refuses to pay for a two thousand dollar CT until the two hundred dollar ultrasound is proven to be inadequate? The only reason I can write this is that I am no longer employed by an administrator heavy group. Most of our youthful colleagues dare not speak. The “Old Guard” will need to take the lead in the actions that must follow. Or, we can just retire...and be treated for our acute MI by a brand new shiny PA., that lives far left on the Dunning Kruger curve (the all-knowing bliss of near complete ignorance)...while the EP and cardiologist cover multiple hospitals from home.

The AAEM Physician Group can help you: • Optimize the management of your emergency physician group • Protect your group from external and internal threats • Recruit the best emergency medicine specialists • Access the expertise of top emergency medicine leaders

AAEM-0321-344

It is time for a NEW ERA in emergency physician group management.

The AAEM Physician Group holds true to the values that have guided AAEM for 30 years: fairness, transparency, and empowering our emergency physicians.

Democratic, physician-owned, emergency medicine groups provide the highest level of patient care and have the strongest commitment to their hospitals and local communities. The AAEM Physician Group supports existing democratic emergency physician groups and can assist in the creation of new groups. Mark Reiter, MD MBA MAAEM FAAEM Chief Executive Officer | ceo@aaempg.com

Robert M. McNamara, MD MAAEM FAAEM Chief Medical Officer | cmo@aaempg.com

COMMON SENSE JULY/AUGUST 2021

COMMITTEE REPORT SOCIAL EM & POPULATION HEALTH

Training Future Leaders: Social Emergency Medicine Fellowships Leah Goldberg, MHS; Sara Urquhart, MA; Ryan DesCamp, MD MPH; and Victor Cisneros, MD MPH

“Social EM fellowships focus

on studying the ways that an individual’s life outside of their physiological health impacts their ED presentation and then using that knowledge to improve care.

”

ince 2008, social emergency medicine has become recognized in its own right as a niche within the field of emergency medicine (EM). One key way that social EM leaders have cultivated the evolution of their field has been through post-graduate fellowship programs to train a new generation of leaders and to facilitate research. Since the first social EM fellowship program was started by Dr. Harrison Alter at Highland Hospital in Oakland, California in 2010, many institutions have followed. In the 2021 fellowship application cycle, there are at least 10 options for senior residents interested in pursuing post-graduate training in social EM (Table). Social EM fellowships focus on studying the ways that an individual’s life outside of their physiological health impacts their ED presentation and then using that knowledge to improve care. Fellows become interested in the field for a variety of reasons and the path to social EM fellowship is flexible and varied. Some fellows became involved in community or public health prior to medical school, while others developed an interest during their training. Some residency programs such as Stanford University, Johns Hopkins University, and the University of Illinois in Chicago allow protected time for residents to receive training in social EM during their early post-graduate education, which has sparked interest in fellowship.

Dr. Victor Cisneros, a fellow at the University of California - Irvine (UCI), recalls his own interest in social EM beginning during his medical school years, even before the term was coined. As a medical student, MPH student, and later emergency medicine resident at UCI, he has studied ways the ED can screen patients for food insecurity. “By the time I was considering fellowships, I knew there were many amazing programs out there, but I had already done so much work in Orange County and I was watching my projects blossom, so I really wanted to stay to see them through. UCI at the time didn’t have an official social EM program, but I thought - why not make one?” With guidance from his mentors, Dr. Cisneros was able to create a social EM track within the Research Fellowship in Population Health at UCI. His work has involved collaborating with a non-profit organization to screen for food insecurity. “What I have been doing this past year is creating a curriculum at UCI for future fellows and further developing and expanding my research projects and methodology at UCI with food insecurity, working with our local children’s hospital, and developing Social Determinants of Health (SDOH) curriculum for medical students and residents,” he states. At UCI, a comprehensive food insecurity screening survey is given to every child that enters the pediatric ED. Individuals with a positive screen are connected with social work and/or appropriate resources to address their food insecurity. By screening every patient, this helps normalize discussions between providers and patients surrounding food insecurity and prevents the perception of singling someone out based on their appearance. This model could be adapted to address other public health interventions such as screening for housing insecurity, intimate partner violence, or substance use disorders.

“Social EM represents the specialty’s

devotion to providing high quality, accessible care to each and every individual who walks through the doors of an emergency department.”. 26

COMMON SENSE JULY/AUGUST 2021

INTEREST GROUP REPORT SOCIAL EM & POPULATION HEALTH

The fellowship programs currently available vary in length, prerequisites, and areas of focus. Some prefer applicants who have completed a PGY-4 year or gained an additional year of experience after a 3-year residency. As of now, applicants apply directly to each program. Most require a CV and letters of recommendation. Application deadlines vary and many are rolling, with the soonest being July 15th for the National Clinician Scholars Program. Many fellowships offer fellows the opportunity to obtain an additional graduate degree such as a Master’s of Public Health. Some programs are EM-specific, while others train fellows from a variety of

Dr. Cisneros emphasizes that the principles of social emergency medicine are important for all practicing doctors: “Every physician should be considering social determinants of health (SDOH),” he says. “Data shows that SDOH account for 80% of patient outcomes regarding quality of life and life expectancy, so, why wouldn’t we be considering it?” Practically, he believes physicians can incorporate SDOH into their history and physical in under 30 seconds: “When you’re doing your abdominal exam, one or two questions about whether the patient has enough food to eat at home or enough money to afford their medications can go a long way.”

>> Table. Social Emergency Medicine and Related Fellowship Programs

Institution

Program Name

Length (years)

Degree Conferred

Website

Stanford University

Social Emergency Medicine Fellowship

MPH or Masters of Health Sciences Research

emed.stanford.edu/fellowships/mph

University of California--Los Angeles

International and Domestic Health Equity and Leadership (IDHEAL)

MPH or MS in Health Policy and Management

www.idheal-ucla.org

University of California--Irvine

Research Fellowship in Population Health

MPH option

www.emergencymed.uci.edu/ Education/research_fellowship.asp

Harvard

The Commonwealth Fund Fellowship in Minority Health Policy

MPH or MPA

cff.hms.harvard.edu

St Barnabas Medical Center Bronx, New York (SUNY Affiliate)

Health Fellowship in Social Emergency Medicine

None

www.sbhny.org/EMResidency/fellowship-in-social-emergency-medicine/

University of Wisconsin--Madison

Wisconsin Population Health Service Fellowship

None

wiphfellowship.org

University of Iowa

Social Medicine Associate Scholar Program

2 years Or 1 year if related Master’s degree/ experience

MPH

medicine.uiowa.edu/emergencymedicine/education/ associate-scholar-program/ associate-scholar-program-info

University of Alabama at Birmingham

Social EM and Population Health Fellowship

1-2

MSPH or MPH

www.uab.edu/medicine/em/education/ fellowships/social-em-link

Integrative Emergency Services/ John Peter Smith Hospital (Dallas, TX)

Street Medicine Fellowship

None

ies.healthcare/careers/ street-medicine-fellowship/

University of Massachusetts

Health Equity Fellowship

MPH or MS in Clinical Investigation

www.umassmed.edu/emed/fellowship/ internationalem/

Duke UCLA UCSF University of Michigan UPenn Yale

National Clinicians Scholars Program

Master’s degree option (site dependent)

nationalcsp.org

COMMON SENSE JULY/AUGUST 2021

INTEREST GROUP REPORT SOCIAL EM & POPULATION HEALTH

“Every physician should be considering social determinants of health (SDOH),” he says. “Data shows that SDOH account for 80% of patient outcomes regarding quality of life and life expectancy, so, why wouldn’t we be considering it?”

backgrounds. For most physicians interested in pursuing social EM fellowship, it is important to be involved in research and leadership projects and to network with various programs around the country to find a good fit. For others, like Dr. Cisneros, there may be an untapped opportunity in one’s own institution. As this field grows, it holds great promise for the improvement of health care delivery to the most vulnerable members of our communities. Social EM represents the specialty’s devotion to providing high quality, accessible care to each and every individual who walks through the doors of an emergency department. Yet, it represents much more—it signifies the recognition that improving health care delivery requires devoting time, energy and resources to better understanding the systemic barriers that patients face, so that emergency physicians can implement appropriate ED-based interventions and advocate at local, national and even international platforms in the interests of their patients and communities. Do you know of a post-graduate opportunity that isn’t on this list? Please let us know. Email: info@aaem.org. Interested in joining the AAEM Social EM & Population Health Committee? Email: info@aaem.org.

Submit a Letter to the Editor What stood out to you from this issue of Common Sense? Have a question, idea, or opinion? Andy Mayer, MD FAAEM, editor of Common Sense, welcomes your comments and suggestions. Submit a letter to the editor and continue the conversation.

Submit a Letter to the Editor at:

www.aaem.org/resources/publications/common-sense/ letters-to-the-editor

COMMON SENSE JULY/AUGUST 2021

References: 1. Rippe, E., & Ledesma, K. J. (n.d.). Population Health and Social Emergency Medicine (1320051771 969526134 K. Shafer, Ed.). Retrieved April 19, 2021, from https://www.emra.org/books/fellowship-guidebook/20-population-health-and-social-emergency-medicine/ 2. The Andrew Levitt Center for Social Emergency Medicine. (n.d.). Retrieved April 25, 2021, from https://www.levittcenter.org/ 3. Fellowship Spotlights. SocialEMpact. (n.d.). Retrieved April 25, 2021 from https://www.socialempact.com/fellowship-spotlights 4. Anderson ES, Lippert S, Newberry J, Bernstein E, Alter HJ, Wang NE. Addressing Social Determinants of Health from the Emergency Department through Social Emergency Medicine. West J Emerg Med. 2016 Jul;17(4):487-9. doi: 10.5811/westjem.2016.5.30240 5. Walter LA, Schoenfeld EM, Smith CH, Shufflebarger E, Khoury C, Baldwin K, Hess J, Heimann M, Crosby C, Sontheimer SY, Gragg S, Hand D, McIlwain J, Greene C, Skains RM, Hess EP. Emergency departmentbased interventions affecting social determinants of health in the United States: A scoping review. Acad Emerg Med. 2020 Dec 24. doi: 10.1111/ acem.14201

COMMITTEE REPORT

DIVERSITY, EQUITY, AND INCLUSION

Diversity as a Vehicle for Excellence: Perspectives on a More Inclusive Recruitment Process in Emergency Medicine Vonzella A. Bryant, MD FAAEM @vonzellab96 | Al’ai Alvarez, MD FAAEM FACEP @alvarezzzy

he benefits for advancing diversity in medicine are clear,1 yet according to recent data,2 no specialty represented either the Black or LatinX populations in proportion to the overall U.S. population. According to projections,2 it will take emergency medicine (EM) as a specialty 54 years to achieve LatinX representation comparable to that of the U.S. population. For reference, OB/GYN is projected to take 35 years, Internal Medicine and Pediatrics, 61 years, and Orthopedic Surgery, 93 years.2 The time is past due for the conversation to move from celebrating why diversity is vital to designing antiracist systems that focus on a more inclusive recruitment process.

“The time is past due for the conversation to

move from celebrating why diversity is vital to designing antiracist systems that focus on a more inclusive recruitment process.”

Underrepresented in medicine (UiM) refers to groups who are underrepresented in the medical profession relative to their numbers in the medical profession. While this gap is more than just a pipeline issue,3 we must also address pathways to increase representation at every level of training and leadership positions. This effort requires deliberate work on recruitment. Implicit bias is a significant barrier in recruitment. We all have our own biases.4 Having these biases do not immediately make us racist, either. How we manage these biases and prevent them from affecting efforts on diversity, equity, and inclusion (DEI) is essential. In undergraduate medical education, bias exists in trainee evaluations and arbitrary metrics such as the USMLE tests.5 These have enormous implications for membership to the Alpha Omega Alpha Honor Society or getting highly competitive residency training and leadership opportunities.6 This leads to a strong

argument for developing a formal holistic review process that moves away from using bottleneck metrics and instead takes careful consideration on one’s distance travel to medicine, grit, and perseverance to life’s challenges, and allyship and service to our community. Developing holistic review requires having the needed challenging conversations with your team.7 This includes acknowledging everyone’s biases and focusing on the alignment of your recruitment process to your department’s mission, vision, and values. Having a shared understanding of your department’s priorities will make it easier to make the necessary changes, such as eliminating or lessening the weight on bottleneck metrics in your recruitment. This also allows you to creatively design screening rubrics and standardized interview questions that value allyship, service to the community, compassion, and all the other characteristics your organization hold in high regard.

For this to be successful, it is important to hear as many dissenting voices in your group so everyone feels heard and the screening process becomes authentic to your own organization. Once everyone has shared their perspectives, the leadership needs to develop a unified goal and be transparent about the process. Who comprises the recruitment team is also important. Representation is key. Evidence is clear the UiM representation in the leadership role affects perceptions of candidates to rank programs higher. If your group is starting with no representation, be clear about your goals, and share evidence of your group’s work to change this. On the other hand, tokenism,8 or using symbolic efforts to highlight diversity, is also detrimental to the process and is inauthentic. Moreover, it is also important to appropriately recognize efforts on recruitment. Minority tax refers to the expectation added to

>> COMMON SENSE JULY/AUGUST 2021

COMMITTEE REPORT DIVERSITY, EQUITY, AND INCLUSION

UiM colleagues to do efforts to help advance diversity, often without added remunerations.9 These roles take the focus away from efforts to advance one’s career─focusing on their academic interests, research, or expertise. The interview in itself is vulnerable to harmful practices that interfere with an inclusive recruitment process. Common pitfalls include microaggressions or the subtle, indirect expressions of prejudice,10 often while not intended to be harmful, that negatively impact the receiver. Microaggressions undervalue the receiver. An example is asking, “do you play sports?” to a Black student attending an Ivy League school, which implies the student does not deserve to being there other than for sports. Stereotype threat assumes that affirmative action facilitates recruitment of UiM faculty to simply check off a box.11 From the recruitment side, tokenism refers to hiring practices just to meet metrics. Homophily is the tendency to share similarities,12 such as talking about hobbies and activities, which may be isolating for those

“How we manage these

biases and prevent them from affecting efforts on diversity, equity, and inclusion (DEI) is essential.

”

UiM candidates. This is why “fit” is prone to bias.13 Let us move away from focusing on fit and instead focus on systematic, measurable, and meaningful qualifications. This holistic review humanizes the candidate. Along this line, create space to encourage belongingness through virtual hangouts that allow candidates to remotely experience your culture--didactics, work environment, meetings. Each of us can play our part to recognize the inequity against UiM candidates and use our role as allies to develop a system that corrects these injustices. We can start by educating

ourselves about these critical concepts. We can create space to discuss how we can then address this to create an inclusive recruitment process. Through careful and intentional efforts, we can design a fair recruitment environment that fosters equity and inclusivity. Celebrate the success of these efforts within your team. Advancing diversity is the vehicle to excellence, and you can play your part. We don’t have to wait the projected half a century to achieve this. We can start now.

“Each of us can play our

part to recognize the inequity against UiM candidates and use our role as alliesw to develop a system that corrects these injustices.

”

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COMMITTEE REPORT

OPERATIONS MANAGEMENT

Why You Should Do a Fellowship in Administration Andrea Blome, MD MBA FAAEM

hen I graduated residency, about a third of my class went into the community, a third stayed in academic practice, and another third went on to do a fellowship. Since then, the number of residency graduates pursuing fellowship positions has been rising, with 2020 showing a 5% increase compared to 2019.1 The COVID-19 pandemic may be contributing to increased interest in fellowships, as the job market for emergency medicine is facing cutbacks.2 When I was deciding on whether or not to complete a fellowship, I considered the salary offered, clinical time, scholarly productivity expectations, opportunities for moonlighting, and career goals. Ultimately, I decided to pursue a fellowship in ED administration, knowing that fellowships offer an opportunity to develop an area of interest within emergency medicine and subsequently allow for a competitive edge when applying for post-fellowship positions. And, I’m glad I did.

“During the fellowship, I was able to apply these skills practically while serving as an assistant director of clinical operations for one of our clinical sites.”

During my two years as an administrative fellow, I was exposed to wide variety of topics. Regular didactics included lectures and discussions with the fellowship directors, other faculty members, hospital administrators, and our department chair. Subjects included staffing models, utilization management, marketing, department budgeting, addressing patient grievances, coaching, management styles, and more. One session even included a mock contract negotiation between an employer and a job applicant. During the fellowship, I was able to apply these skills practically while serving as an assistant director of clinical operations for one of our clinical sites. This was an incredibly valuable experience, since I could gain leadership skills while honing my clinical skills as a new attending. While I found that, in residency, I developed the skills necessary to manage emergencies of all varieties, I had not received

“Knowing how to optimally interact with your team members really allows you to provide the best care possible.”

any training in managing people. Knowing how to optimally interact with your team members really allows you to provide the best care possible. Furthermore, understanding how different people operate allows you to effectively implement new tools and procedures to improve the clinical environment for both patients and providers. Fellowships are additionally conducive to obtaining other advanced degrees, as the clinical load is less than a full-time position. I had the opportunity to earn my Master of Business Administration (MBA) degree during my administrative fellowship. While I had never considered getting an MBA before, it’s something I’m glad I did now. As someone who had previously taken mostly science classes, an education in business and financial concepts was completely new to me, but it was also something many of my peers had no experience in, making it advantageous. In addition to emergency medicine administration, I found that an MBA can be broadly applicable to suit any career path because the skills you learn are universal. I applied business models and theories learned in each course, well beyond budgets and business statistics, to projects I worked on in the emergency department. For instance, a risk management class introduced me to the concept of ‘risk maps,’ which are used to identify and prioritize opportunities to address Exposure to financial and risk associated with an oroperational challenges during ganization or business.3 During the fellowship, our the fellowship allowed me to department leaders comexpand my mindset and better pleted our own risk map understand the emergency to pinpoint operational department, the people within it, projects to decrease risk to patients and staff.

“

and how it functions within the hospital system.”

The fellowship and MBA completely prepared me for my current position, which is to serve as a liaison between the emergency department and other services in the hospital. Exposure to financial and operational challenges during the fellowship allowed me to expand my mindset and better understand the emergency department, the people within it, and how it functions within the hospital system. I continually apply the concepts I learned to improve the coordination and quality of care provided to patients.

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COMMITTEE REPORT OPERATIONS MANAGEMENT

In summary, an administrative fellowship offers a unique experience to build your career, expand your knowledge base, and develop leadership skills. After completing the fellowship and MBA, I was able to advance my career by obtaining an administrative role right after graduation. If you aren’t already, I encourage you to consider this widely applicable opportunity after residency.

Resources:

2. Guarino, B. “Young ER doctors risk their lives on the pandemic’s front lines. But they struggle to find jobs.” Jan. 20201. The Washington Post. Available at: https://www.washingtonpost.com/health/2021/01/04/erdoctors-covid-jobs/. 3. “Conducting a Risk Assessment.” Harvard Financial Administration Risk Management and Audit Services. Available at: https://rmas.fad. harvard.edu/files/rmas/files/conducting_a_risk_assessment_guidance. pdf?m=1563824449.

1. “Press Release: NRMP Report: 2020 Appt Year Is Largest For Fellowship Matches.” 2020-2021. National Resident Matching Program. Available at: https://www.nrmp.org/nrmp-report-shows-2018-appointment-yearfellowship-matches-record-high-2-2/.

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COMMON SENSE JULY/AUGUST 2021

www.aaemlg.com (414) 276-7390 • info@aaemlg.com

“In a situation where things are usually pretty clear, straightforward, and efficient: it was just frustratingly sticky.”

COMMITTEE REPORT WELLNESS

“You said ‘some time ago,’ can you give me an estimate of when your pain started?” This unfortunately leads to the patient screaming at me about ‘how is he supposed to know when the pain started, why am I bothering him’ etc. Then he won’t even talk to me until he pulls up his call log to see when his call was to his landlord. This was 10:17am...so I try again.

Verbal Abuse Robyn Hitchcock, MD FAAEM

started yet another job at a small critical access hospital somewhere else in the northwest this past week. Most small towns are pretty proud of their local hospital. They appreciate the personalized care, and they are glad that they don’t have to drive all the way to the next town or several towns away to seek medical care. I’m learning that the dynamic at this facility is quite different. For whatever reason, the hospital seems to have a bad reputation and quite a few patients and their families walk in with a chip on their shoulder, announcing how much they dislike the place in opening remarks. Saturday was my second solo day there. I had a shadow shift on Thursday to learn the ropes and then Friday was my first day. We had a critically ill patient in need of higher-level care stuck in the emergency department for nearly 24 hours. Not only was air transport grounded, but a major winter storm closed all the highways leading to any higher care facility. I had taken care of him the night before, signed him out to the night doc, and picked him back up in the morning. Strangely, we were able to get the airport plowed and then de-iced before the roads opened. I was on the phone with the intensivist at the tertiary care facility finetuning his care before transport when I got handed an EKG from a new patient. “I have a STEMI, I’ve got to go.” I walk into the room and see a gruff looking older man with shaggy hair and a long beard. I introduce myself and ask him to tell me about his symptoms this morning. “Well, I started getting this pain some time ago. I was just sitting on the couch. So I drink some apple juice and then ate a bear claw and that didn’t help so I called my landlord who brought me here.”

“When did it become okay to treat another person like this?”

“Would it be fair to estimate perhaps 30 minutes before the call is when your pain started?” This unfortunately leads to another round of screaming. Now I’m being yelled at because he found the time of the landlord call, isn’t that what I was looking for? I remind him it’s not, because you told me you drank some apple juice and had a bear claw and I assumed that took some time. But he’s just screaming and screaming at me at this point and I’m not going to get any information out of him regarding the time. So I take my estimate and move on to my next task. “Did you take aspirin this morning?” “My pills are in the bag over there...” This is not what I asked. Knowing his medication list does not tell me if he took them this morning. When you’re taking care of a STEMI especially at a critical access place, you need to be doing several things simultaneously. Getting a history and starting initial therapy. Reviewing the rhythm strip and watching for arrhythmias. Contacting the transfer, arranging air or ground transport, discussing with cardiology who will generally activate the cath lab. This guy doesn’t seem able or willing to answer a direct question so while he’s still talking about his medicines and all the things that he’s packed in his little bag, I asked the nurse to get him some aspirin and nitroglycerin. This incites another round of yelling. He starts murmuring under his breath how I’m not listening to him, I don’t care, what kind of doctor am I etc. etc. To the point where my nurse actually pulls him up short and tells him under no uncertain terms he needs to be more respectful. I let him know, again, that he’s having a heart attack and because time is of the essence I need to initiate therapy and transfer at the same time I’m getting a history and I apologize for any perceived inattention. In a situation where things are usually pretty clear, straightforward, and efficient: it was just frustratingly sticky. But despite everything, we got him taken care of and out of there pretty quickly. My next verbal attack of the day was a mother with a sick baby. She got angry with me at the outset because I wouldn’t pay attention to her ridiculous Google diagnosis. I just couldn’t. I did let her know that her infant’s symptoms were because he was dehydrated, and it was not meningiococcus like she found on Google. But she kept shoving her phone in my face and I was just not interested. Couldn’t even pretend. Unfortunately

>> COMMON SENSE JULY/AUGUST 2021

COMMITTEE REPORT WELLNESS

we had a difficult time getting the IV and it took a while to get her kid feeling better so she was pretty snarky and rude. But hey it’s a sick baby right? Those are always tough on the parents. The third one takes the cake though. A young man comes in with Coronavirus symptoms. Some respiratory and some GI. His wife is in the room with him. I let them know that I think this is Coronavirus, I’m planning on an X-ray and giving him some medicine for nausea. If that doesn’t work we can talk about an IV. As I walk out of the room his wife starts muttering, “Oh so we’re here for an hour and we’re finally getting medicine for nausea, boy that’s something...” I can actually hear her eyes rolling.

I try to clarify. “No, I did not say that. What I said was that his X-ray is clear. I’m worried about Coronavirus so it’ll be some time before he can go back to work even if his test is negative, because of the high false negative rate.” “Well it’s not like you’re really a doctor so I’m certainly not going to ask for a doctor’s note.” No exaggeration. She said those exact words to me. I let her know that it was clear she wasn’t interested in anything I had to say, but I wrote explicit discharge instructions and they could follow them if they wished. And of course I wrote a doctor’s note for work.

“Nobody goes into medicine to be a punching bag, yet that’s what I felt like all day.” Later the nurse updates me and lets me know that the oral medicine worked and he’s keeping down fluids. Vitals remain stable and I’m getting ready to discharge them. I walk into the room to let them know I’m preparing the discharge. His wife asks me about the X-ray results. I told her I just looked at three X-rays I thought it was okay, but let me double check it so I don’t give her misinformation. She starts muttering again, “Oh sure you did the X-ray, oh yeah right you looked at it etc. etc.” I double checked the film, it was fine so I go back to the room to let them know the X-ray was clear. “So you’re saying he can go to work at 2:30. That’s what you’re saying? It’s fine for him to go to work?” I actually look behind me because I’m trying to figure out who she’s had this conversation with. Nobody is there. I look back at her and say, “Did somebody tell you it was okay for him to go to work?” “You just did. That’s what you said right, it’s fine for him to go to work: everything is fine and he can go to work at 2:30.”

When did it become okay to treat another person like this? Not only okay, but somewhat expected and acceptable apparently. And the worst part is that if I even try to defend myself or call out her rude and inappropriate behavior, I will get nailed to the wall for not bowing to the patient satisfaction score, not creating a positive customer experience, and somehow it becomes my mistake. This isn’t even wanting to be treated with respect because I’m a doctor and have more training and education and experience. This just comes down to simple human decency. Which is clearly lacking. Nobody goes into medicine to be a punching bag, yet that’s what I felt like all day. It’s disheartening. People talk about moral injury in medicine and how it contributes to escalating burnout; it’s moments like this that contribute to that. And dozens and hundreds of them over the years that just make you cynical, and feel like a robot at work. I don’t know when it became okay to verbally assault your doctor. I don’t know when defending yourself became inappropriate and expecting basic human decency or courtesy was a pie in the sky thing. I know even when I was in pre-med in the early ‘80s people were telling me, “Don’t be a doctor it’s not like it used to be.” So I think it’s been a slippery slope for a long time. I am grateful that this is not the small town that I live in. I can take pride that my ethics and belief in basic human decency still exist. If I can still believe in people, then it is okay to expect more. Courtesy and civility still belong in public discourse, The Golden rule applies to all of us.

AAEM Wellness Resources AAEM recognizes the burnout that emergency physicians can feel. Our jobs are demanding under normal conditions, and COVID has just increased that demand and feeling of burnout. The AAEM Wellness Committee works on resources and efforts to decrease burnout and increase well-being. Examples of Wellness Committee projects include: • • • •

Wellness activities at the Annual Scientific Assembly AAEM Position Statement on Interruptions in the Emergency Department Suicide Prevention and Awareness Efforts Articles in the AAEM member magazine, Common Sense

To access these wellness resources, please visit: www.aaem.org/get-involved/committees/committee-groups/wellness 34

COMMON SENSE JULY/AUGUST 2021

SECTON REPORT CRITICAL CARE MEDICINE

2020-2021: A One Year Summary of the Critical Care Medicine Section Skyler Lentz, MD FAAEM, 2021-22 Chair and Andrew W. Phillips, MD MEd FAAEM, 2021-22 Immediate Past Chair

Mentorship Program

ho, What, When, Where–Why?

As your incoming chair and immediate past chair of the Critical Care Medicine Section (CCMS), we are happy to see AAEM members’ continued interest and expanding practice in critical care medicine. The pathway to critical care training for emergency physicians has become clearer. There are over 389 emergency physicians boarded in critical care subspecialties (259 ABIM; 93 Anesthesiology Critical Care; 37 Surgical Critical Care) and many others certified in and practicing neurocritical care.1 The majority of dual trained physicians practice both emergency medicine and critical care. Finding a balanced job and gaining acceptance into the subspecialty practice of critical care medicine remains a challenge for emergency physicians after fellowship training.2 The pandemic has shown the value of all emergency physicians taking care of critically ill patients beyond the initial presentation. We understand the challenges of practicing emergency medicine and critical care both in the ICU and in the ED. Our aim is to support members practicing critical care, support those with an interest in critical care, provide quality critical care education to practicing physicians, and mentor trainees pursuing emergency medicine and critical care.

Where We Have Been This Year and Where We Are Headed In between realizing that an SpO2 of 82% is not necessarily an indication for intubation and re-litigating vitamin C and steroids as the cure for everything, the section pushed forward on huge initiatives this year.

If you are not a mentor or mentee yet, you are missing out! Whether you are a student, resident, fellow, or even a junior attending, everyone benefits from third party perspectives in their careers. This group of mentors is focused on you without any skin in the game other than your success. This year marked the first year of matching mentors and mentees, and so far it is a success. We continue to expand this program and offer the opportunity to author a Common Sense article or deliver a lecture at our annual meeting or at a virtual meeting. Our mentors can help you prepare!

“We understand the challenges of practicing emergency medicine and critical care both in the ICU and in the ED.” Speakers Exchange If only there were a place where conference planners could find critical care expert speakers and their areas of expertise, for free, to promote speakers and high-quality critical care education. Well, now there is! Attendings and fellows are invited to post their CV and areas of expertise. Find a favorite clip of yourself speaking and add it to your profile. This year we will expand our speakers and offer the exchange as a resource to local AAEM chapter divisions seeking critical care expertise.

Regular Meetings The section meetings were always open, but the date and time varied, so it was difficult to keep up. The meetings are now every first Thursday of the month at 8:00pm ET. Since the change, member involvement has increased, the section is growing and feels like a community--an important goal. The meetings are a combination of formal and informal

portions with members exchanging ideas and planning the future growth of the section. At a virtual meeting in January 2021, “Breviloquent 2021: Briefly educated, eloquently delivered” we had four members deliver excellent lectures on sedation during non-invasive ventilation, ARDS ventilator management, pCO2 gap use during resuscitation, and the use of ultrasound in evaluation for venous congestion. Contact CCMS@aaem.org for the link and password to the monthly meetings.

Salon: The Anti-Journal Club Most of us do not practice in huge centers with on-call palliative care and in-house fellows for every specialty to consult at all hours of the day, yet, that is the setting of most studies upon which our practices are based. Rather than dissecting a single article and arguing p-values vs 95% CI, we started the quarterly CCMS Salon. The Salon takes on a single, intentionally controversial and difficult topic, stirring the pot with various studies while acknowledging the limitations of being a pit doc. The goal is real solutions to real challenges. The first salon was on fluid resuscitation and the second was on palliative care in the age of COVID. This has been a fantastic way to provide education that is important and relevant to our members. Tell us what you want to discuss next!

Future Fellows A poorly kept secret is that navigating the four critical care fellowship application options for emergency physicians—a wonderful challenge to have now, compared to the challenges of achieving critical care board certification in prior years—is a significant hurdle. So, CCMSAAEM has dedicated itself to helping future fellows navigate the choices and timelines. We have members from all the different training pathways. The nuances change on an annual basis, and we change with it.

COMMON SENSE JULY/AUGUST 2021

SECTON REPORT CRITICAL CARE MEDICINE

Newsletters and Novelties CCMS published its first three editions of our newsletter this year! The newsletter keeps our members engaged and up to date. More than just updates and insights, it is a community and outlet for a little levity. The pandemic forced us to reconcile with the challenging experiences from the last year; the tears, the laughter, or both, and with that sentiment, we added a comic section to remind ourselves of the value of laughter as medicine.

“This has been a fantastic way to provide education that is important and relevant to our members. Tell us what you want to discuss next!” Continued Growth As we expand on last year’s successes, we hope that you will join our section. Add your name to our speakers exchange, sign up as a mentor or mentee, submit an article to Common Sense, deliver a lecture at one of our events, join us at our monthly meetings, share ideas and gain knowledge at our next Salon, and look out for our members delivering critical care education at the next scientific assembly.

References: 1. ABEM. Examination and Certification Statistics. Available at https://www.abem.org/public/resources/ exam-certification-statistics. Accessed Feb 20, 2021 2. Strickler SS, Choi DJ, Singer DJ, Oropello JM. Emergency physicians in critical care: where are we now?. J Am Coll Emerg Physicians Open. 2020;1(5):1062-1070. Published 2020 Jun 2. doi:10.1002/ emp2.12105

CCMS Resources Join the Critical Care Medicine Section of AAEM and benefit from the below resources.

Critical Care Speakers Exchange

This member benefit is a resource for conference organizers to recruit topquality speakers in critical care medicine. All speakers must be members of the Critical Care Medicine Section of AAEM. Join today!

Mentoring Program

In addition to the traditional mentormentee relationship, CCMS offers several opportunities for mentors and mentees to create something together. Apply today to become a mentor or mentee!

Critical Care Hacks

This video library provides quick resources for different critical care medicine topics. Watch today!

COVID-19 Resources

The CCMS Council has created and gathered resources specific to helping members during the COVID-19 pandemic. Join our listerv to connect.

Learn more: www.aaem.org/get-involved/sections/ccms/resources

COMMON SENSE JULY/AUGUST 2021

SECTON REPORT EMERGENCY ULTRASOUND

“As our health care system devolves into more of a business, here was a place where the idea of medicine as a service, and physicians as servant-leaders, still exists.”

Ultrasound as My Antidote Neha Bhatnagar, MD

I know I am far from the only emergency physician feeling the weight of this past year. I have read and heard numerous stories about the collective trauma, grief, and tragedy we have all faced in this trying time. I have my own such stories I could share. But instead, I hope to share with you a few anecdotes based on real encounters that I have tried consciously to carry with me as glimmers of hope. What follows are a few examples of how I have tried to combat the moral injury I have absorbed using the facet of my career that I am most nerdy about: Ultrasound. I know, I know, I drank the Kool-AidTM. But bear with me, these stories are not really about ultrasound. They are about people. I moved to the big city for my ultrasound fellowship in June 2020. I am grateful for so much of what I have experienced here, but moving across the country, away from my support systems, during a global pandemic has raised its fair share of challenges. For months I worked, learned, fumbled, adapted, and worked some more. I barely unpacked or settled in, I barely explored my new home due to shutdowns and quarantines, and I barely socialized with my new coworkers and friends for fear of contracting this invisible, unpredictable deadly disease. When the pandemic restrictions began to lift in the spring after mass vaccination efforts, I began to seek out other avenues to do good. I began to volunteer at a local free clinic serving the city’s Spanishspeaking population. I am no primary care physician, but having the opportunity to discuss whole-body health issues with vulnerable patients made all the difference. Once I mentioned my ultrasound training, they eagerly asked me to evaluate a few patients using my handheld device. In doing so, I helped expedite referral to surgery for two patients who needed biopsy or excision of their concerning soft tissue masses. In this space, no one cared about my metrics, no one was counting how many patients per hour I was seeing, no one was asking me to stop counseling a patient or discharge them more quickly in order to get the next patient into that room. As our health care system devolves into more of a business, here was a place where the idea of medicine as a service, and physicians as servant-leaders, still exists. There I can be the generous, attentive, thorough doctor I want to be. And it makes me smile. While on one of my weekend night shifts, I had an elderly woman present with abdominal pain and bloating. Her workup quickly revealed a perforated bowel. As I discussed her results and the surgeon’s recommendations, she acknowledged the gravity of the situation, and voiced her wishes for comfort measures only. Once her symptoms were controlled, I tenderly asked if she would allow me to obtain a few

educational ultrasound images of her pneumoperitoneum. Her smile widened as she consented and warned me that the longer I stayed in the room with her, the more she would tell me about her children. I said I would love to hear all about them. She chatted and I scanned, and for a few minutes that was all there was. When my exam was complete, I helped her get situated in her bed, and she asked that I push her blanket in further, proclaiming, “You’re only ever as cold as your feet!” I laughed, told her how true that was, and tucked her feet snugly under the blanket. I thanked her for letting me perform the scan and wished her goodnight. Two days later, I opened her chart to follow up and was met with the EMR’s alert asking if I was sure that I wanted to enter the chart of a deceased patient. Like hundreds of thousands of others this past year, she has passed on, but our connection has not. Now I think of her every time I tuck a patient’s feet under their blanket. And I smile. The biggest reason I chose to do an ultrasound fellowship in the first place was my love for teaching. While the pandemic has raged, there have been limitations on in-person ultrasound workshops, emergency department rotators, and of course national assemblies this past year. Like many other educators, I have endeavored to expand beyond the never-ending drone of video-conference lectures with games and more interactive content. I strive to teach as much as I can on-shift, but with only limited time to dedicate to learners while balancing my duties as a new attending in a busy urban academic ED, I have felt pulled in multiple directions. I have struggled with imposter syndrome at every turn, without being able to focus on what brought me to this job. However, the kind and unexpected words of one of my students this past year has helped me pull out of that dizzying array of responsibilities: “Dr. Bhatnagar is an exemplary teacher and clinician. Her ability to distill complex ideas into more manageable bits of information was not only helpful to learners like me, but also for her patients… Both compassionate and confident... Grace and empathy… It is rare to find preceptors so dedicated to your learning.” I do not share this student’s words as any sort of humble-brag. I share them because they are words that I have not been telling myself. They are words that I did not know I needed to hear. And I would dare assert that many other emergency physicians out there are similarly not seeing, appreciating, or valuing their own worth in this difficult time. My best is not what it used to be, but it is enough. And when I revive my sense of purpose, it is everything. When my dark days come back, as they have with every wave of this catastrophe, I re-read his words. And I cannot help but smile. In a world where close contact can kill, the power of touch while using bedside ultrasound has been a lifesaver for me: to touch an underserved community’s needs, to touch a dying mother’s feet, to touch a bright-eyed student’s heart. Ultrasound alone is not the cure for all the languishing I have been experiencing. Yet what it represents is: service, connection, and purpose. I hope you find yours too, and I wish you well. COMMON SENSE JULY/AUGUST 2021

SECTON REPORT WOMEN IN EMERGENCY MEDICINE

How to Increase Your Effectiveness in Committee Representation and Leadership Marianne Haughey, MD FAAEM and Loice A. Swisher, MD MAAEM FAAEM

ear current and future EM leaders:

A challenge in emergency medicine and medicine in general is there are not enough women in leadership. A path to representing points of view particular to women, is to increase female membership and leadership in committees. There are local hospital committees, regional committees, and national and international committees available. They may be particular to emergency medicine or multidisciplinary. There is always work to be done, and joining a committee allows you to meet others with similar concerns and goals, across specialties and/or across geographic lines and allows communication among a diverse group of individuals. Once you have found a committee that has a mission worth your time and effort, there is a skill set needed to be an effective member and leader of a committee. These are not skills directly taught in any medical school curriculum.

Here are some bullet points to guide you: ● The chair has responsibilities to help guide the committee. They should: • Identify the mission of the committee. This should be clearly stated and repeated. If there is no mission statement, the chair should take the time with the group to create it. The mission of the committee allows focus on the matters at hand and hopefully can limit tangents and distractions. • Make sure all members know each other. The group should feel inclusive. All new members should be introduced and once a year it would be good to refresh all introductions. It may also be appropriate to do a round table quick introduction session at each meeting. • The chair should set expectations for the group. If a member will be absent who should they notify and how? How will their contribution be measured? Set expectations for preparation and contributions. The chair should ensure members understand all voices should be heard during meetings, and no one person should dominate the conversation. • The chair controls the agenda, and its distribution before the meeting as well as distributing any additional materials which will be required. Making sure this information is communicated in advance with plenty of time for the participants to review the material again helps support the members and allows them to fully participate during the scheduled meeting time.

COMMON SENSE JULY/AUGUST 2021

● Encouraging involvement: People join committees for different reasons. Some are passionate about the topics, some join out of a sense of purpose, some to make connections and find mentorship relationships, and some to build a CV. None of these reasons are bad reasons, but it will help the chair if they can get to know your members and their motivations. If someone is looking for a mentor/ mentee connection, a small group project with senior and junior members may lead to a more productive activity. If someone is looking to build a CV, perhaps there is a project that could turn into something publishable in the work the group is tasked with addressing. Always consider grooming a successor(s) to take over as chair. It is good to have fresh leadership to have fresh ideas. There should be a plan for the chair to rotate off that position to allow another member to take over with a fresh perspective.

● Logistics: There will often be staff or administrators assigned to the committee. It is essential that you understand their role and how they can help the work get done. Often they may not rotate off the committee as other members might do and may have more institutional memory than any one particular member. It is also essential to understand the expectations of any overseeing board. Do they expect reports on a particular schedule? If so, when might those be expected? If the committee wants to make proposals, what is the route to do so? It is important to understand the “chain of command” involved in getting committee work moved forward once your group has signed off on an action item.

SECTON REPORT WOMEN IN EMERGENCY MEDICINE

● Process: what is the process to produce an effective meeting? Planning the meeting schedule is imperative. Giving the group enough time to know when the meetings will be lets them adjust other aspects of their schedule so you can maximize attendance and involvement.

“A path to representing points of view particular to

women, is to increase female membership and leadership in committees.”

“People join committees for different reasons. Some are passionate about the topics, some join out of a sense of purpose, some to make connections and find mentorship ”

The agenda should be sent in adequate time for members to be able to review it. It should go out at least a week in advance. Topics include: the title of the meeting, approval of prior minutes, subgroup reports, old and new business. It should also include the date and ● Communication: time of the next meeting. Communication about the work of the committee inside the group is paramount. During • Minutes need to be taken and submitted your meeting you will identify tasks to be and distributed to the group. addressed and deadlines for those tasks • Action items should be listed with identified to be completed along with a point person due dates and persons responsible for the in charge of accomplishing the task. That tasks and clearly reviewed each session information should be shared post meeting and included in the minutes. so all on the committee, present or not, can • Stick to the time limits scheduled for the be aware and involved. If the committee is meeting. Start and finish at the predea local hospital committee perhaps hospital termined times. Members will have other email will be adequate. But there are other commitments and it is essential to respect tech tools to help everyone communicate everyone’s time. Also always leave time easily and in real time. Slack, Whatsapp, for new business. New topics often crop and Google Docs can all be used to get up and there should be planned time to information into the hands of the members discuss them. efficiently and quickly.

Meetings might be held in person, by Zoom or Teams, or by phone. All have advantages and disadvantages. • The good work of the committee should be advertised. Others outside of the committee should learn of the work being done. There may be a general reporting session for all committees of a group, or there might be other ways of publicizing the work. It could be through group newsletters, email updates, or published work. By publicizing the committee work it also allows those who are not members to see what is being done and consider joining the group. Enjoy your committee!

AAEM Online Flinging a Spotted Arm Joshua Mirkin, MD; Daniel Simpson, DO; Erica Harris, MD

The patient’s rash, in the setting of HIV, was immediately suspicious for secondary syphilis. In the morning, the patient’s RPR and FTA-ABS were positive. The patient had no recollection of a chancre and thought he had the pictured rash for a long time. Infectious disease saw the patient in the morning and felt this was residual hyperpigmentation from a previous rash associated with secondary syphilis. Because the rash was no longer pink or violaceous, typical of secondary syphilis, he was deemed to currently not be infectious. Because the patient did not know when he was infected or started having the rash, he was treated as late latent syphilis with 3 weekly doses of penicillin G benzathine.

48-year-old man history of hypertension and HIV, unknown CD4 count, brought in by EMS for shortness of breath. Patient states that he became short of breath just prior to arrival. Patient is awake and alert, but confused and has difficulty answering many questions. As an IV is being placed, the patient apologizes that his arm keeps on moving. He states that he is short of breath because he has not been able to stop his arm from moving for 3 hours.

Physical Exam

Because of the patient’s unmanaged HIV and syphilis, we had a broad differential for the cause of the patient’s hemiballismus. The patient denied any personal or family history of epilepsy. Because of his history of HIV we considered the possibility of seizures caused by an intracranial infection such as, toxoplasma, cryptococcus, and herpes encephalitis. Other potential causes included CNS lymphoma and progressive multifocal leukoencephalopathy. We also considered that the patient’s altered mental status and involuntary motions could be due to neurosyphilis.

Vitals: BP 114/71 HR 92 RR 20 T 36.9C General: oriented to person and place, NAD CV: nl s1s2, RRR, no MRG Resp: tachypneic, CTAB Abd: SNDNT Neuro: intermittent flinging of right upper extremity, CN II-XII intact, normal strength and sensation.

Labs

Women in EM Section Poster Pearls www.aaem.org/aaem-online

POC Glucose >600 VBG pH 7.60, pCO2 21, HCO3 20.6, BE 1.0 CBC: WBC 5.21, Hgb 12.9, Hct 40.5, Plt 41 BMP: Na 116, K 4.1, Cl 78, CO2 19, BUN 14, Cr 0.8, Glu 1,397 Osmolality 327

Questions 1. What is the differential diagnosis of the rash? 2. Why is the patient flinging his right arm?

Answers 1. Secondary syphilis, pityriasis rosea, lichen planus, guttate psoriasis, rocky mountain spotted fever 2. The patient was clinically diagnosed with hyperglycemic hemiballismus syndrome, but we were suspicious for partial seizures.

Department of Emergency Medicine Albert Einstein Medical Center Philadelphia, PA Case Discussion

History of Present Illness CC: shortness of breath

Pearls • Patients with fading or hyperpigmentation after the rash of secondary syphilis may need a longer course of treatment (3 doses versus 1 dose of penicillin G benzathine) than those with an active, violaceous rash. • Keep a wide differential for those with syphilis or HIV and neurological symptoms.

Early in the ED course, the patient was newly diagnosed with diabetes and found to be in a hyperosmolar hyperglycemic state. The patient’s mental status and hemiballismus improved with IV hydration. CT of his head was unremarkable. At the time of admission, he was fully oriented and hemiballismus had ceased. When the patient was signed out to the ICU, we discussed that if the patient continued to have hemiballismus, change in mental status, or seizure-like activity, the above differential should be explored. Ultimately, none of these symptoms returned and he was clinically diagnosed with hyperglycemic hemiballismus syndrome. If an MRI is done there is often hyperintensity of the contralateral basal ganglia, most commonly of the putamen.

References 1. 2.

Cosentino C, et al. Hemichorea/Hemiballism Associated with Hyperglycemia: Report of 20 Cases. Tremor Other Hyperkinet Mov (NY). 2016;6:402. Published 2016 Jul 19. Tintinalli, J.E., Stapczynski, J.S., Ma, O.J. et al. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 8th ed. McGraw-Hill Education, New York, NY; 2015.

Now available! COMMON SENSE JULY/AUGUST 2021

AAEM CHAPTER DIVISION UPDATE TNAAEM

Medicine and Politics Andy Walker, MD FAAEM

“One of the penalties for refusing to participate in politics is that you end up being governed by your inferiors.” -Plato (paraphrased from The Republic)

didn’t go to medical school in the hope of becoming involved in politics. Neither did the thought ever occur to me during residency. All I ever wanted to do was take care of acutely injured and seriously ill patients in the emergency department. To that end I spent a fortune in time, effort, and money in acquiring the knowledge, skills, and judgment needed to provide the best possible emergency medical care. Once in practice I quickly learned, however, that a host of people wanted to interfere in my ability to exercise my sorely acquired professional judgment on behalf of patients. Even worse, none of those people had sworn an oath – as I had when I took the Oath of Hippocrates – to put the patient’s health above financial and other interests.

“You start by simply paying attention and staying informed.” That is why I found myself involved in politics and regulatory policy: taking good care of patients required it, and I feel an ethical obligation to do my best for my patients. If you are a member of AAEM you probably feel the same ethical obligation to our patients and our profession, and I urge you to take action on that feeling. Don’t leave it up to others. How do you make a real difference in the regulatory environment in which emergency physicians work? You start by simply paying attention and staying informed. The vast majority of medical regulation takes place at the state level. Plus, AAEM’s leadership, Government & National Affairs Committee, and DC lobbying firm, Williams and Jensen, do a great job of taking care of things at the federal level. So, keep an eye on your state

COMMON SENSE JULY/AUGUST 2021

legislature. Every legislature has a website you can use to find your legislators, search for bills relevant to the practice of medicine, read and track those bills and their amendments, and communicate with legislators. Every February, after the deadline for filing bills passes, I go to the Tennessee General Assembly’s website and search for bills by topic using keywords like physician, medicine, tort reform, and surprise bills. If I find something important, I notify TNAAEM, AAEM’s Tennessee Chapter Division, as well as the Tennessee Medical Society (TMA). You can find your legislature’s website (and more) at govengine.com. I also strongly recommend that you join your state medical society and donate to its PAC (political action committee). Believe me - tort lawyers, the insurance industry, hospital administrators, contract management groups (CMGs), and everyone else who wants to control the practice of medicine is supporting their professional organization and its PAC. State medical societies usually do a good job of keeping members informed of important bills and proposed regulations, and are always one of the most powerful lobbies in the state. Your state society deserves your support, and you need its help. However, it needs your help too. Our specialty is unique in many ways, and your state society’s lobbyists may not understand the unique impact a law will have on emergency physicians and our patients. Surprise billing legislation is one example of that. It is up to us to explain such issues to our state medical societies, so they can go to bat for us. You can’t rely on the ACEP chapter in your state for that either. I believe ACEP and its state chapters are

“Always frame your argument in terms of what is best for patients.” too influenced by CMGs, and too willing to sacrifice the interests of individual emergency physicians and our patients to corporate business interests. A big example of that in Tennessee was the legislative battle over restrictive covenants in physician employment contracts. Because of TNAAEM’s involvement, emergency physicians are now the only physicians in Tennessee exempt from such non-compete clauses. Your state medical society needs to hear from AAEM, not just ACEP. Next, get to know your state legislators. Subscribe to their email newsletters. Offer to be an information resource for them. If you generally support their positions, donate a little money to their campaign or PAC – as little as $25-50 is enough to put you on their radar. Educate them on how relevant bills would affect emergency physicians and our patients. Be sure to thank them when they do the right thing. If they are consistently supportive of emergency medicine, let AAEM’s leadership know and suggest a donation from AAEM’s PAC. Communicating with your legislators and state medical society over the long term can pay big dividends. TNAAEM and I spent years educating the Tennessee Medical Association (TMA) and legislators on the unique position of emergency medicine in regard to EMTALA obligations and

AAEM CHAPTER DIVISION TNAAEM

surprise billing legislation. Not only did we successfully fight off insurance industry attempts to cap what out-of-network physicians and hospitals could bill insurers, the TMA decided to make the issue one of its highest legislative priorities. This relieved TNAAEM of much of the lobbying work and, more importantly, moved us from defense to offense when my state senator filed surprise billing legislation that protects patients without sacrificing the medical safety net to insurance industry profits. “

issue at hand, the battle isn’t over – it is just on pause. Never let your attention lag or your guard down, and never give up. Another opportunity to get what you want will likely arise. Be open to working with anybody if your interests align. Politics does indeed make strange bedfellows. And never, ever burn any bridges – no matter how frustrating a defeat may be.

As battered as physicians are right now – and especially We can’t win every battle, but we are guaranteed to lose every emergency physicians – the Make a good argument – a rabiggest obstacle we face is battle we don’t fight.” tional and polite argument that our own sense of hopelessputs patients first. In your more ness. It is easy to forget that cynical moments you may think that whoever donates the most money to we are still widely respected in society and in government, and we are a politician will win, but that is rarely the case. While I may agree with Otto hard to resist when we are protecting patients and their health. The belief von Bismark’s aphorism that laws are like sausages, it is better not to see that there is no point in trying to achieve the right thing because we are them being made, I have learned that in most cases whoever makes the doomed to fail is what leads to most of our defeats. We can’t win every strongest argument wins. Remember that you are almost always explainbattle, but we are guaranteed to lose every battle we don’t fight. ing the issue to someone who is not a physician, much less an emergency Pay attention, support your state medical society, get to know your legphysician. Keep it simple. Always frame your argument in terms of what is islators and communicate with them occasionally, craft your argument in best for patients. Nobody cares about how something affects you personterms of patient welfare, never give up or lose hope, and most basic of ally, if it doesn’t also affect patient care and the general public. all – when AAEM or its chapter division asks you to contact your legislaFinally, be patient. Politics never ends. Whether you won or lost on the tors, do it! There is strength in numbers.

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COMMON SENSE JULY/AUGUST 2021

AAEM CHAPTER DIVISION UPDATE TNAAEM

Chapter Division Update: Tennessee James Parnell, MD FAAEM–President, TNAAEM

he Tennessee Chapter Division of AAEM (TNAAEM) has had a busy and exciting last year. Our membership is representative of emergency medicine across the state from medical students to long tenured, national physician leaders. It is my pleasure to highlight some recent activities and successes of our chapter division.

EM residency programs have 100% membership in AAEM and TNAAEM. We will continue to be an advocate for the youngest of our emergency physicians, as we face issues such as excess workforce issues and corporate influence. Our board will continue to listen to young emergency physicians and attempt to better our specialty.

Advocacy TNAAEM has a long history of being engaged in legislative issues and government affairs, and we have worked to keep that momentum. Throughout 2020, we actively worked at the state and federal level to influence balanced billing legislation in an attempt to be the champion of the emergency physician. Along with an official TNAAEM press release, multiple TNAAEM board members have penned several op-eds that have run in all of the major newspapers across the state of Tennessee. Through their effect on Senator Lamar Alexander, these positively changed the federal legislation that became law as the No Surprises Act. Our correspondence and meetings with state legislators and the Tennessee Medical Association resulted in the filing of Senate Bill 1, putting the insurance industry on the defensive in regards to surprise billing legislation for the first time in our state. We have had correspondence and meetings with many of our elected leaders. Our TNAAEM membership and leadership have stepped up to insure that the voice of the emergency physician is heard regarding this issue. The COVID-19 pandemic has certainly challenged emergency physicians across our state and nation. Tennessee never had a statewide mask mandate and messaging about masking importance was not a consistent priority. Several of our TNAAEM members engaged Governor Bill Lee and fellow Tennesseans about the importance of masking to prevent the spread of COVID-19, helping emergency physicians manage the surges of COVID-19 patients. As our president, I had

“TNAAEM has a long history of being engaged in legislative issues and government affairs, and we have worked to keep that momentum.”

the chance to make several news media appearances across the state to promote public health through masking and COVID-19 education. TNAAEM stood up for emergency physicians and contributed to a successful response to COVID-19.

Membership Our chapter division currently has over 150 members. Although our biannual Residency Day and conference in 2020 was cancelled because of the pandemic, we have worked to sustain and engage our membership. Two of our state’s

COMMON SENSE JULY/AUGUST 2021

“Several of our TNAAEM members engaged Governor Bill Lee and fellow Tennesseans about the importance of masking to prevent the spread of COVID-19, helping emergency physicians manage the surges of COVID-19 patients.” Leadership Many TNAAEM members actively serve on committees and boards at the national AAEM level; including the Wellness Committee, Women in EM Section, the Palliative Care Interest Group, and the AAEM Physician Group; and we are proud that several of these members have taken leadership roles at the national level. To highlight a few, Dr. Andy Walker is Treasurer of AAEM-PG and co-chair the AAEM Government & National Affairs Committee with another TNAAEM member, Dr. Kevin Beier. Dr. Mark Reiter is now the CEO of AAEM-PG, and Dr. Arthur Smolensky serves on its Board of Directors. Additionally, Dr. Corey McNeilly, PGY-1 at the University of Tennessee-Nashville, is our TNAAEM Resident Representative and also serves as the secretary and Treasurer for the AAEM Resident and Student Association. Our chapter division is fortunate to have many long-standing leaders within AAEM who continue to mentor and grow our specialty. I take great pride in serving as the President of the Tennessee Chapter Division of AAEM. Our chapter division is fortunate to have so many great physicians and leaders who want to carry out the mission of AAEM, keeping it the Champion of the Emergency Physician.

Fake It ‘Til You Make It?: Recognizing and Combating Imposter Syndrome

SECTON REPORT YOUNG PHYSICIANS

Cara Kanter, MD FAAEM, Chair

t’s July. You’ve graduated residency and it’s your first day on the job. Four years of college, four years of medical school, three plus years of emergency medicine training, countless standardized tests, successful patient interactions, and high-risk procedures have all given you the training and confidence you need to take this next step. Attending physician. You’ve got this…Right? Somewhere deep down you’re wondering how you conned your way to the top. How you’ve gotten away with it all this time. How there’s no way you’re capable of doing this very important, very high stakes job. Diagnosis? Imposter Syndrome. Imposter syndrome, the phenomenon of feeling that one’s achievements are not duly earned and that one will inevitably be discovered as a fraud, was first described by psychologists Suzanne Imes and Pauline Rose Clance in 1978. Originally thought to primarily affect women, imposter syndrome has been demonstrated to occur in high achievers across all genders, age groups, races and ethnicities, with some studies showing increased rates among underrepresented minorities. A review article in the Journal of Behavioral Sciences estimates that up to 70% of people will experience feelings of imposter syndrome at some point in their lives. Tom Hanks, Maya Angelou, Supreme Court Justice Sonia Sotomayor, and Albert Einstein are a few notable self-identified sufferers. Imposter syndrome has been documented in the medical literature across all levels of training. It is a strong predictor of psychological distress and has been linked to feelings of exhaustion, cynicism, depersonalization, and burnout among physicians. LaDonna et al (2018) describe, “transitions, challenges, and increased responsibilities [as] notable culprits for triggering self-doubt.” Transitions are ubiquitous in the medical field: medical school, residency, fellowship, clinical environments, leadership roles in medical education or administration, and the list goes on. With each step in an individual’s career path, there is exposure to imposter syndrome and the associated risks, but there are also opportunities for mitigation. If these feelings of imposter syndrome sound familiar – and chances are they do – consider the following tactics to help combat the effects of imposter syndrome:

“With each step in an individual’s career path, there is

exposure to imposter syndrome and the associated risks, but there are also opportunities for mitigation.”

Name the beast. Acknowledging imposter thoughts helps put what you are feeling into perspective. Recognize that no one is expecting perfection. Continuing education is a foundation of medicine. You are supposed to keep learning; you are supposed to ask for help when you need it.

Talk to your mentors. Imposter syndrome is pervasive in our field. Talking to others about your concerns will not only help validate your accomplishments as completely warranted, but will also demonstrate just how pervasive the imposter phenomenon is. Peer mentors are just as valuable as other types of mentorship. Talk to your advisors and department leadership who can give you constructive feedback on your performance, but also talk to your peers. You may be surprised by how many of them have similar feelings of self-doubt.

“Originally thought to primarily affect women, imposter

syndrome has been demonstrated to occur in high achievers across all genders, age groups, races and ethnicities, with some studies showing increased rates among underrepresented minorities.” Be the expert you are. The opportunity to teach others can help validate your expertise. Volunteer to give a lecture at resident conference. Let a pre-medical undergraduate student shadow you. Take on a mentee. Your vast experience and training has prepared you to answer their questions; it will be a rewarding experience for both of you.

Celebrate your successes. Take time to recognize and celebrate your accomplishments before moving on to the next thing. Promoted to associate professor? Well done! You’ve worked hard for this - teaching, researching, writing, and publishing. How are you celebrating? Take a night off and go to that restaurant you’ve been eyeing. Splurge on that questionably necessary tech item. Plan a vacation. You deserve it!

COMMON SENSE JULY/AUGUST 2021

SECTON REPORT CRITICAL CARE MEDICINE

Seek professional help. The stigma associated with therapy is fading with the widespread recognition of emotional exhaustion, burnout, substance use disorder, and physician suicide plaguing the medical field. Talk to human resources at your hospital; many departments have confidential resources for physicians needing extra support. Do NOT think of seeking professional help as some sort of failure; it is the opposite.

References: 1. Abrams, A. (2018, June 20). Yes, Impostor Syndrome Is Real. Here’s How to Deal With It. TIME. Retrieved April 27, 2021, from https://time. com/5312483/how-to-deal-with-impostor-syndrome/ 2. Baumann, N., Faulk, C., Vanderlan, J., Chen, J., & Bhayani, R. (2020). Small-Group Discussion Sessions on Imposter Syndrome. MedEdPORTAL, 16. doi:https://doi.org/10.15766/mep_2374-8265.11004

AAEM

3. Bravata DM, Watts SA, et al. “Prevalence, Predictors, and Treatment of Impostor Syndrome: a Systematic Review”. J Gen Intern Med. 230; 35(4):1252-1275. 4. LaDonna, Kori A. PhD; Ginsburg, Shiphra MD, PhD; Watling, Christopher MD, PhD “Rising to the Level of Your Incompetence”: What Physicians’ Self-Assessment of Their Performance Reveals About the Imposter Syndrome in Medicine. Academic Medicine. 2018; 93(5):763-768 doi: 10.1097/ACM.0000000000002046 5. Sakulku, J. (1). The Impostor Phenomenon. The Journal of Behavioral Science, 6(1), 75-97. https://doi.org/10.14456/ijbs.2011.6 6. Villwock JA, Sobin LB, Koester LA, Harris TM. “Imposter syndrome and burnout among American medical students: a pilot study.” Int J Med Educ. 2016; 7:364-369; doi: 10.5116/ijme.5801.eac4 7. Weir, K. (2013, November). Feel like a fraud? GradPSYCH, 11(4). Retrieved April 28, 2021, from https://www.apa.org/gradpsych/2013/11/ fraud

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Starting Strong: Essential Steps to Making the Right First Impression at Your New Job

SECTON REPORT YOUNG PHYSICIANS

J. David Gatz, MD

hether you’ve been in the game for a few years or are fresh out of residency, it is essential you make the right first impression at any new job. Outside of being able to intubate blindfolded or knowing obscure eponyms for your boards, what will make you stand out? Surveying a large network of ED medical directors who manage everything from small freestanding EDs to large academic sites about the most important things new ED physicians can do to stand out provided interesting and sometimes unexpected answers. While there were common themes, some of the results may surprise you!

(“on time” for a shift is late), be responsive to emails and phone calls (while you are not expected to be glued to your phone and email, neither should requests or emails sit for weeks unanswered), and pay attention to department communications (as annoying as emails may be, it is essential that any attending be aware of and up to date on departmental communications). In the ED, it is important to recognize that to your patients, you are the face to the hospital. Equally important, to consultants and executives you are the face of the department (and the rest of us emergency medicine docs!). In our field, we inevitably encounter a wide variety of personality types. As an EM physician, you must cultivate your emotional intelligence to learn to manage all types of temperaments and often challenging attitudes. Even if someone is unprofessional with you, never stoop to their level. Inform your director about it or handle it privately in the moment, but always be the bigger person. Your medical director will thank you! It is not by coincidence that emergency physicians are frequently promoted to leadership positions throughout their hospitals. The need to mold ourselves and adjust to understand and get along with so many different specialties in the ED environment provides the ideal training ground for such positions. Playing nicely in the sandbox finally pays off!! Remind yourself of that when you are struggling to keep your cool.

“As an EM physician, you must cultivate your

1. Believe in Yourself, but Stay Humble It is assumed, coming out of residency, that you are competent in emergency medicine (from a clinical, procedural, and knowledge standpoint). While you might not have seen every piece of pathology present in a board review book, you have had the training to troubleshoot anything that walks through the door. That being said, generate respect from your colleagues and your team by showing that you recognize that there is room for growth and experiences to learn from every day. Medicine (especially emergency medicine) requires lifelong learning. Recognize your weaknesses (i.e. Foleys, eyeballs, subclavian lines…) and then commit to seeking them out until you no longer dread facing them. You will thank yourself in the future, on your own during that inevitable single-coverage night shift!

2. Be Professional (at All Times!) Professional conduct should be the rule - not just with your patients, but also in your interactions with colleagues, co-workers and consultants. Some expectations seem obvious: Come in a little early to your shift

emotional intelligence to learn to manage all types of temperaments and often challenging attitudes.” 3. Establish a Strong Relationship with Your Staff (Especially Nursing!) While seemingly obvious, this point is often overlooked. As the new kid on the block, it is essential that you build relationships with those around you. How? It is actually pretty straightforward: be courteous, thoughtful, kind and approachable. First impressions matter (and stick!). If a new doc gets labeled as mean or slow or difficult, it can be hard to shake that reputation. Small gestures, such as bringing in some treats for the staff, being generous with verbal expressions of your appreciation or even just knowing someone’s name can go a long way in building your reputation as a team player. This is not bribery; it is simple recognition of the incredibly hard work your coworkers put in each day. Earning their gratitude makes it more likely they will step up to assist when you inevitably find yourself in a pinch.

SECTON REPORT YOUNG PHYSICIANS

“You want your

patient to leave feeling that they were fully heard and treated as a complete person…not just a constellation of symptoms.”

4. Establish a Strong Relationship with Your Patients

Develop a wonderful bedside manner. Sit down. Listen. Don’t interrupt. Ask your patients what is important to them. Before honing in too quickly on a chief complaint, always ask, “Was there anything else that brought you to the emergency department today?” Make sure that you really listen and hear what they are saying. You want your patient to leave feeling that they were fully heard and treated as a complete person…not just a constellation of symptoms.

You will inevitably identify areas for system improvement in your new department. But remember: don’t just identify problems. Develop a potential solution and bring it to your director in an appropriate forum. Offering solutions to problems is well received and demonstrates your engagement within the practice.

One of the most common sources of frustration and anger for patients is that while they may have received appropriate care, they did not feel cared for. Patients may not remember much about their visit – but they will remember how you made them feel. Understand the difference between sympathy and empathy. Empathy is a powerful tool that you should wield often.

Thank you to the following individuals who provided comments for this article:

5. Seek (and Give) Feedback A good director should give feedback early and often, but may be overwhelmed. Take the initiative and solicit feedback. Inquiring about productivity and patient satisfaction data (or whatever other topic feeds your curiosity) will demonstrate your interest in the department. While you don’t have to be the fastest doc in the department, it is best not to be the slowest; knowing your numbers is important. Don’t forget to get

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to know nursing leadership as well. They can be a great source of feedback (especially if they know you are seeking it), and also a great source of support if they connect with you.

COMMON SENSE JULY/AUGUST 2021

Three Questions to Get You on the Fast Track for Success • Ask the most recent hires before you – what piece of advice did you not get, that you wish you did, when you started here? • Ask the director – what is your biggest pet peeve of new hires? Ideally, they will be open and honest with you, and then you can avoid it! • Ask the nurses – who is their favorite doc to work with and why? Emulate those behaviors.

• • • • •

Dr. Amit Chandra Dr. Chirag Chaudhari Dr. Brandon Cole Dr. Richard Ferraro Dr. Jon Mark Hirshon

• • • • •

Dr. Joel Klein Dr. Doug Mayo Dr. Steve Schenkel Dr. Angela Smedley Dr. Laura Pimentel

“It is actually pretty straightforward: be courteous, thoughtful, kind and approachable. First”

This program matches emerging speakers with a mentor who is a nationally recognized AAEM speaker.

An Open Letter to the Specialty of Emergency Medicine

AAEM/RSA PRESIDENT’S MESSAGE

AAEM/RSA

ecently, the ACEP EM Physician Workforce released the results of a study determining the current and projected supply of EM physicians in 2030. The study concluded that the current trends in EM would result in a surplus of 9,413 emergency physicians in 2030. AAEM and AAEM/RSA have been warning our specialty of the potential for significant oversupply of EM physicians since 2016, when a study by Reiter et al., Past President of AAEM, stated, “within the next 5 to 10 years, there will be enough board certified or eligible emergency physicians to provide care to all patients in the U.S. EDs.” Indeed, this analysis appears to have been wholly accurate. Two significant factors have led us to this point. ● Between 2012 and today, the number of accredited EM training programs has grown by over 100 programs, from 160 to 265. (ACGME) ● There has been a more than 100% increase in the number of visits seen by non-physicians, particularly NPs, since 2010. (AAPA) All of our specialty societies can agree, objectively, that the specialty of emergency medicine is facing a significant oversupply of physicians. Given this, it is imperative that our specialty take collective action to address the issue immediately. AAEM/RSA supports the multi-organizational effort being organized and suggests four key interventions be taken in order to adequately address the security of our specialty and safety of our patients. ● We must purge our specialty societies from the influence and funding from corporate entities. This conflict of interest has prevailed in our largest organizations and prevented the adequate advocacy and security to acknowledge the issues we are now facing, as they evolved. False narratives have led to delays in combating both the over-expansion of EM residency programs by CMGs and corporate hospital groups, and the expanding scope of practice of midlevel providers. ● We must have a moratorium on new EM residency training programs and address the ACGME’s longtime inaction in prohibiting corporate entities from opening and funding EM residency training programs. AAEM/RSA believes that the ACGME has been complacent in allowing the significant oversupply of EM physicians. The substandard training requirements have and continue to be exploited by corporate entities to produce programs of questionable quality. The commandeering of medical training for cheap labor and to influence

supply and demand economics by these profit driven corporations has been a significant factor in resident oversupply. We must demand the ACGME not only make requirements more stringent for future programs, but hold a moratorium on all new residency program applications until these issues are addressed. ● We must end all NP and PA “fellowships” and begin to replace non-physicians with physicians. NPs and PAs have historically been physician extenders during a time of physician shortage. Without this shortage, there is no longer a need for physician extension through the use of midlevel providers, and the most qualified individual to care for patients should do so. We must not give priority to non-physicians, in education or in department jobs, when there exists a market of thousands of graduating EM physicians who do not have employment opportunities and are significantly more qualified to fill these patient care roles. ● We must formally consider broad unionization of EM physicians. The considerable control of contract management groups and corporate entities on our profession has and continues to erode multiple facets of our profession. Their ability to significantly influence the specialty, including by manipulating the workforce and undermining our duty as physicians through replacement with NPPs, must be halted. Unionization may be the only feasible option to having a stronger independent voice within the corporate practice of emergency medicine. As emergency medicine becomes increasingly controlled by corporate entities, unionization may be the only measure in ensuring the needs and protections of emergency physicians. AAEM/RSA is exceedingly concerned with the future of emergency medicine. Our residency positions are expanding uncontrollably under the influence of profit driven corporations, our patients are being more frequently treated by non-physicians, and because of these and other failures, our graduates are entering an increasingly impermeable job market. AAEM/RSA believes that should we want our specialty to survive the impending market failure, we must take drastic actions as listed above, not only for the health of our profession, but for the safety of our patients.

Haig Aintablian, MD 2019-2021 AAEM/RSA President Approved 4/10/2021

COMMON SENSE JULY/AUGUST 2021

AAEM/RSA ABEM NEWS

Residents Guide to ABEM Certification Written by the ABEM Resident Ambassador Panel: Haig K. Aintablian, MD; Alaa M. Aldalati, MD; and William Spinosi, DO

anel members serve two-year terms during their residency training and provide a resident perspective to ABEM activities. Working with ABEM over the past year, the 2020-2022 ABEM Resident Ambassador Panel has gained insights into the process of becoming ABEM-certified, and have outlined those steps from their perspective. We hope this helps residents in preparing for the certification process.

Becoming board certified in emergency medicine by the American Board of Emergency Medicine is a simple process requiring three steps for residents who are in their final years of training.

STEP 1: Applying for certification

STEP 2: Passing the qualifying exam

STEP 3: Passing the oral board exam

During the last year of a resident’s emergency medicine training, graduating residents destined to finish residency by October 31st can access application information by signing into the ABEM initial certification page. ABEM will also send application information to the program director of the residency program, usually around April. Those graduating later than October 31, will apply in the next application cycle. For EM residents who graduate between November 1st and October 31st, it’s important to apply in the current application period. If you delay this, you may need additional certification requirements, including a state medical license, if you do not have one already. The entire application and fee payment process is online. Applications are processed as soon as they are completed.

The second step in becoming ABEM board certified is to pass the qualifying examination, a “written examination” that is actually a computerized test with 305 multiple choice questions (with only single best answer choices). The qualifying examination is offered in about 200 Pearson testing centers across the US, making it easy to take the exam in the state you graduated from or plan on practicing in. The exam itself is offered during one 6-day period, typically in the fall. In order to take the exam during this time, you must schedule yourself during one 8-hour block in this 5-day period.

The third and final step in completing board certification is to pass the oral board examination. To be eligible for this section of board certification, you must have passed the qualifying examination, as well as have a state medical license. Once you pass your qualifying examination, you must take the oral board exam the next calendar year.

Board eligible means that a resident graduated from a ACGME or RCPSC accredited emergency medicine program or an ABEM-approved combined program. Additionally, you must fulfill all medical licensure per ABEM policy. If you are applying right out of residency, you do not need to hold a state medical license. This starts on the day you graduate from residency and extends to December 31st five years after your graduation date.

Should you be unable to attend the exam, you can cancel the exam before 24 hours from the start of the exam. Please arrive 30 minutes before your exam time and make sure to bring a valid form of identification. This process is similar to many of the other examinations you have taken to get to this point in your career as a physician! The exam appointment is a total of eight hours long, but divided into two testing sections, each about three hours and 10 minutes long with a one hour break in between. The question topics are based on the EM Model, similar in makeup to the in training exams, which you have likely already experienced during your residency training. Once you have completed this qualifying examination, you can expect your score within 90 days of completion.

COMMON SENSE JULY/AUGUST 2021

It’s important to note that given the COVID-19 pandemic, there have been some changes to the implementation of this section of board certification. Notably, the examination has been offered on a virtual platform, as opposed to in-person, for the safety of test takers and testing staff. The oral board examination comprises 6 single patient cases, each 15-minutes long. The examiner will provide pertinent history and offer answers to the examinee’s questions. The examiner will track eight specific markers during these patient cases. These markers include: • • • • • •

Data acquisition Problem solving Patient management Resource utilization Healthcare provided or outcome Interpersonal relations and communication skills • Comprehension of pathophysiology • Clinical competence

AAEM/RSA NEWS, RESIDENTS GUIDE TO ABEM CERTIFICATION

Examiners assign a score from 1-8, with one being very unacceptable to eight being very acceptable. In addition to the six single patient cases, a discussion on your approach to patient care will evaluate your thought processes. Structured interviews are scored as 25 points spread across eight stages of a typical patient interaction. These include: • • • • • • • •

History Physical Exam Differential Diagnosis Testing Treatment Final Diagnosis Disposition Transitions of Care

to determine a passing score, instead after each examination, ABEM testers meet to determine the standard of care for each case and then determine whether testers passed or failed. The final passing score is then sent to the ABEM Board to determine performance expectations for a pass or fail score. ABEM does not allow for rescoring or second scoring any examinations. Once you have passed the Oral Board Examination, congratulations! You are now an ABEM board certified EM physician! ABEM-certified physicians serve a valuable and irreplaceable clinical role in the care of the critically ill and injured. The delivery of emergency care is best led by physicians with EM training, experience, and ABEM certification. ABEM will support you throughout your career in continuing certification activities and promoting the important and valuable role ABEM-certified physicians bring to emergency care in the ED.

Ultimately, once you are done with the oral board examination, ABEM will let you know if you have passed or failed typically within 45-60 days, and definitely within 90 days. ABEM does not use quotas or percentages

Do you have questions about the certification process? Reach out to your program director, or contact ABEM at abem@abem. org.

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COMMON SENSE JULY/AUGUST 2021

The Value of Reflection during Residency

AAEM/RSA NEWS

Richard J. Cunningham, MD

originally swore to never return to my mindless jottings (the thought of reading my own writing, especially that which is as personal as found in a diary, is about as abhorrent to me as listening to recordings of my own voice), I recently took the plunge and reviewed the thoughts, hesitations, and emotions I’ve taken the time to put down since starting residency.

“Looking back on where

I’ve been and what I’ve gone through makes me hopeful that whatever the future holds, I will end up where I need to be.”

s a fourth year medical student, I spent a month working in a remote clinic in Bolivia after matching into emergency medicine (EM). Inspired by reading about turn-of-the-century archaeologists working in Central and South America, I decided to purchase a leather-bound notebook in order to keep a record of my foray into the South American jungle. While there, I documented the interesting pathology that I still have yet to encounter in the United States: rheumatoid nodules from poorly controlled arthritis, oral cancer induced by chewing coca leaves tainted with pesticide, a slew of bizarre ECG findings due to cardiomyopathy from Chagas Disease, and many others. My journal also served as a record of the myriad of rainforest fauna I spotted while traversing the jungle early in the morning before clinic, local colloquialisms in Spanish (and Quechua) I had learned, and an array of peculiar and fascinating cultural customs I encountered while accompanying a Bolivian physician (whom I am glad to now call my friend) to his native city of Cochabamba. Upon my return to the United States, with inertia on my side, I carried forward this habit of journaling into my residency. While my training has not taken place in a setting as exotic as the forests of South America, I am grateful that this habit has stuck. Though I

COMMON SENSE JULY/AUGUST 2021

“Now that I am

almost a third year, it’s refreshing to view my progression since starting out as an anxious intern.”

I’m glad I did. Now that I am almost a third year, it’s refreshing to view my progression since starting out as an anxious intern. In July of 2019, I mused over the seemingly unattainable confidence of my senior residents and the mountain of knowledge I was expected to master. Over the following months, this hesitancy turned into hope, and my insecurities sprouted into aspirations. The doctor I wanted to become began to take on a primordial, amoebic form. Fast forward to the early spring of 2020, while on the cusp of a dawning pandemic, the uncertainty and frustration I experienced at the time were laid bare. With volumes down and residents restricted from caring for those stricken with an invisible threat that had yet to reach our hospital, I struggled with how these changes would negatively impact our training (with the benefit of hindsight, I today would be happy to reassure my past self). I then recorded the surreal moment of diagnosing my first patient with COVID-19 and later chronicled the crushing toll of running my first (unsuccessful) code on a patient with the same nasty, destructive disease. While enduring the whirlwind of the winter surge, I was fortunate enough to find time to continue cataloging the ups and downs of training during a once-in-a-century pandemic. Looking back on where I’ve been and what I’ve gone through makes me hopeful that whatever the future holds, I will end up where I need to be. Whether the COVID-19 pandemic will have a net negative or net positive impact on our training overall, it is certain that we are passing through one of the most consequential periods in medicine as we also navigate the tough and messy, yet infinitely rewarding process of becoming emergency physicians. Keeping a journal during these tumultuous times has helped keep me grounded. For the soon-to-be interns, the classes of 2024 and 2025, my advice is to begin to record these experiences now. Residency is one of, if not the defining stage of our careers, and while I am just shy of a mere two years in this field, I feel confident that your future selves will thank you for taking time to document this incredible journey.

A Reflection on Residency

AAEM/RSA EDITOR’S MESSAGE

Ryan P. Gibney, MD

s you go through this journey, you will learn all about every aspect of the human anatomy and physiology, and it will be fascinating. You will know you have found the right specialty for you, not by the body part or procedure or subject matter, but by the group of people you absolutely have to work with. It is when you find that group, that you will know you are where you belong. Those words have always stuck with me; advice given to me by the dean of the medical school when I asked him about his path in medicine. I can’t help to reflect on those words now as I approach the end of my time as a resident in emergency medicine, and how now, more than ever, it was the perfect advice. For some the path to a career in medicine is clear cut, linear, without doubt or stumble; however, for me, well, let’s just say I took the scenic route. I started college at 18, like I was supposed to, quickly realizing I wanted to explore life a bit before focusing on my career. I spent time as a musician, cook, bartender, mortgage officer; got married, had a child. I succeeded some, failed a lot, learning a lot about myself, life, and people along the way. Somewhere in my mid-thirties I decided medicine was the career path I wanted to pursue, ultimately a career in emergency medicine. Many said I was crazy, but if I had to do it over one hundred times, I would do it exactly the same way. Every. Single. Time. And, I would choose emergency medicine again and again. Starting out as a freshly minted doctor in the world of emergency medicine is one filled with idyllic wonder: visions of never ending streams of resuscitations, procedures, trauma, and complex patients flash across your mind like an artfully composed symphony. Walking into the ED, head held high, shoulders broad, and chest puffed up to go and take on the world. I think every reality check starts with the same preconceptions and idyllic view, followed by swift

realization that what we do is quite different. The terms often used to describe ER physicians are as varied as the specialty itself: Jack of all trades, master of none, resuscitation masters, JAFERD and BAFERD, risk stratification experts, movers of the meat, and on and on. Looking back, I guess I have become a bit of all of those, and then some. Residency has been one of the most challenging things I have ever done. The transition from wide-eyed first year to fullfledged ER doctor has also been one of the most rewarding experiences of my life. In the first year of residency, I quickly learned that I knew very little and that was ok. I heard once that first year residents were like baby tigers: cute and fluffy, full of energy, but could also accidentally kill someone if you aren’t paying attention. It’s laughably pretty accurate. But also first year, for me, was about realizing limitations and growing both clinically and personally. I recall a shift about three-quarters through my first year where I was inundated with sick patient after sick patient: intubate room A, central line room B, code room E. I finished that shift exhausted, defeated, but also for the first time realizing that I was becoming extremely capable and comfortable with my skills. This transition and growth has continued throughout my training.

“I learned more about myself

and my abilities that I had in the previous 40 years of life, and I am grateful for this challenge and who I have become in the face of it.”

“And, I would choose emergency medicine again and again.” Second year in my program is where ER doctors are made. It is rigorous, busy, complex, exhausting. We worked 20+ shifts per month, seeing the most complex patients. I remember a time around Christmas, I had been in the hospital 20 of 21 days with my only time off being post night shifts. I missed my family, was perpetually exhausted, and this was the first time where I questioned my choices about medicine and ER both. Enter in a new challenge with COVID, and second year ended like Infinity Wars—all that work and still defeated. I felt my first taste of burnout as I struggled in my personal and professional life, which I have previously shared with you. I had uncertainty about the next year and my future as and ER doc, but looking back, I learned more about myself and my abilities that I had in the previous 40 years of life, and I am grateful for this challenge and who I have become in the face of it.

>> COMMON SENSE JULY/AUGUST 2021

AAEM/RSA EDITOR’S MESSAGE

Oh sweet third year, how I love you so. Our program rewards us with more responsibility but less shifts. I once again was able to encounter the mythical creature known as free time, and was able to focus on self-growth and spend time with my family. My skills as a clinician have become second nature and I am comfortable in my new role. As a chief resident, I started working with the new interns and second years, to teach them and share my experience, and let them know that it WILL be all right. I started focusing on the bigger picture as an ER physician and really connecting with my patients and others. I realized I’m good but I can always be better. I have chosen fellowship in Admin/Ops,

as I want to continue to expand my knowledge and fill in the gaps of things I don’t fully understand. Here I stand 25 shifts away from graduation (but who’s counting), excited to be done, but more importantly excited to take on the next part of this career. The road ahead is paved with uncertainty; the current security of EM as a specialty is a hot topic, hospitals are making sweeping changes in structure and function, patients can read our notes and ask us to make changes. All of these things are just that—things. Job markets will ebb and flow as they have done for 100 years, someone at the top will always have new idea, but in the end people adapt. One thing I know for certain, as an emergency medicine doctor, adapting is my thing! My message to all of the graduating residents, and past-present-future me is: We are all amazing doctors, more importantly, ER doctors, we are equipped with a certain set of skills to handle anything that comes our way, and we are honored to care for those on the worsts days of their lives and make a difference no matter how big or small. We put the “BA” in BAFERD. Congratulations to all of you!

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COMMON SENSE JULY/AUGUST 2021

AAEM/RSA RESIDENT JOURNAL REVIEW

Adjunctive Therapies in Septic Shock, Part 2: Steroids Authors: Christianna Sim, MD MPH; Taylor M. Douglas, MD; Wesley Chan, MD; and Christopher Kiang, MD Editors: Kelly Maurelus, MD FAAEM and Kami Hu, MD FAAEM FACEP

Introduction Sepsis is a common emergency department presentation which unfortunately carries a mortality rate estimated to be as high as 50% in severe sepsis and 80% in septic shock.1 Beyond the mainstay of treatment–IV fluid resuscitation, vasopressors as needed, and timely administration of antibiotics–it is not uncommon to see the use of steroids in septic shock patients from the ED to the intensive care unit (ICU).2,3 The physiologic basis of this therapy stems from the concept that acute stressors such as severe infection can cause acute adrenal insufficiency compounding the hypotension seen in septic shock and potentiating organ dysfunction.2 It is unclear, however, if treatment of this potential adrenal insufficiency translates to a clinical benefit and the use of steroids in septic shock remains somewhat controversial, although the latest iteration of the Surviving Sepsis Campaign have recommended the addition of hydrocortisone therapy in patients with septic shock who remain hemodynamically unstable despite fluid and vasopressor resuscitation.3 We have already looked at some studies using steroids as an adjuvant therapy in a previous Resident Journal Review. Here, we will review additional literature regarding the possible benefit of steroids in the management of septic shock.

Question What is the remaining evidence for the use of steroids in patients with septic shock?

Sprung CL, Annane D, Keh D, et al. Hydrocortisone therapy for patients with septic shock. N Engl J Med. 2008;358(2):111-124. doi:10.1056/NEJMoa071366 Prior to 2008, a short course of high-dose corticosteroids was a generally accepted therapy for septic shock patients based on studies such as the 1976 study by Schumer et al. and the 2002 Annane Trial suggesting a survival benefit.4-5 Subsequent studies failed to replicate the beneficial results and even suggested superimposed infections with corticosteroid use. The 2008 CORTICUS (Corticosteroid Therapy of Septic Shock) Trial was a multicenter, double-blinded randomized trial of 499 patients with persistent septic shock (defined as systolic blood pressure of < 90 mmHg despite adequate fluid replacement or a need for vasopressor for a least 1 hour) and hypoperfusion or organ dysfunction attributable to sepsis, enrolled within 72 hours. It excluded patients with underlying disease carrying an overall poor prognosis, life expectancy < 24h, immunosuppression, and patients with recent treatment with long-term corticosteroids within the past 6 months or short-term corticosteroids within the past 4 weeks. The majority of patients were older (mean age 63 years), male (66%), and white (94%).

Participants were randomized to receive either 50mg of hydrocortisone or placebo IV every six hours for five days, every 12 hours for three days, then daily for three days. Prior to treatment, all patients received an ACTH stimulation test and were classified as responders (cortisol rise > 9 mcg/dL) or non-responders (cortisol rise ≤ 9 mcg/dL). There was no significant difference (34% vs 32%, p=0.51) in the primary outcome of 28-day mortality regardless of corticotropin response. While there was no survival benefit, hydrocortisone was associated with a quicker reversal of shock (3.3 vs 5.8 days, p<0.0001) in all subgroups studied. Etomidate use was associated with higher 28-day mortality (60% vs 43%, p=0.004) in ACTH non-responders. There were no significant differences in secondary outcomes such as reversal of shock, length of stay, reversal of organ failure, and superimposed infection. The lack of mortality benefit in the CORTICUS trial outcomes contrasted with the results of previous trials, potentially due to less-sick study population with a lower mortality rate than the Annane trial, and omission of the use of fludrocortisone. The authors acknowledge the trial was likely underpowered, falling short of the 800 patients needed to detect a 10% mortality difference with an expected mortality of 50%. Neuromuscularspecific testing for myopathy development among subjects was not performed, and the authors acknowledge potential methodologic issues surrounding the accurate diagnosis of adrenal insufficiency in criticallyill patients, although the findings may indicate a decreased prognostic importance of this phenomenon in less severe shock. They authors concluded that hydrocortisone cannot be recommended as general adjuvant therapy for septic shock, but stated hydrocortisone may have a benefit in selected patients who despite appropriate treatment remain vasopressor unresponsive.

Annane D, Bellissant E, Bollaert PE, et al. Corticosteroids for treating sepsis in children and adults. Cochrane Database Syst Rev. 2019;12(12):CD002243. doi:10.1002/14651858. CD002243.pub4 The original Cochrane review examining the utility of corticosteroids in septic shock was first published in 2004, with this most recent update in 2019.6 In this systematic review, the authors included randomized control trials (RCTs) assessing steroids versus placebo or usual care in both adults and children. They included studies of patients in sepsis, defined as a suspected or documented infection with the presence of at least two of four SIRS (systemic inflammatory response syndrome) criteria and at least one sign of organ dysfunction (metabolic acidosis, hypoxemia PaO2:FiO2 < 250 mmHg, oliguria < 30 mL/h for ≥ 3 hours, coagulopathy, or encephalopathy), and septic shock which was defined as sepsis with hypotension (persistent systolic blood pressure < 90 mmHg refractory to fluid resuscitation, requiring vasopressor support). >> COMMON SENSE JULY/AUGUST 2021

AAEM/RSA RESIDENT JOURNAL REVIEW

The trials included assessed the use of continuous or bolus low-dose systemic corticosteroids (cortisone, hydrocortisone, methylprednisolone, betamethasone, dexamethasone) of ≤ 400 mg hydrocortisone daily (or equivalent dose) for both short (< 3 days) and long (≥ 3 days) courses. Steroid intervention was compared to standard treatment (antibiotics, fluids, inotropic or vasopressor therapy, mechanical ventilation, renal replacement therapy) and/or placebo. The primary outcome was 28-day all-cause mortality. Secondary outcomes included all-cause mortality at 90-days, long-term (longest available follow-up beyond three months), ICU, and hospital, shock reversal (hemodynamic stability ≥ 24 hours after cessation of vasopressors) at day seven and 28, number of organs affected and severity of organ dysfunction at day seven as measured by SOFA score, ICU and hospital length of stay (LOS), and adverse events (gastrointestinal bleeds, superinfection, hyperglycemia, hypernatremia, muscle weakness, neuropsychiatric event, stroke, cardiac events, or other adverse events associated with corticosteroids). A total of 8,928 studies were screened with a final of 61 studies included of which 28 were new trials since the most recent update. From the data extracted from these studies, the authors did find a slight reduction in 28-day mortality (RR 0.91, 95% CI 0.84 to 0.99, p=0.01). There may be a reduction in 90-day mortality (RR 0.93, 95% CI 0.87 to 1.00, p=0.05), but they found no mortality benefit beyond that (RR 0.07, 95% CI 0.91 to 1.03, p=0.29). There was a slight reduction in hospital (RR 0.90, 95% CI 0.82 to 0.99, p=0.03) and ICU (RR 0.89, 95% CI 0.83 to 0.96) mortality as well as both hospital (mean difference (MD) -1.63 days, 95% CI -2.93 to -0.33, p=0.01) and ICU (MD -1.07 days, 95% CI -1.95 to -0.19, p=0.02) length of stay (LOS). Corticosteroids were also shown to be associated with shock reversal at day 7 (RR 1.23, 95% CI 1.13 to 1.34, p<0.00001) and at day 28 (RR 1.06, 95% CI 1.03 to 1.08, p<0.0000). Corticosteroids were also associated with better SOFA scores at day 7 (MD -1.37, 95% CI -1.84 to -0.09, p<0.00001). The authors also performed subgroup analyses that showed no difference in study drug, dose, or duration (though it should be noted most studies looked at low-dose long courses of > 72 hours) on 28-day mortality but did see an increased benefit with combination hydrocortisone plus fludrocortisone. While there was an increased risk of muscle weakness (p=0.04), hypernatremia (p<0.00001), and hyperglycemia (p<0.00001) associated with corticosteroid therapy, the authors found no increased risk of superinfection (p=0.27), gastrointestinal (GI) bleeding (p=0.55), stroke (p=0.73), neuropsychiatric (p=0.73) or cardiac events (p=0.68). In this review, the authors found that while corticosteroids may reduce short-term mortality, decrease hospital and ICU LOS, and are associated with shock reversal and lower SOFA scores at day seven, there was no benefit on long-term mortality. It should be noted that the authors found the evidence to be inconsistent with heterogeneity of results among studies reducing the overall reliability and certainty of the conclusion.

Bonnin S, Radosevich JJ, Lee YG, et al. Comparison of shock reversal with high or low dose hydrocortisone in intensive care unit patients with septic shock: A retrospective cohort study. J Crit Care. 2021;62:111-6. doi:10.1016/j.jcrc.2020.12.001 This was a multicenter retrospective cohort study conducted at two hospitals, evaluating outcomes associated with either low-dose (50 mg every six hours) or high-dose (100 mg every eight hours) hydrocortisone. The primary outcome was shock reversal, defined as discontinuation of vasopressors for four hours or more. Secondary outcomes included need for additional vasopressor therapy post steroid use, recurrence of shock, development of new shock, and adverse drug events. Univariate and multivariate analysis was used for the entire study cohort to assess outcomes. Study participants included ICU patients in septic shock receiving vasopressors and hydrocortisone between years 2013 and 2018. Institutional protocols for sepsis treatment were similar between the two institutions and guided by recommendations from Surviving Sepsis Campaign guidelines, including fluid administration and broad-spectrum antibiotics with vasopressor support to maintain mean arterial pressure of at least 65 mmHg. Patients were identified using centralized medical records. Inclusion criteria were age greater than 18 years, suspicion of or proven infection, and receipt of at least 48 hours of either steroid regimen. Exclusion criteria included death within 48 hours of ICU admission or pre-existing diagnosis of immunosuppression requiring daily steroid use. Patients were matched in a 1:1 manner using a nearest neighbor approach and a caliper of 0.1. T-test were used to compare continuous data while Mann Whitney U was used for any skewed data. A total of 319 patients met inclusion criteria, with 134 patients in the lowdose group and 185 patients in the high dose group. Mean age was 61 years old with a SOFA score of 10.7 +/- 3.3. Pneumonia was the most common primary source. Baseline characteristics between the groups were similar with exception of slightly younger age and higher SOFA scores and need for mechanical ventilation in the high-dose group. There was no statistically different rate of shock reversal between the low and high dose regimens (84% vs 88%, p=0.247) on propensity-matched analysis. Secondary outcomes were similar between groups with exception for a higher incidence of additional vasopressor post steroid initiation (34% vs 22%, p=0.012) and shock recurrence (11% vs 4.3%, p=0.039) in the low-dose group. The authors based the discordant results of their primary outcome on differences in baseline characteristics between the two groups. They also noted that the small sample size fell below the calculated threshold required for the study. As a retrospective cohort study, the presence of various confounding factors was unavoidable; attempts to control these using multivariate analysis with score matching were, of course, inferior to randomization. The lack of a standard protocol to guide all aspects of septic shock management produced a high likelihood of variation between the

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two medical centers. As there is a paucity of studies comparing low and high dose steroid use in patients in septic shock, this article may perhaps be a preview of possible future prospective studies to delineate the optimal dosage of steroids.

Conclusion Although data from the 2002 Annane trial and the APROCCHSS trial did suggest some short-term mortality benefit, this benefit was not seen in studies such as the CORTICUS and ADRENAL trials. The more recent Cochrane review did suggest some potential short-term benefits (28-day mortality and reversal of shock at day seven) without a benefit to longterm survival. The use of corticosteroids in critically ill septic patients is still widespread, most likely due to their more reproducible effect on shortening time to shock reversal, and should be considered in patients with refractory shock despite adequate fluid resuscitation and vasopressor therapy.

Answer: Although the impact of steroids on mortality remains unclear, they have repeatedly been associated with a shortened time to shock reversal. Patients with refractory septic shock failing to improve after fluid and vasopressor resuscitation may benefit from their use. Exact dosage and duration are still a subject of debate.

References: 1. Jawad I, Lukšić I, Rafnsson SB. Assessing available information on the burden of sepsis: global estimates of incidence, prevalence and mortality. J Glob Health. 2012;2(1):010404. doi:10.7189/jogh.02.010404 2. Rushworth RL, Torpy DJ, Falhammar H. Adrenal Crisis. N Engl J Med. 2019;381(9):852-61. doi:10.1056/NEJMra1807486 3. Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017;43(3):304-77. doi:10.1007/s00134-0174683-6 4. Schumer W. Steroids in the treatment of clinical septic shock. Ann Surg. 1976;184(3):333-41. doi:10.1097/00000658-197609000-00011 5. Annane D, Sébille V, Charpentier C, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock [published correction appears in JAMA. 2008 Oct 8;300(14):1652. Chaumet-Riffaut, Philippe [corrected to Chaumet-Riffaud, Philippe]]. JAMA. 2002;288(7):862-71. doi:10.1001/ jama.288.7.862 6. Annane D, Bellissant E, Bollaert PE, Briegel J, Keh D, Kupfer Y. Corticosteroids for treating severe sepsis and septic shock. Cochrane Database Syst Rev. 2004;(1):CD002243. doi:10.1002/14651858. CD002243.pub2

SAVE THE DATE #AAEM22 www.aaem.org/aaem22

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MEDICAL STUDENT COUNCIL PRESIDENT’S MESSAGE

Medical School Reflections through a #MedTwitter Lens Ashley Iannantone, MA — Chair, AAEM/RSA Medical Student Council

y name is Ashley Iannantone and I am incredibly honored and excited to be serving as this year’s AAEM/RSA Medical Student Council Chair. The timing of my first Common Sense article catches me in a period of immense reflection at the transition between my third and fourth year of medical school. This month also happens to coincide with my two-year anniversary of joining #MedTwitter, so I have decided to take a walk down memory lane via my Twitter feed and talk about lessons I’ve learned thus far in medical school and advice for students at each stage in training:

September 19, 2019: “@WIMSummit inspired me to make a Twitter…” I first joined #MedTwitter while attending the inaugural Women in Medicine Summit in Chicago in 2019. I was a couple months into my second year and I immediately regretted not joining sooner. I am the first in my family to pursue a career in medicine, and the entire journey — from applying, to studying during preclinical years, to board exams, to treating your first patients in clinical years — can be incredibly long, difficult, and confusing along the way. Which brings me to my first piece of advice: As early as possible, find a community that can support you while also fostering your growth. This community may change throughout your training as your interests develop, but the most important thing is taking that first step to seek it out. Mentorship is truly invaluable in medical school. (Just a few days later, I tweeted about attending the AAEM/RSA Midwest Medical Student Symposium for my first time and added this amazing organization to my ever-expanding community.)

September 25, 2019: “Some things I learned after failing a med school exam for the first time: … If you’re drowning, it’s ok (and sometimes even better) to pull yourself out of the water and prepare to jump back in stronger.” 56

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I struggled a lot with tweeting this at the time. It’s sometimes too easy to only show your “greatest hits” on social media — the times when everything seems to be going right — but there will be times in medical school where nothing seems to be going right. My advice during these times? Remember what brought you to medical school in the first place and take a step back to look at how far you’ve come. I sometimes like to read my personal statement or essays from when I was applying to medical school to help with this. Remember that you were accepted to medical school for a reason, and that you have so much value to add to your class and the medical community as a whole. Give yourself grace and give yourself breaks, and use those times to rejuvenate your passion and perspective.

October 24, 2019: “Thought of the day: Point of care ultrasound is really cool.” I had just attended one of my Emergency Medicine Interest Group’s Journal Clubs and we discussed an article regarding utilizing ultrasound in the evaluation for pulmonary emboli. I entered medical school with my sights set on a career in emergency medicine, but in my last three years, I’ve realized how broad that statement truly is. For first and second-year students considering EM: Shadowing is a great way to gain exposure into the specialty as a whole, but make sure to keep your eyes out for subspecialty areas of interest — ultrasound, toxicology, disaster medicine, critical care, and EMS, to name a few. Identifying these interests can help you seek out unique learning opportunities (such as electives during your third and fourth years) and will be useful when you begin researching and applying to residency programs.

July 6, 2020: “Something all new M3s should hear today: ‘I am so excited you all are here. I know you feel like you don’t know enough to be in third year, but you do. You are all so smart and you are all going to be amazing physicians.’”

“As early as possible,

find a community that can support you while also fostering your growth.” July 23, 2020: “Ok I had my first assessment of M3 year today and I finally feel ready to announce — this is SO MUCH better than preclinicals.” Aug. 6, 2020: “Also today I got to find fetal heart tones with a doppler for the first time and I think I was more excited than the patient.” Now at the end of my third-year clerkships, looking back at these tweets I feel exactly the same in some ways and completely different in others. This past year has gone by in the blink of an eye and while I may sometimes still feel as though I don’t “know enough” to be where I’m at, I know that I have grown in my skills, confidence, and passions. My biggest piece of advice to those entering their clerkships: Start a daily journal. On a practical note, this will help you build your personal statement and answer questions during interviews when residency applications roll around. But perhaps more importantly, on a personal note, you’ll be able to look back through the year and relive the highs and lows that come so quickly at times that it can be impossible to process them all in real time. I look forward to continuing to grow and learn in my last year of medical school, and especially in my new role as the MSC Chair. If you’d like to follow my journey more closely, you can follow me on Twitter: @ashleyiann.

June Board of Directors Meeting Summary

June Board of Directors Meeting Summary The members of the AAEM Board of Directors met during AAEM21 in-person to discuss current and future activities. The members of the Board of Directors appreciate and value the work of AAEM committee, section, interest group, and chapter division members and chairs as they strive toward the AAEM mission and to be the specialty society of emergency medicine. Over the course of the meeting, a number of significant decisions and actions were made. Here are the highlights:

Presentations President Lisa A. Moreno, MD MS MSCR FAAEM FIFEM presented her President’s report which highlighted the many activities that she and other leaders have been involved in over the past year. Highlights of the report included the many position statements released, two clinical policy statements, two joint statements, and the statements AAEM released on COVID-19. In addition, she highlighted the interviews, leadership meetings, and the work of appointed AAEM representatives working on projects in collaboration with other organizations. Treasurer Robert Frolichstein, MD FAAEM reported on AAEM and AAEM subsidiaries financial performance. He reported that year-end financials look different due to the pandemic,

however, overall AAEM is in a strong financial position. Dr. Frolichstein also reported on the annual audit that was performed by an outside independent firm, Reilly, Penner & Benton. The auditors gave AAEM a unqualified or “clean” opinion, which is the best type of report to receive for a non-profit business. Other reports were provided by AAEM Lobbyist Matt Hoekstra on federal legislative efforts. AAEM-PG President Mark Reiter, MD MBA MAAEM FAAEM reported on the activities of AAEM-PG. In addition, marketing consultant firm, Association Management Center, reported on the recent AAEM survey that was conducted. A task force was appointed to work with the firm and staff to implement the recommendations to increase membership and AAEM messaging.

2021-2022 Elected Board of Directors Approvals A number of approvals took place during the meeting including: the approval of new software that will assist with the advocacy efforts for grassroots and on the state level, transitioning the Social EM and Population Health IG to a committee, updating the AAEM advertisement policy, and approving the position statement on raising emergency medicine residency standards.

Miscellaneous In addition, AAEM will be engaging an outside firm to help redesign the website and a new award grants will be created using the LEADEM funds to promote education, develop leadership, and advance the specialty of emergency medicine.

What

When

Where

The next Board of Directors meeting

September 16, 2021

AAEM National Headquarters Milwaukee, Wisconsin

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AAEM Job Bank Service Promote Your Open Position To place an ad in the Job Bank: Equitable positions consistent with the Mission Statement of the American Academy of Emergency Medicine and absent of restrictive covenants, will be published (upon approval). All ads run for a six month period or until canceled and will appear in the AAEM member magazine Common Sense and online. For pricing and more information visit www.aaem.org/membership/benefits/ job-bank. Complete a Job Bank registration form, along with the Criteria for Advertising Section, and submit payment. If you are an outside recruiting agent, the Job Bank Criteria for Advertising must be downloaded and completed by a representative from the recruiting hospital/group. Direct all inquiries to: www.aaem.org/membership/benefits/job-bank or email info@aaem.org.

Positions Available For further information on a particular listing, please use the contact information listed. Section I: Positions in full compliance with AAEM’s job bank advertising criteria, meaning the practice is wholly-owned by its physicians, with no lay shareholders; the practice is equitable and democratic; due process is guaranteed after a probationary period of no more than one year; there are no post-employment restrictive covenants; and board certified emergency physicians are treated equally, whether they achieved ABEM/AOBEM/RCPSC certification via residency training or the practice track. Section II: Positions that cannot be in full compliance with AAEM’s job bank criteria, because they are employee positions with hospitals or medical schools and the practice is not owned by its emergency physicians. Thus there may not be financial transparency or political equity. Section III: Positions that cannot be in full compliance with AAEM’s job bank criteria, because they are government or military employee positions. The practice is not owned by its emergency physicians, and there may not be financial transparency or political equity. Section IV: Position listings that are independent contractor positions rather than owner-partner or employee positions.

SECTION I: POSITIONS RECOGNIZED AS BEING IN FULL COMPLIANCE WITH AAEM’S JOB BANK CRITERIA

INDIANA

South Bend Emergency Physicians, Inc. is a stable, democratic, 30 member group seeking additional BC/BE Emergency Physicians. 60K visits, Level II Trauma Center, double, triple and quad physician coverage at Memorial Hospital of South Bend. We also have single coverage at a 10K visits suburban branch small, acute-care hospital, as well as single coverage at a 4.5K visits critical access hospital about 20 miles from Memorial Hospital. Equal pay, schedule and your voice is heard from day one. Over 450K total package with qualified retirement plan; group health plan and disability insurance, CME reimbursement, etc. Favorable Indiana malpractice environment. University town, low cost of living, good schools, 90 minutes to Chicago, 40 minutes to Lake Michigan. Teaching opportunities at four

year medical school and with the hospital FP residency program. Contact Jennifer Burks, Practice Manager, jburks2@r1rcm.com (PA 1859) Email: jburks2@r1rcm.com

OREGON

ZOOM+Care is hiring a Family Medicine Physician for our Neighborhood Clinics! Requirements: Board Certified or Board Eligible in Family Medicine or Internal Med-Peds with 2+ years of post-residency clinical practice, or the equivalent. Experience and comfort with infants, children and adultsExperience with office-based procedures (laceration repair, I&Ds, skin biopsies, joint injections). Experience in “bedside” teaching and mentoring appreciated. Experience in a leadership role is preferred but

not required. Benefits: Market-leading salaried compensation and benefits plansPaid time off and paid parental leave. $3,000 CME stipend and one week of CME PTO per year. 401k with 4% employer match. License and professional society membership reimbursement. Employer paid short-term disability, longterm disability and life insurance. Fully paid malpractice insurance with tails coverage. Apply at https://jobs.lever.co/ zoomcare/18182255-b647-4810-84aa-7ea19729d47f or contact myfuture@zoomcare.com (PA 1844) Email: myfuture@zoomcare.com Website: https://jobs.lever.co/zoomcare/18182255-b647-481084aa-7ea19729d47f

SECTION II: POSITIONS NOT RECOGNIZED AS BEING IN FULL COMPLIANCE WITH AAEM’S JOB BANK ADVERTISING CRITERIA (Below are hospitals, non-profit or medical school employed positions.)

ILLINOIS

The University of Illinois College of Medicine Rockford is seeking an innovative educator for a 12-month, full-time faculty position. The selected individual will be responsible for teaching and directing the Doctoring and Clinical Skills course, a fundamental course on history-taking, physical examination, clinical reasoning, and professionalism, which extends throughout the first 2 years of medical school. To apply please visit https://jobs. uic.edu/Rockford. For fullest consideration, please apply by 3/16/2021. Applications will be accepted until 4/16/2021. The ideal applicant will have an MD/DO or its foreign equivalent in primary or emergency care specialty. (PA 1848) Email: mquinte3@uic.edu Website: https://rockford.medicine.uic.edu

KENTUCKY

NEW EMERGENCY MEDICINE PHYSICIAN OPPORTUNITY IN OWENSBORO, KY Owensboro Health Medical Group is seeking additional Board-Certified/Board-Eligible Emergency Medicine

(ABEM, AOBEM) physicians. Join our team of 12 physicians and 6 NPs/PAs who welcome an average of 50,000-55,000 annual ED visits. Our 40 bed, level 3 trauma unit is located in a cutting edge facility licensed for 477 beds where patient experience and quality care drive every decision for the 500,000 population we serve. • $385,000 Guaranteed Base Compensation • $50,000 Potential Engagement Bonus Compensation • $35,000 Upfront Bonus • $25,000 Student Loan Forgiveness annually (total of $50,000) • 186 Nine hour shifts annually (PA 1850) Email: jerry.price@owensborohealth.org

WEST VIRGINIA

The Charleston Area Medical Center, Department of Emergency Medicine is seeking a pediatric emergency medicine physician to work at Women and Children’s Hospital located in Charleston, WV. This 120-bed dedicated Women and Children’s Hospital is a part of a large university-affiliated regional referral center with a drawing population of 562,000. We have in-house

Neonatologist with 24/7 coverage in Level III NICU as well as a PICU with pediatric intensivists. Job Requirements by the time of appointment: • MD, DO degree or foreign equivalent degree from an accredited pediatric emergency medicine fellowship program • Board Certification by the American Board of Emergency Medicine or the American Osteopathic Board of Emergency Medicine • Eligible for WV Medical License. Benefits include: • Excellent benefits package with generous PTO • Vibrant community • Superb family environment • Unsurpassed recreational activities • Outstanding school systems. To apply, send your CV to carol.wamsley@camc.org. (PA 1860) Email: carol.wamsley@camc.org Website: http://www.camc.org

SECTION III: POSITIONS NOT RECOGNIZED AS BEING IN FULL COMPLIANCE WITH AAEM’S JOB BANK ADVERTISING CRITERIA (Below are military/government employed positions.) Non Available at this time.

SECTION IV: RECOGNIZED AS BEING IN FULL COMPLIANCE WITH AAEM’S JOB BANK ADVERTISING CRITERIA (Below are independent contractor positions.) Non Available at this time. COMMON SENSE JULY/AUGUST 2021

COMMONSENSE

Pre-Sorted Standard Mail US Postage PAID Milwaukee, WI Permit No. 1310

555 East Wells Street / Suite 1100 Milwaukee, WI 53202-3823

MEMC21 Malta 10-13 November 2021 St. Julian’s

XIth Mediterranean Emergency Medicine Congress

#MEMC21

July/August2021 Common Sense

Articles inside

Job Bank

Board of Directors Meeting Summary: June

The Value of Reflection during Residency

Resident Journal Review: Adjunctive Therapies in Septic Shock, Part 2: Steroids

AAEM/RSA President: An Open Letter to the Specialty of Emergency Medicine

AAEM/RSA ABEM News: Residents Guide to ABEM Certification

Medical Student Council Chair’s Message: Medical School Reflections through a #MedTwitter Lens

Young Physicians: Starting Strong: Essential Steps to Making the Right First Impression at Your New Job

Critical Care Medicine: 2020-2021: A One Year Summary of the Critical Care Medicine Section

AAEM Chapter Division Updates: Tennessee

AAEM Chapter Division Updates: Medicine and Politics

Emergency Ultrasound: Ultrasound as My Antidote

Wellness: Verbal Abuse

Women in EM: How to Increase Your Effectiveness in Committee Representation and Leadership

Operations Management: Why You Should Do a Fellowship in Administration

Legislators in the News: An Interview with Representative Mark Green, MD

Social EM & Population Health: Training Future Leaders: Social Emergency Medicine Fellowships

ABEM News

The New AAEM Physician Group

President’s Message: The State of the Academy: It’s GREAT

The Rise and Fall of Medicine

From the Editor’s Desk: The New Threat

AAEM-LG Spring 2021 President’s Message